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Is Antenatal Care Worthwhile?

Is Antenatal Care Worthwhile?

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Is Antenatal Care Worthwhile?

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  1. Is Antenatal Care Worthwhile? Max Brinsmead MB BS PhD May 2015

  2. I will not directly answer this because: • There are no trials of AN care vs no AN care • Instead I will… • Look at what we are we doing in AN care • This requires a diversion into epidemiology • Review those parts of AN care that has been tested by rigorous RCT? • What will AN care look like in the future?

  3. Why do we: • Take a history? • Perform blood tests? • Measure BP? • Perform ultrasound? • Palpate the abdomen? • Weigh patients? • Test urine?

  4. Antenatal care is designed to: • Single out pregnancies that are abnormal, disordered or high risk… • In order to provide interventions that will optimise an outcome • Provide preparation for childbirth and parenting

  5. Screening is: • The application of a TEST to an ASYMPTOMATIC population in order to FIND cases of DISEASE or ABNORMALITY.

  6. The objective of screening:

  7. The objective of screening:

  8. A good screening test

  9. A typical screening scenario:

  10. Characteristics of a Test • Sensitivity = the chance that the disease will be detected • Positive predictive value = the chance that a screen positive individual will have the disease

  11. Down syndrome detection: • Sensitivity based on age = 30% • Based on 2nd trimester triple test = 60% • Based on 1st trimester combined test = 88% and • Positive predictive value = 1:10

  12. Urinalysis Antenatal Care as Screening

  13. Urinalysis Pre eclampsia Antenatal Care as Screening

  14. Urinalysis BP measures Pre eclampsia Antenatal Care as Screening

  15. Urinalysis BP measures Pre eclampsia Pre eclampsia Antenatal Care as Screening

  16. Urinalysis BP measures Detection of oedema Pre eclampsia Pre eclampsia Antenatal Care as Screening

  17. Urinalysis BP measures Detection of oedema Pre eclampsia Pre eclampsia Pre eclampsia Antenatal Care as Screening

  18. Urinalysis BP measures Detection of oedema Maternal weight gain Pre eclampsia Pre eclampsia Pre eclampsia Antenatal Care as Screening

  19. Urinalysis BP measures Detection of oedema Maternal weight gain Pre eclampsia Pre eclampsia Pre eclampsia Fetal growth Antenatal Care as Screening

  20. Haemaglobin Red cell indices RBC antibodies Reagin tests Anaemia Thalassaemia Fetal isoimmunisation Syphilis Antenatal Care as Screening

  21. Glucose challenge test Vaginal swab Hep C testing Gestational diabetes Group B Streptococci Hep C infection Antenatal Care as Screening

  22. 7 Criteria to test a screening program • Is there a good screening test available? • Is there an intervention available? • Is the disease worth detecting? • Will screen positive patients comply? • Will the test reach those applicable? • Has the program been tested by RCT? • Can the health system cope with the program?

  23. Problems with Screening: • FALSE POSITIVES • And the resources required to deal with them • UNREALISTIC EXPECATATIONS • ie misunderstanding about the sensitivity of the test

  24. An Evidence Base for Antenatal Care The Cochrane Library

  25. The Cochrane Library on Antenatal Care • 64 Analyses of which: • 7 evaluate routine antenatal care • 15 evaluate routine advice during pregnancy • 16 evaluate management of common minor problems • 26 evaluate management of high risk pregnancies

  26. Trials of care for low risk women • Ten trials with >60,000 women • Fewer visits not associated with adverse outcome • But women less satisfied • Midwife or GP care as good as Specialist care • And women more satisfied

  27. Continuity of care • Two trials with 1815 women cared for by a team of midwives vs traditional care • Fewer hospital admissions • More likely to attend antenatal education • Used less analgesic drugs in labour • Less requirement for neonatal resuscitation. • No difference for other obstetric outcomes

  28. Women who carry their own record • Three trials with 675 women • More likely to feel in control • Insignificant risk of lost or left records • More likely to deliver operatively • No difference for other obstetric outcomes

  29. Measuring symphysis fundal height • 1639 women recruited No difference for any obstetric outcomes

  30. Psychosocial support and postpartum depression • 7600 women studied: • No benefit if provided antenatally • Postpartum support is required

  31. So, in your antenatal clinic will you: • Weigh your patients at every visit? • Record their height? • Urine test every visit? • Measure symphysis fundal height? • Record presentation and engagement? • Screen for depression? • Screen for domestic abuse? • Screen for thalassaemia? • Offer Down’s Risk testing? • Screen for diabetes? • Screen for GBS colonisation?

  32. A New Model of Antenatal Care? • 12w • History for risk factors • Check weight, BP and urine • Scan for dates, NT (and more?) • Blood for routine tests + aneuploidy markers

  33. A New Model of Antenatal Care? • 12w • History for risk factors • Check weight, BP and urine • Scan for dates, NT (and more?) • Blood for routine tests + aneuploidy markers • 20w • Scan for morphology, placenta, check uterine artery Dopplers and cervical length

  34. A New Model of Antenatal Care? • 12w • History for risk factors • Check weight, BP and urine • Scan for dates, NT (and more?) • Blood for routine tests + aneuploidy markers • 20w • Scan for morphology, placenta, check uterine artery Dopplers and cervical length • 28w • Screen for gestational diabetes • Anti D for Rh negative • 34w • Anti D for Rh negative

  35. A New Model of Antenatal Care? • 12w • History for risk factors • Check weight, BP and urine • Scan for dates, NT (and more?) • Blood for routine tests + aneuploidy markers • 20w • Scan for morphology, placenta, check uterine artery Dopplers and cervical length • 28w • Screen for gestational diabetes • Anti D for Rh negative • 34w • Anti D for Rh negative • 36w • Scan to exclude breech

  36. A New Model of Antenatal Care? • 12w • History for risk factors • Check weight, BP and urine • Scan for dates, NT (and more?) • Blood for routine tests + aneuploidy markers • 20w • Scan for morphology, placenta, check uterine artery Dopplers and cervical length • 28w • Screen for gestational diabetes • Anti D for Rh negative • 34w • Anti D for Rh negative • 36w • Scan to exclude breech • 38 & 40w • Check primigravida for late onset pre eclampsia

  37. A New Model of Antenatal Care? • 12w • History for risk factors • Check weight, BP and urine • Scan for dates, NT (and more?) • Blood for routine tests + aneuploidy markers • 20w • Scan for morphology, placenta, check uterine artery Dopplers and cervical length • 28w • Screen for gestational diabetes • Anti D for Rh negative • 34w • Anti D for Rh negative • 36w • Scan to exclude breech • 38 & 40w • Check primigravida for late onset pre eclampsia • 41W • Sweep membranes. Arrange induction of labour