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DR. Mazin Daghestani

Antenatal care & High Risk Assessment. DR. Mazin Daghestani. Normal pregnancy. Definition: Embryo: Fetus: Gravidity Parity Abortion: Immature infant: Preterm/premature infant: Term: Post term Date/Post date. Birth rate Fertility rate Neonatal period: I, II & III

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DR. Mazin Daghestani

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  1. Antenatal care & High Risk Assessment DR. Mazin Daghestani

  2. Normal pregnancy • Definition: • Embryo: • Fetus: • Gravidity • Parity • Abortion: • Immature infant: • Preterm/premature infant: • Term: • Post term • Date/Post date • Birth rate • Fertility rate • Neonatal period: • I, II & III • Perinatal period: • Perinatal mortality rate: • Maternal mortality rate:

  3. Diagnosis of pregnancy Sign & symptoms of PRESUMPTIVE /PROBABLE manifestations • Pregnancy test: • Biological • Immunological • Radioimmunoassay for HCG • Serum vs urine

  4. “”Antenatal care is the clinical assessment of mother and fetus during pregnancy, for the purpose of obtaining the best possible outcome for both the mother and the fetus” • The aims of antenatal care: • Assessment and management of maternal risk and symptoms • Assessment and management of fetal risk • Prenatal diagnosis and management of fetal abnormalities • Diagnosis and management of perinatal complications • Decision regarding timing and mode of delivery • Education regarding pregnancy and childbirth

  5. Frequency of antenatal visits • 12 weeks –booking + viability uss • 16 weeks-blood screening (MW) • 18 weeks-dating &detailed uss • 24 weeks- • 28 weeks- FBS, auto ab • 30 weeks • 32 weeks- growth uss • 34 weeks • 36 weeks – • 38 weeks • 40 weeks • 41 weeks -

  6. booking visit (first visit): • The aim: • obtain a comprehensive history and physical examination • establish the gestational age • identify the maternal and foetal risk factors • History: • A FULL obstetric history particularly: • LMP (last menstrual period) • EDD (estimated delivery date) • Past obstetric, gynaecological, medical and surgical history • Family history • Social history ( inquire about smoking, alcohol, drugs) • Identify factors and categories which make patient high or low risk.

  7. Assessment of gestational age: Nagel’s rule (EDD) : Subtract 3 months from the date of the last menstrual period and add 7 days( 14 days in Arabic months). If the cycle was longer than 28 days, the number of additional days are added to the days used in the rule Do the opposite if the cycle is shorter Biparietal diameter: accurate +/- 3 weeks ( useful between wks 7-12) Crown rump length: accurate +/- 1 week (useful between wks 7-12) Fundal height: correspond to gestational age in weeks .

  8. Measurement Symphyseal Fundal height • Evidence supports either palpation or S- F measurement at every AN visit to monitor fetal growth • measurement should start at the variable point (F) and continue to the fixed point (S) • SF measurement should be recorded in a consistent manner (therefore cms at RWH)

  9. Fetal Presentation and Descent • Check presenting part beginning around 30 weeks • Descent of presenting part is important as term approaches

  10. Auscultation of fetal heart • Listening to fetal heart is of no known clinical benefit, but may be of psychological benefit to mother (Consensus opinion) • Should be offered at each visit after about 20 weeks

  11. Routine BP measurement • HT is defined when systolic BP is 140mmHg +/or DBP is 90 mmHg or there is an incremental rise of 30 systolic or 15 diastolic • Automated devices & ambulatory devices should not be used (Mercury devises seem best)

  12. Urinalysis by dipstick for proteinuria - evidence • high incidence of false +ve and - ve using dipsticks cf 24 hr urine collection • reliable in detecting highly variable elevations in protein in pre-eclampsia • Gribble et al AJOG 1995; 173: 214-7

  13. Urinalysis by dipstick forn proteinuria - evidence • no statistical differences in rates of PAH, fetal distress, abruptio placentae, neonatal outcome in those with absent, mild or marked proteinuria by dipstick • US and Canadian Guidelines recommend screening for pre-eclampsia by BP measurement rather than dipstick

  14. Urinalysis by dipstick for proteinuria - guidelines • Routine screening for proteinuria in low risk pregnant women not recommended IV • assessment hypertensive pregnancies requires estimation of total protein in 24-hr collection IV • If detect hypertension then use dipstick for testing proteinuria

  15. Routine weighing at A/N visits - evidence • weighing at every antenatal visit routine practice for many years • No conclusive evidence for weighing at each visit. Maternal weight not clinically useful screening tool for detection of IUGR, macrosomia or pre-eclampsia IV • Weighing at booking or other times may be indicated eg anaesthetic risk assessment (done BIV at RWH) or maternal weight concerns

  16. Initial recommended tests • FBE • MCHC/MCV (Thal screen. Ferritin and Hb electrophoresis if low) • Blood group/Ab screen • HIV (level 1 evidence) • Hep B • Syphilis (ideally prior 16 weeks) • Rubella Abs

  17. Urine testing- either 2 step or MSU+dipstick • PAP if due Consider • Hep C • Ferritin • Vit D levels - common in patients at RWH • addit Thal screen • dating US

  18. Hepatitis C screening • Should be offered to all at increased risk • history of injecting drugs • partner who injected drugs • tattoo or piercing • been in prison • blood t/f later positive for Hep C • long-term dialysis or organ transplant before 7/92

  19. Prenatal testing Down screening • Screening - : early US, 15-17 week MSST, Early combined screening(first trimester MSST and early US) • diagnostic testing - CVS, amniocentesis Other testing according to history eg for CF, Fragile X, Thalassaemia, Huntington's disease

  20. Prenatal screening for Down’s syndrome • All women should be offered screening irrespective of age III/IV • counselling given by appropriately trained staff and specific to age of each woman III/IV

  21. Down syndrome screening • Screening should • include accurate dating by 1st T u/s IV • either by 2nd T biochem, or nuchal translucency alone or combination III • notify result irrespective of risk in understandable format II • if increased risk should be offered further counselling and diagnostic testing within 72 hrs or ASAP IV

  22. Down’s syndrome screening • Quality of counselling is of primary importance, non-directional, if chooses screening, should be single-step III • Nuchal translucency should be performed at 11-14 weeks by trained operators and risks derived in conjunction with gestation and maternal age IV

  23. Other recommended tests • 26 weeks (at hospital) • Gestational diabetes screening - • AB screen on all women • 36 weeks • GBS screen • (Ab if RH -ve has been ceased)

  24. Screening for GDM • In absence of high level evidence to either support or abandon screening reasonable to • not offer screening • selectively offer screening to all with risk factors • offer screening to all • if screening do so between 24-28 weeks • RWH screen all women at 26 weeks

  25. Prevention of Early Onset GBS • Swabs should be taken between 35-37 weeks’ III • Intrapartum antibiotics recommended if • <37 weeks’ • ruptured membranes >18 before delivery • maternal temperature 38 C • previous GBS colonisation, bacteruria or infant with GBS III

  26. Antenatal anti-D prophylaxis • Prophylactic Anti-D at 28 and 34 weeks’ gestation • No level I evidence • Level II and III evidence would suggest that the 1.5 percent immunisation rate could be reduced to 0.1-0.2% through antenatal prophylaxis (Huchet et al, 1987;Bowman and Pollock, 1978; Hermann et al, 1974) • www.health.gov.au/nhmrc/publications/pdf/wh27.pdf

  27. Investigation: • routine test: • Blood group and Rh type ( if positive, appropriate management) • CBC • Urine analysis- to prevent UTI affecting pregnancy) • MSU • HBs Ag ( if a mother has it, 70-90% chance of foetus getting it, • 90% chance of being chronic carrier. Prevent by treating newborn • of HBs AG+ve mother with B immune globulin and hep B vaccine) • Rubella • Syphilis • U/S: • Determine foetal crown rump length and thus gestational age • Identify multiple gestation • Identify gross abnormalities/ markers of genetic disease. • Cervical cytology

  28. 2-Screening tests: Anaemia Gestational DM (best carried out between 24 and 28 weeks, observe 1 hr after 50g glucose solution. A reading of 126 mg/dl or greater is abnormal, according to the amended WHO recommendations 1999 regarding DM, as is HbAlc of greater than 90%. In these cases proceed to glucose tolerance test) Antibodies Triple test: Alpha feto protein in normal serum, oestriol, HGG ( to detect neural tube defect or chromosomal defect, 16-18 weeks) Hb electrophoresis Tuberculin skin testing Urine culture- for glucose, ketones and protein, bacilli Cervical culture: N gonorrhoea, group B streptococci, Chlamydia trachomatis, Mycoplasma hominis Toxoplasma antibody test HIV

  29. HIV: Voluntary Counseling and Testing • Voluntary HIV counseling and testing should be available to every pregnant woman--for public health reasons as well as for the benefit to the individual woman. • Pre and post-test counseling is an essential part of managing HIV in pregnancy. Source: WHO and UNAIDS 1999.

  30. Benefits of Voluntary HIV Counseling and Testing • If the HIV test is positive, the woman can get early counseling and treatment • Allows appropriate follow-up and treatment of child • Enables a woman to make decisions regarding continuation of the pregnancy and future fertility • May allow the institution of anti-retroviral (ARV) therapy Source: WHO and UNAIDS 1999.

  31. Benefits of Voluntary HIV Counseling and Testing continued • Provides the opportunity to implement strategies that attempt to prevent transmission to the child • Can inform partner and enable him to get counseling and testing • Women can take precautions to prevent transmission to partners • If the HIV test is negative, the woman can be guided in appropriate HIV prevention Source: WHO and UNAIDS 1999.

  32. Syphilis • Maternal-fetal transmission may be as high as 80%. • Incidence of adverse effects on the fetus/infant due to untreated maternal syphilis reported in some studies was: • Spontaneous abortion – 20% • Perinatal death – 30% • Congenital syphilis – 25% Source: WHO 1991.

  33. Syphilis continued • A study in Zambia found syphilis to be the single most common cause of fetal wastage. The adverse outcomes of syphilis were halved by a fairly incomplete program of screening and treatment. Sources: Hira et al 1990; Tinker and Koblinsky 1993.

  34. Syphilis continued • Even where prevalance is relatively low (i.e., as in most industrialized countries) an antenatal syphilis screening program is a cost-effective intervention. • Initiation of treatment should occur at the same visit as the screening. Source: Wang and Smaill 1989.

  35. Tuberculosis • Infants born to women with tuberculosis (TB) have an increased risk of morbidity and mortality in the neonatal period. Source: Figueroa-Damian and Arredondo-Garcia 2001.

  36. Severe anemia • Mild or moderate anemia is not correlated with adverse pregnancy outcomes • Severe anemia, however, (hgb <7 g/dL or hct <20%) is associated with increased preterm delivery, inadequate intrauterine growth, increased perinatal mortality and increased maternal mortality.

  37. Severe anemia continued • Providers can screen for anemia by • Hemoglobin (hgb) by thin film/smear • Hematocrat (hct) test • Hemoglobin Color Scale, or • Clinical observation of the inferior conjunctiva of the eye, the nail beds and the palm. If any of these are pale, the woman is severely anemic. • Other symptoms include shortness of breath and signs of heart failure.

  38. Tetanus Toxoid • Tetanus toxoid is • An effective, stable, cheap toxoid which has been available for > 50 years and is produced in many developing countries. • Effective in preventing neonatal tetanus (NNT), which causes approximately half a million deaths/year) and maternal tetanus, which is estimated to cause 30,000 deaths annually. Sources: Fauveau V et al 1993; Bennett JV 2000.

  39. Iron Deficiency • Globally among all populations, iron deficiency (and its manifestation in anemia) is the single most prevalent nutrient deficiency condition. The World Health Organization (WHO) estimates put anemia prevalence at 52% among pregnant women. Source: MotherCare, John Snow, Inc. 2000.

  40. Iron Folate Supplements • The International Nutritional Anemia Consultative Group, WHO and UNICEF have endorsed the following guidelines: • All women should consume daily iron folate supplements for 6 months during pregnancy. • Where anemia prevalence is <40%, women should receive supplements of 60 mg iron and 400 micrograms of folate • In areas where anemia prevalence is high among pregnant women (40%), women should continue the same dosage for 3 months into postpartum. Sources: Stoltzfus and Dreyfuss 1998; McDonagh 1996.

  41. 3-Specific nutritional advice: 0.4 mg Folic Acid per day ( it prevents tube defects) 30 mg ferrous iron 60 mg ferrous iron 2 times a day ( anaemic patients) Supplement copper and zinc in anaemic patients Avoid Vitamin A in huge amounts as it is teratogenic

  42. Nutrition Requirements Good antenatal nutrition includes: • Meeting the caloric needs • Eating foods which supply specific micronutrients • Providing micronutrient supplementation An underweight mother increases the likelihood of a low birth weight (LBW) baby; low iron intake contributes to anemia.

  43. Models of antenatal care • At each visit midwives and doctors should offer information, consistent advice, clear explanations and provide opportunity to ask questions III/IV • More likely to be satisfied with A/N care when perceive care givers are kind, supportive, courteous, respectful, recognise individual needs IV

  44. Complications Cannot Be Reliably Predicted • No formula or scoring system can reliably distinguish those who will develop complications from those who will not.

  45. Complication Readiness is Key to Survival Nepal Study • Less than 50% of families of women who died in pregnancy, delivery or postpartum, recognized the problem. • 36% decided within 2 hours to seek care and get transport. • 15% decided in 2 to 23 hours to seek care and get transport. • 29% made the decision and arranged transport 1 to 8 or more days after recognition of a life-threatening complication. Source: MOH, Nepal 1998.

  46. The interval from onset to death for antepartum hemorrhage can be approximately 12 hours. The interval from onset to death for postpartum hemorrhage can be two hours. The hours required for making arrangements (which could have been made prior to the emergency) may define the line between survival and mortality. Complication Readiness is Key to Survival continued Sources: Maine 1991; MOH, Nepal 1998.

  47. Danger Signals • Families of pregnant women need to know how to recognize the signs of complications as well as what to do and where to get help • In Nepal, less than 50% of families of women who died recognized the problem. Source: MOH, Nepal 1998.

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