Antenatal Care

2. Antenatal Care Introduction The first visit Subsequent visits Screening tests Prenatal diagnosis and ultrasonogram General advice Summary

3. Introduction Objectives education and information screening early identification of complications treatment of complications

4. Introduction Patterns of routine antenatal care for low-risk pregnancy assess the effects of antenatal care programmes for low-risk women three trials, all conducted in developed countries, evaluating the type of care provider Cochrane Database Syst Rev 2001;4:CD000934

5. Introduction Giles 1992 � midwives versus obstetricians, 89 women, cost savings Tucker 1996 � general practitioners and midwives versus shared care, 1765 women, clinical effectiveness and satisfaction Turnbull 1996 � midwives versus shared care, 1299 women, clinical effectiveness and satisfaction

6. Introduction no difference for several outcome variables including caesarean section, anaemia, urinary tract infections and postpartum haemorrhage there is a trend to lower rate of preterm delivery, antepartum haemorrhage, lower perinatal mortality lack of recognition of fetal malpresentations tended to be higher in this group Cochrane Database Syst Rev 2001;4:CD000934

7. Introduction the midwife/general practitioner managed care group had a statistically significant lower rate of pregnancy induced hypertension and pre-eclampsia overall, it appears that satisfaction with midwife/general practitioner managed care was similar or higher (in some variables) Cochrane Database Syst Rev 2001;4:CD000934

8. Introduction the midwife/general practitioner managed care group had a statistically significant lower rate of pregnancy induced hypertension and pre-eclampsia overall, it appears that satisfaction with midwife/general practitioner managed care was similar or higher (in some variables) Cochrane Database Syst Rev 2001;4:CD000934

9. Introduction Shared antenatal care between Family Health Services and Hospital(Consultant) Services for Low Risk Women decrease in workload to hospital clinics diagnosis of IUGR, malpresentation, pregnancy induced hypertension improved number of NST, hospital admission, duration of stay reduced Chan FY et al 1993 Asia-Oceania J Obstet Gynaecol 19(3):291-298

10. Antenatal Care Introduction The first visit Subsequent visits Screening tests Prenatal diagnosis and ultrasonogram General advice Summary

11. The first visit timing history physical examination risk determination

12. The first visit Timing pregnancy test positive within a few days after missed period early pregnancy complications like miscarriages, ectopic pregnancy may be first diagnosed in the clinic

13. Guidance on Ultrasound Procedures in Early Pregnancy Royal College of Radiologists, Royal College of Obstetricians and Gynaecologists 1995

14. What should be reported number of sacs and mean gestation sac diameter regularity and outline of the sac presence of any haematoma presence of a yolk sac presence of a fetal pole CRL presence/absence of fetal heart movement extrauterine observations should include the appearance of the ovaries, the presence of any ovarian cyst or any findings suggestive of an ectopic pregnancy

15. Miscarriage Silent miscarriage sac diameter >20 mm with no evidence of embryo or yolk sac CRL >6 mm with no evidence of cardiac pulsation if sac diameter <20 mm or CRL < 6 mm, repeat at least 1 week later

16. Miscarriage Incomplete miscarriage thick irregular echoes in the midline of the uterine cavity differential diagnosis: blood clots

17. Miscarriage Complete miscarriage well defined regular endometrial line reliability: 98%

18. Ectopic pregnancy live embryo within a gestational sac in the adnexa - gold standard poorly defined tubal ring presence of varying amount of fluid in the Pouch of Douglas

19. Ectopic pregnancy may be normal in up to a quarter of patients enlarged but empty uterus with or without an adnexal mass and/or fluid in the Pouch of Douglas early diagnosis of normal intrauterine pregnancy in transvaginal scan complex adnexal mass seen in 7% of patients with normal intrauterine pregnancies

20. The first visit Early Pregnancy Assessment Unit Streamline the management of women with early pregnancy bleeding or pain Reduce the admission time

21. The first visit timing history physical examination risk determination

22. The first visit Is routine antenatal booking vaginal examination necessary for reasons other than cervical cytology if ultrasound examination is planned? 11622 consecutive case records abstracted retrospectively If ultrasound is planned has few advantages beyond the taking of a cervical smear O�Donovan et al 1988 Br J Obstet Gynaecol 95:556-9

23. The first visit Routine vaginal examination at antenatal booking reasonable to reserve VE at the booking antenatal clinic for women with a clinical indication, such as pain, bleeding or vaginitis who have not had a satisfactory smear within the past 3 years Lancet 1988:432-3

24. The first visit Pitfalls associated with cervical screening during pregnancy sampling difficulty because of enlargement of cervix, increased mucous secretion and increased difficulty in viewing the cervix(Cronje et al 2000 Int J Gynecol Obstet 68:19-23) cytological diagnostic pitfalls unique to this population(Michael & Esfahani 1997 Diagn Cytopatho 17:99-107)

25. The first visit timing history physical examination risk determination

26. The first visit Risk scoring system difficult to make quantitative estimates of the exact risk associated with a given factor validity of adding weighed scores difficulty in definition of risk factors more predictive of outcome in second or late pregnancies

27. The first visit Risk scoring system both the positive(10-30%) and negative predictive values of all scoring systems are poor risk of increase in intervention may help to provide a minimum level of care and attention in settings where these are inadequate

28. The first visit Modified McGill�s score with score 2 and above will be seen at TYH Demographic Obstetrical history Habits Growth Medical problems Current pregnancy

29. Modified McGill Score(1) Demographic age <16(1) parity >5(1) weight <38 kg(1) weight >70 kg(1) unstable family(2)

30. Modified McGill Score(2) Obstetric History perinatal death(2) SGA/LBW baby(2) gestational proteinuric hypertension(2) abruptio placentae(2) previous caesarean section(1) infertility(1) IGT/GDM(1)

31. Modified McGill Score(3) Habits smoking(1) alcohol(1) drug addiction(2) Growth discrepancy >2 weeks(2)

32. Modified McGill Score(4) Medical problems recurrent UTI(2) impaired renal function(2) heart disease(2) essential hypertension(2) severe respiratory disease(2) diabetes mellitus(2) hyperthyroidism(2) jaundice(2) other major disease(2)

33. Modified McGill Score(5) Current pregnancy recurrent vaginal bleeding > 12 weeks(2) anaemia <10 g(1), <9 g(2) hypertension(2) hydramnios(2) oligohydramnios(2) multiple pregnancy(2) Rh negative mother(2)

34. Antenatal Care Introduction The first visit Subsequent visits Screening tests Prenatal diagnosis and ultrasonogram General advice Summary

35. Subsequent visits Patterns of routine antenatal care for low-risk pregnancy in developed countries with well established obstetrics services, small reductions in the number of prenatal visits (equal or less than two visits) are compatible with similar good perinatal outcomes women may be somehow disappointed with fewer visits Cochrane Database Syst Rev 2001;4:CD000934

36. Subsequent visits Patterns of routine antenatal care for low-risk pregnancy in developing countries, in which a proportionally major reduction in the number of visits was achieved, also supports this conclusion in the light of the available evidence, the four antenatal care visits schedule tested in the largest trials appears to be the minimum that should be offered to low risk pregnant women. Cochrane Database Syst Rev 2001;4:CD000934

38. Subsequent visits every 4 week till 28 weeks every 2 week till 36 weeks every week till delivery

39. Subsequent visits Fundal height for IUGR high specificity moderate sensitivity high negative predictive value only one randomized trial � �unwise to abandon�(Cochrane Database Syst Rev. 2000;(2):CD000944)

40. Antenatal Care Introduction The first visit Subsequent visits Screening tests Prenatal diagnosis and ultrasonogram General advice Summary

41. Screening tests Hb � at booking and at 30-32 weeks Rh � for isoimmunisation rubella immune status VDRL HbsAg status cervical smear MCV

44. Screening tests HIV opt-out screening since 1/9/2001 information to be given HIV is the virus causing AIDS but HIV infection may not lead to AIDS till years later positive result means infection; although there is no cure but treatment can delay the onset of AIDS

45. Screening tests HIV information to be given mother to baby transmission occurs in 15-40% and treatment can reduce the chance window period confidentiality

46. Screening tests Results of the first 3 months 10238 tests were performed 4% chose not to be tested 6 positive results

47. Screening tests Biochemical screening for Down�s Syndrome 97% of Down syndrome pregnancies are sporadic age as screening test is not sensitive AFP and HCG for screening between 15-20 weeks improves the sensitivity(screen positive rate of 5% or less, sensitivity of 60-70%)

48. Screening tests Biochemical screening for Down�s Syndrome value of addition of oestriol controversial role of nuchal lucency measurement

49. Screening tests Gestational diabetes increase in perinatal mortality associated with abnormal glucose tolerance appears to be predicted as much by the indication for glucose tolerance testing no convincing evidence that treatment of women with an abnormal glucose tolerance test will reduce perinatal mortality or morbidity no benefit has been established for glucose screening

50. Screening tests Gestational glucose tolerance screening at TYH 75 g OGTT for those with risk factors spot glucose screening using cut off of more than 5 mmol/l(more than) or 5.8 mmol/l(less than 2 hours after meal) for those without risk factors

51. Screening tests Urine culture reduce the risk of pyelonephritis if followed by single dose therapy if culture not available, can be screened by a urine dipstick multiple test for leucocyte esterase and nitrite

52. Screening tests Other screening tests Group B streptococcus Bacterial vaginosis ��

53. Antenatal Care Introduction The first visit Subsequent visits Screening tests Prenatal diagnosis and ultrasonogram General advice Summary

54. Prenatal diagnosis and ultrasonogram Referral to Prenatal Diagnosis and Counselling Department advanced maternal age hereditary disease maternal exposure to teratogen previous abnormal children abnormal screening test suspected fetal abnormality

55. Prenatal diagnosis and ultrasonogram Possible merits of USG confirmation of the term date if performed before 24 weeks assessment of term date when history is unreliable detection of malformation detection of multiple pregnancy

56. Prenatal diagnosis and ultrasonogram Possible merits of USG placenta localisation sex of child others: some chromosome disorders, fetal death, ectopic pregnancy, molar pregnancy

57. Prenatal diagnosis and ultrasonogram screening does not improve the outcome of pregnancy in terms of live births and morbidity reduced incidence of induction of labour for apparent post-term pregnancy twin pregnancies are detected earlier no clear evidence of harm ?increase in left handedness

58. Antenatal Care Introduction The first visit Subsequent visits Screening tests Prenatal diagnosis and ultrasonogram General advice Summary

59. General advice Major difference of RDA in pregnancy Calorie 150 kcal more in first trimester, 350 kcal more subsequently Protein 60g (44 g in non-pregnant) Folate 400 ug (180 ug in non-pregnant) Calcium 1200 mg (800 mg in non-pregnant) Iron 30 mg (15 mg in non-pregnant)

60. General advice 236 ml of milk contains 146.3 kcal 7.3 g protein Ca 259.6 mg

61. General advice Iron and folate supplement clear evidence of an improvement in haematological indices in women receiving routine iron and folate supplementation in pregnancy no conclusions can be drawn in terms of any effects, beneficial or harmful, on clinical outcomes for mother and baby as available data are often from single small trials (Cochrane Database Syst Rev 2002 Issue 1)

62. General advice Iron and folate supplement at present, there is no evidence to advise against a policy of routine iron and folate supplementation in pregnancy routine iron and folate supplementation could be warranted in populations in which iron and folate deficiency is common. (Cochrane Database Syst Rev 2002 Issue 1)

63. General advice Incidence of anaemia 1990-1992 7.5% of patients with anaemia 54.8% had thalassaemia 42.6% classified as iron deficiency (Lao & Pun 1996 Eur J OG Reprod Bio 68: 53-8)

64. General advice Effect of folate supplement on pregnant women with beta-thalassaemia minor Patients who received 5 mg folate daily showed a significant increase in predelivery Hb concentration Does not influence obstetric performance (Leung et al 1989 Eur J OG Reprod Bio 33:209-13)

65. General advice Smoking 5-15 minutes Office based intervention increased cessation by 30-70% use of nicotine replacement products or other pharmaceuticals as smoking cessation aids during pregnancy has not been sufficiently evaluated (ACOG Education Bulletin #260)

66. General advice Alcohol known teratogen heavy maternal use is related to fetal alcohol syndrome moderate use may be related to spontaneous abortions and to developmental and behavioural dysfunction in the infant

67. General advice Alcohol should limit to no more than 2 drinks daily(1 ounce or 30 ml of absolute alcohol) (Am Council on Science and Health) a drink- 12 ounces(350 ml) of regular beer (150 calories) 5 ounces(150 ml) of wine (100 calories) 1.5 ounces(45 ml) of 80-proof distilled spirits (100 calories) safest course is abstinence

68. General advice Coffee amount of caffeine in commonly used beverages varies widely caffeinated coffee (66-146 mg) non-herbal tea(20-46 mg) caffeinated soft drinks (47 mg)

69. General advice Coffee when used in moderation, no association with congenital malformation, miscarriage, preterm birth and low birth weight has been proven high dose may be associated with miscarriage, difficulty in becoming pregnant and infertility

70. General advice Seat belt above and below the bump, not over it three-point seat belts should be worn throughout if necessary, the seat should be adjusted (Why mothers die: a report on confidential enquiries into maternal deaths in the UK 1997-1999)

72. General advice Air bag potential concern: the proximity of the gravid uterus to the deploying air bag creates an increased risk of fetal death benefits appear to outweigh risks in pregnant women further study be done (National Conference on Medical Indications for Air Bag Disconnection 1997)

74. General advice Air travel can fly safely up to 36 weeks(ACOG Committee Opinion 2001 #264) prevention of deep vein thrombosis general � isometric calf exercise, walking around, drink water/juices/soft drinks, avoid alcohol and caffeine ?compression stockings if over 3 hours (RCOG Scientific Advisory Committee 2001 #1)

75. General advice Exercise 30 minutes or more of moderate exercise a day should occur on most, if not all, days of the week pregnant women also can adopt this recommendation (ACOG Committee Opinion 2002 #267)

76. General advice Warning signs to terminate exercise while pregnant vaginal bleeding dyspnea prior to exertion dizziness headache chest pain muscle weakness calf pain or swelling preterm labour decreased fetal movement amniotic fluid leakage (ACOG Committee Opinion 2002 #267)

77. General advice Exercise avoid motionless standing avoid sports with high potential for contact, risk of falling, abdominal trauma, scuba diving avoid supine position after first trimester (ACOG Committee Opinion 2002 #267)

78. General advice Work most jobs cause no increased hazard to the mother or baby should be warned that if any complications arise she must be able to leave work easily specific hazards � chemical, physical, biological, others (Chamberlain & Morgan 2002 in ABC of Antenatal Care)

79. General advice Umbilical cord blood banking routine directed commercial cord blood collection and stem-cell storage cannot be recommended because of insufficient scientific base to support such practice and the attendant logistic problems of collection collection of altruistic donations and directed donations for at risk families remain acceptable procedures (RCOG Scientific Advisory Committee 2001 #2)

80. Summary(1) family physicians should be involved in the provision of antenatal care in low risk patients early pregnancy complications are more commonly seen in primary care settings vaginal examination is not necessarily an integral part of antenatal care fundal height is probably useful for detecting IUGR

81. Summary(2) MCV and HIV tests are integral part of antenatal screening test urine culture and biochemical screening can be considered routine USG is useful in confirming the gestational age and detecting multiple pregnancy

82. Summary(3) additional 1-2 servings of milk should cover the additional nutritional need of pregnancy routine prescription of iron and folate is a reasonable practice additional folate supplement in thalassaemic patients can reduce anaemia seat belt should be worn and air bag should not be deactivated

83. Summary(4) usual exercise and work should not be affected commercial cord blood collection and stem-cell storage should not be recommended