Antenatal Care

OBJECTIVES

• Antenatal education
  • Provision of information
  • Lifestyle concerns
  • Common symptoms
  • Counseling for screening tests
• Identification of pre-existing health or social problems à Risk categorization
• Screening for maternal problems
• Screening for fetal complications

       – Downs            – Anomaly        – Wellbeing

THE PRINCIPLES OF ANTENATAL CARE FOR WOMEN WITH UNCOMPLICATED PREGNANCIES

• Provide advice
• Education
• Reassurance and support
• To address and treat minor problems arising during pregnancy
• To provide effective screening during the pregnancy
• To identify problems as they arise with referral when appropriate.

RECOMMENDED ANTENATAL VISITS – Parous with an uncomplicated pregnancy

12 weeks

16 weeks – To discuss the results of screening tests

20 weeks – Anomaly scan

28 weeks – Antibodies, anaemia

34 weeks – Review results and RhD

36 weeks – Fetal presentation

41 weeks – Induction

FOR NULLIPAROUS ADDITIONAL APPOINTMENTS AT

25 weeks

31 weeks

40 weeks

• All eligible couples should be registered in the eligible couple register (H 526) by the area PHM
• All women who are getting pregnant are assumed to have pre-pregnancy care (Rubella immunization, preconception folic acid supplementation, screening for medical condition and nutritional assessment and if required necessary family planning services).
• During pre-pregnant care, couples should be educated regarding pregnancy symptoms & importance of early initiation of antenatal care.
• In Sri Lanka, antenatal care provides through clinic care and domiciliary care.
• Antenatal care consists of:
  • Assessment
    • Maternal risk factors
    • Ongoing assessment of maternal & fetal well-being
    • Screening for maternal complications
  • Care provision
  • Health promotion
• Following the registration at the clinic or at home, pregnant mother should receive the clinic  antenatal care as early as possible, preferably around 6-8 weeks of gestation (BOOKING VISIT)

OBJECTIVES OF THE BOOKING VISIT

1. To provisional establishment of pregnancy (either clinically/ with laboratory testing)

2. To assess medical and obstetric risk factors and take necessary actions

3. To assess the psychological/nutritional status and take necessary actions

4. To provide necessary care and health promotion

5. Screening for anaemia, syphilis and testing for blood group and Rh

6. Check for dental conditions and appropriate referral

7. Examination of heart to identify heart diseases

DIAGNOSIS
Pregnancy test – U.Hcg
AT BOOKING DATING – Reduce incidence of induction of labour for prolonged pregnancy??
Best between 11 – 13+6 weeks – CRL (45-84mm) After 14 weeks – HC / BPD (If CRL > 84mm) IUPViabilityConfirm datesNumber of pregnancyNTMajor anomalies- anencephaly (if before 9 weeks acrania),neural tube defects, major cardiac anomalies, anterior abdominal wall defects
TESTING
Urine		Asymptomatic bacteriuria (UFR + midstream U.Culture & ABST) à  reduces risk of pyelonephritis Glucose (Benedicts test)/Protein (coagulation test) – Strip if available   Coagulation test for protein Necessary equipment:  Clean bottle, two test tubs, Spirit Lamp, Test tube holder, Acetic acid, pipette Procedure Collect urine into a clean bottle & fill 2/3 of test tube with collected urine  Heat the upper part of the tube till urine gets boiled If the heated part gets cloudy, add 4 – 5 drops of acetic acid & heat again. If cloudiness disappears it is due to urinary PO4-3 & it is not significant. If the cloudiness continues it is due to urinary albumin.  Results should be as follows Negative Trace Positives + 1 to + 4   Benedict’s test for urine sugar Necessary equipment: as for heat test and   Benedict’s reagent Procedure: Put 2.5 ml of Benedict’s solution to a test tube. Add 8 drops of urine. Heat this mixture for 2 minutes. Put the tube in the test tube holder till the tube gets cooled. Colour of urine will change from green to brick red depending on the amount of sugar in urine. Results should be as follows Negative – clear blue  If present – Green , Yellow, Orange, Brick red
Anaemia		FBC (Repeat again at 28 and 36 weeks)
Diabetes		Screening test at booking visit & (3 Point OGTT – @ 24-28 wks to all (SL) Risk based – in UK If Previous GDM àearly self monitoring of blood glucose/75g OGTT 2hr value as soon as possible after booking If  1st one negative GTT or If other risk factors – test at 24-28 weeks
Blood grouping Red cell alloantibodies		Blood group & Rh Atypical red-cell alloantibodies (@ 28 weeks),regardless of Rh D status Rh D-negative, consideration should be given to offering partner testing to determine whether administration of anti-D prophylaxis is necessary
Infections		Rubella antibody status – 2% non-immune in UK Hep B HIV Syphillis – VDRL At1st visit preferably 6-8 weeks to prevent congenital infection. For high risk mothers, re- testing should be offered in T3 BV    – Routine screening not recommended    – Identification & Rx of asymptomatic BV does not lower risk of preterm         birth & other adverse reproductive outcomes. GBS, Hep C, toxoplasmosis, or CMV – not recommended
IDENTIFYING RISK FACTORS
Preterm birth		Routine screening for preterm labour should not be offered
Risk for VTE
Increased risk for pre-eclampsia		Major risk factors Hypertensive disease during a previous pregnancy Chronic kidney disease Autoimmune disease such as SLE / APLSType 1 or type 2 diabetes Chronic hypertension Moderate risk factors include: First pregnancy Age 40 years or older Pregnancy interval of more than 10 yearsBody mass index (BMI) of 35 kg/m2 or more at first visitFamily history of pre-eclampsia Multiple pregnancy 1  MAJOR RISK FACTORS OR ≥2 MODERATE RISK FACTORS à START ASPIRIN 75MG FROM 12 WEEKS TILL DELIVERY
SGA
GDM			Risk factors for gestational diabetes Body mass index above 30 kg/m2 (In SL )Previous macrosomic baby weighing 4.5 kg or abovePrevious gestational diabetes Family history of DM (1st-degree relative with -diabetes) Family origin with a high prevalence of diabetes: South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh)             Risk factors according to SL maternal care package   75g 2hr OGTT – UK If Previous GDM – test at 16-18 weeks If other risk factors – test at 26-28 weeks
Screening for mental health problems			At booking (again postnatally), 2 screening questions are asked of all pregnant women: During the past month, have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things? Edingburgh Postnatal Depression Scale (EPDS) à PP
LIFE STYLE CHANGES
BMI & Weight gain
Diet	Beware of food born infections Listeriosis: drinking only pasteurised milkSalmonella: avoiding raw/partially cooked eggs/meat, especially poultry Food hygiene
Exercise	Moderate course of exercise is not associated with adverse outcomes 30 minutes daily Including pelvic floor exercises Avoid scuba diving – increase anomaly and fetal decompression disease Potential dangers of certain activities during pregnancy (contact sports, high-impact sports and vigorous racquet sports that may involve the risk of abdominal trauma, falls or excessive joint stress)
Alcohol	Avoid alcohol in T1 – increased risk of miscarriage Not drink >2 units/weeks àno evidence of harm to unborn baby
Smoking	Avoid in pregnancy MiscarriagePreterm birthSGA/low birth weightAbruptionPerinatal mortality Sudden infant death
Working	It is safe to continue working during pregnancy Avoid radiation exposure
Travel	Avoid >37 weeks singleton or >32 weeks with risk factors >4hrs – Thromboprophylaxis, wearing compression stockings
COMPLEX SOCIAL ISSUES
Teenage pregnancy
Domestic violence	25% of women suffer domestic violence 17% in pregnancy
SUPPLEMENTATION
Folic acid	400µg daily 3/12 before conception & throughout 1st 12 weeks, reduces risk of having a baby with a NTD (anencephaly or spina bifida) Consider 5mg if Past history of neural tube defect child or they themselves havingObese > 30 Kg/m2DMCoeliac diseaseOn anticonvulsantsThalassemia/sickle cell anaemia Continue at least 12 week, then reduce to 1mg/day (SL) Continue >5 mg throughout pregnancy – lower psychomotor development & ?? hyperactive children or autism à few recent studies – emerging evidence
Iron	Routine iron supplementation not recommended But for haematological or biochemical evidence of iron deficiency 200 mg feSO4 on alternate day is as effective as once or twice daily dosing   Vitamin C
Calcium
Vitamin A	(Intake >700 µg) might be teratogenic Affect cranial neural crest cell Liver & liver products may also contain high levels of vitamin A & therefore consumption of these products should also be avoided
Vitamin D	10 µg/day in high risk women Obese > 30 Kg/m2Women with darker skin (African, African–Caribbean / South Asian)Limited sun exposure (housebound/confined indoors for long periods/ who cover their skin for cultural reasons)Diet low in Vit-D rich foods (Eggs, meat)
EDUCATION
	Minor illness in pregnancy Nausea & vomiting Varicose veins Vaginal discharge Backache Labour Pain relief Breastfeeding
2ND TRIMESTER / 3RD TRIMESTER ASSESSING ONGOING RISK
BP Monitoring U.analysis (Protein)				Each clinic visits Each clinic visits
SFH Abdominal palpation				Size – from 24 weeks, plot in customized chart Height ,weight, ethnicity, parity, fetal sex +/- 2cm à 20 to 36 weeks, +/- 3cm à after 36 weeks Sensitivity 30% At 36 fetal lie and presentation Head engagement in T3 Gently palpate with 2 hands pacing down over abdomen than to prod around with Paulik’s grip, which in non-experienced hands is painful.
USS				Routine USS in uncomplicated women is not recommended Routine Doppler should not be used in low-risk pregnancies Suspected malpresentation should be confirmed by USS assessment
Fetal movements				Routine formal fetal-movement counting should not be offered KCC from 36 weeks A kick count chart may be reassuring to a mother Others may find kick charts time consuming, bothersome &stressful, particularly if their baby doesn’t move Most common types of kick charts – ‘Cardiff count to ten’ method Should use 8-12 hr period to record at least 10 baby’s movements Mother should choose a time when she thinks her baby is most active If baby has at least 10 movements within 12 hour period they are thought to be well If mother use this method – should start timing at same time each day If mother feels more kicks at one moment consider it as a one  kick 10 movements for a day is enough for the day. The time period between 2 kicks should less than 3 hours
ANOMALY SCAN
18+0 to 20+6 weeks Fetal anomaliesPlacental location If low-lying placentas detected àshould be offered another TAS at 32 weeks If TAS is unclear, a transvaginal scan should be offered
SCREENINGS
GDM				OGTT at 26-28 weeks
Anaemia				FBC at 28 week (in twin – also between 20-24 weeks) ( 11 g/dl at first contact and 10.5 g/dl at 28 weeks)
Red cell antibodies				At 28 week
INTERVENTIONS
Anthelminthic				Mebendazole just after completion of 12 weeks of POA O.Mebendazole 100mg  twice a day for 3days/500 mg as single dose Should be informed regarding other preventive methods of worm infestations ( use of sleepers, proper construction and use of toilets, use of safe water, washing hands before meals & after toileting)
Tetanus toxoid				Tetanus is a fatal infectious disease Caused by toxigenic strains of Clostredium Tetani Neonatal tetanus have reached elimination levels in SL AIM: To prevent neonatal tetanus Chemically inactivated tetanus toxin which could induce production of antibodies against tetanus toxin Available as Monovalent tetanus toxoid (TT)Pentavalent vaccine – combined diphtheria, pertussis, tetanus, hepatitis B and HibCombined diphtheria and pertussis, tetanus vaccine (DPT)Combined diphtheria, tetanus vaccine (DT)Adult tetanus diphtheria vaccine (aTd) Immunization from infancy up to adolescence Immunization during pregnancy Number of doses required & timing of boosters during pregnancy will depend on past immunization history of the pregnant mother with tetanus containing vaccines Immunization of pregnant mothers who have not received tetanus containing vaccines in infancy & childhood as per EPI Pregnant mothers, who have received 5 doses of TT during previous pregnancies, do not need further booster doses of TT during subsequent pregnancies. Immunization of pregnant mothers who  received tetanus containing vaccines as per the national EPI schedule
Malaria				Low prevalent disease in Sri Lanka It is not recommended the routine prophylaxis           At the booking visit, all pregnant mothers in endemic areas should be tested for malaria using a blood smear Prophylaxis Chloroquine 300mg (2 tablets) weekly after meal during T2 & T3 and 42 days after delivery Treatment Day 1 – Chloroquine 600mg (4 tablets) Day 2 – Chloroquine 600mg (4 tablets) Day 3 – Chloroquine 300mg (2 tablets) After that Chloroquine prophylaxis should be continued the rest of the pregnancy and postpartum period Primaquine should not be given during pregnancy & postpartum After initiation of Rx, repeat blood smears should be examined on day 3, day 14 and day 28 to assess the efficacy of the treatment.
Routine anti -D prophylaxis				Single dose at around 28 wks (1500 IU between 28 & 30 weeks) Two doses à 500 IU at 28 and 34 weeks
BEFORE OR AT 36 WEEKS
Breastfeeding information, including technique and good management practices Preparation for labour and birth, including information about coping with pain in labour & birth plan Recognition of active labour Care of the new baby Vitamin K prophylaxis Newborn screening tests Postnatal self-care Awareness of ‘baby blues’ and postnatal depression.
Induction of labour
From 41 week, complete by 42 weeks

•  
• Medical problems
• Clinical examination
• CVS/RS/ Breast/PV – not routinely needed
• Cervical smears can be delayed. If suspicious refer to colposcopist

Weight and height measured

BMI < 20 (high risk of SGA) – needs repeated weighing

BMI > 30 – repeated weight each trimester

Normal BMI – No need of repeated weighing unless there is suspicious of significant weight gain

Downs screening

• Combined screening is offered from 11 to 13+6
• If book later – most clinically and cost-effective serum screening test (triple or quadruple test)
  • Next best test if combined screening has not been possible
  • Offered from 15 to 20 weeks
• The cut-off for all screening tests is 1 in 150 (this means that women with a 1 in 150 chance or greater of having a baby with Down’s syndrome should be offered diagnostic testing)
• Diagnostic tests offered should be CVS (chorionic villus sampling) in the first trimester and amniocentesis in the second trimester
• Confirmatory tests (QF-PCR) should be offered to allow a diagnosis to be accurately & quickly establish
• Routine anomaly scan (at 18+0 to 20+6 weeks) should not be routinely used for Down’s syndrome screening using soft markers
• Presence of an isolated soft marker, with the exception of increased nuchal fold, on the routine anomaly scan, should not be used to adjust the a priori risk for Down’s syndrome
• Presence of an increased nuchal fold (≥ 6 mm) or ≥2 soft markers on routine anomaly scan should prompt offer of a referral to a fetal medicine specialist or appropriate healthcare professional with a special interest in fetal medicine

WOMEN REQUIRING ADDITIONAL CARE

• Cardiac disease, including hypertension
• Renal disease
• Endocrine disorders or diabetes requiring insulin
• Psychiatric disorders (being treated with medication)
• Haematological disorders
• Autoimmune disorders
• Epilepsy requiring anticonvulsant drugs
• Malignant disease
• Severe asthma
• Use of recreational drugs such as heroin, cocaine (including crack cocaine) and ecstasy
• HIV or HBV infection
• Obesity (BMI ≥30 kg/m2) or underweight (BMI < 18 kg/m2) at first contact
• Higher risk of developing complications, for example, women aged 40 and older, women who
• Smoke
• Women who are particularly vulnerable (such as teenagers) or who lack social support.

Women who have experienced any of the following in previous pregnancies:

• Recurrent miscarriage (three or more consecutive pregnancy losses or a mid-trimester loss)
• Preterm birth
• Severe pre-eclampsia, (H) hemolytic anaemia, (EL) elevated liver enzymes, and (LP) low platelet count (HELLP syndrome) or eclampsia
• Rhesus isoimmunisation or other significant blood group antibodies
• Uterine surgery including caesarean section, myomectomy or cone biopsy
• Antenatal or postpartum haemorrhage on two occasions
• Puerperal psychosis
• Grand multiparity (more than six pregnancies)
• A stillbirth or neonatal death1111
• A small-for-gestational-age infant (below 5thcentile)
• A large-for-gestational-age infant (above 95thcentile)
• A baby weighing below 2.5 kg or above 4.5 kg
• A baby with a congenital abnormality (structural or chromosomal)

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