Antenatal Care

By Dr.Hind Sabah Ideally ,antenatal care should begin before pregnancy.Organogenesis begins early in pregnancy,&placental development starts with implantation at 7 days postconception .By the time most pregnant women have their first antenatal visit ,it is often too late to prevent birth defects or . defective placental development The importance of woman's health before pregnancy has drawn increasing attention to preconception care which is defined as (set of interventions that aim to identify & modify biochemical ,behavioural & social risks to mother's health &pregnancy .outcome Preconception care is probably more than a single visit before pregnancy because most of the pregnancies in our country are unplanned ,so the PCC should be provided for every woman of .reproductive age

MAJOR COMPONENT OF PRECONCEPTION COUNCELLING & CARE :A)Reproductive life plan Ask your patient if she has plans to have any (more) children & how long the spacing between pregnancies & .(help her to achieve this goal (providing contraception :B)Past reproductive history Review prior adverse pregnancy outcomes , such as fetal loss ,birth defect, ,preterm birth & assess for ongoing

risks that could lead to recurrence in subsequent .pregnancy :C)Past medical history Such as congenital heart dis. , thromboembolism autoimmune dis.that could affect future pregnancy. Screen for ongoing chronic conditions such as HPT & DM :D)Medications Review current medication use. Avoid teratogenic drugs such as anticancer drugs. Some potentially harmful drugs can be given during pregnancy ,when the benefit outweighs the fetal risk, ex.warfarin. Review use of .over_the_counter medications,herbs,&supplements :E)Infections & immunizations Screen for periodontal , urogenital , STD (syphilis,HIV,hepatitis B ) &screening for TORCH (toxoplasmosis ,rubella ,cytomegalovirus ,herpes ) , as .indicated Update immunization for hepatitis B ,rubella varicella . ,human papillomavirus &influenza virus as needed :F)Genetic screening & family history Assess risk for chromosomal or genetic disorder based on family history ethnic background & age .Discuss management of known genetic disorders such as . galactosemia :G)Nutritional assessment BMI , biochemical assessment (ex. Anaemia), clinical & . dietary risks :H)Substance abuse

.Smocking , alcohol ,&substance abuse :I)Toxins & teratogens Check exposure at home or work :J)Psychosocial concerns Screen for depression , intimate partner violence & major psychosocial stressors :K)Physical examination Focus on periodontal , thyroid , heart , breasts , & pelvic . examination with performing Pap. Smear if due :L)Laboratory tests CBP , GUE , blood group & Rh. Rubella , syphilis , hepatitis B , HIV , screen for gonorrhoea , Chlamydia & diabetes in selected populations. Consider thyroid .stimulating hormone

ANTENATAL CARE
:The aims of ANC are to prevent , detect , & manage those factors that (1 .adversely affect the health of mother & baby .to deal with the minor complaints of pregnancy (2 to provide advise , reassurance , education , & support (3 to the mother & her family . to provide general health screening (4

CLASSIFICATION OF ANTENATAL CARE

a)shared care: provided jointly by maternity hospital team,a general practitioner (GP) &community midwives

b)community_based care:provided by community midwives with variable involvement of GPs in this type of (care (for low risk women c)hospital _based care:structured programme of visits to .a hospital ANC which may well be highly specialized

THE BOOKING VISIT

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The degree of risk in a pregnancy is determined by the use of repeated history Taking , physical examination & investigations . the booking visit can be carried out in hospital or in the community . if risk factor is identified , the woman is . likely to be referred to hospital based or shared care Before the risk assessment begins , the pregnancy should .be confirmed & EDD should be calculated A)confirmation of pregnancy : the symptoms of pregnancy combined with a positive urinary or serum pregnancy test usually sufficient to confirm pregnancy . early US scan can both confirm & .accurately date pregnancy Fetal heart can be heared with Doppler devise from approximately 12 weeks onwards B)dating the pregnancy : a pregnancy can be dated either by using Naegele's rule (states that the EDD is calculated by adding 7 days to the 1st day of the LMP & taking away 3 months . this rule assume a 28 days . menstrual cycle with an accurate LMP Dating scan when the LMP is uncertain or there is menstrual irregularity, a dating scan in the 1 st or .early in the 2nd trimester should be considered

BENEFITS OF DATING SCAN accurate dating of pregnancies in women with (1 menstrual irregularity on un reliable LMP reduce incidence of induction of labour for prolonged (2 pregnancy maximizing the potential for serum screening to (3 detect fetal anomalies early detection of multiple pregnancy (4 detection of otherwise asymptomatic failed (5 intrauterine pregnancy detection of early pregnancy complication as ectopic (6 or molar pregnancy Before 16 weeks gestation , there is minimal variations in fetal size between individual pregnancies ,so the fetal measurements (CRL , BPD ,FL) can be plotted on standard fetal biometry chart with accurate assessment of GA Beyond 20 weeks gestation ,the effects of genes & environment will cause significant variability in fetal size . Dating a pregnancy by US scan therefore become . progressively less accurate as the gestation advances

C)THE BOOKING HISTORY age : women at the extremes of reproductive ages at (1 greater risk of certain pregnancy complications(eg.fetal (chromosomal abnormality in older women race: specific racial groups carry higher sisks of (2 medical conditions(eg.sickle cell anaemia & (thalasaemia

past medical history: pregnant women with other (3 health problems are often managed jointly by obstetricians & physicians in high _risk clinics.the dis. & it's treatment ,may adversely affect pregnancy&fetus (eg.congenital heart dis.,epilepsy). The pregnancy itself may cause improvement (eg.migrane) or deterioration (in the co_existing medical condition (eg.renal failure past obstetrical history : pregnancy complications of (4 most kinds carry a recurrence risk . eg.gestational DM ,cholestasis of pregnancy . details of previous labours & deliveries may also determine choises in the (future (eg.previous C/S previous gynaecological history : a previous history of (5 infertility or recurrent miscarriage may affect .management during pregnancy & labour A history of gynaecological surgery may also be important . a cone biopsy may cause cervical .incompetence or stenosis family history : a no. of medical condition with familial (6 tendencies may complicate the pregnancy (eg.DM , HPT (, thromboembolic dis. & mental handicap social history : smoking , alcohol & substance abuse (7 may adversely affect pregnancy. Social deprivation & . domestic violence ass.with poor pregnancy outcome D)THE BOOKING EXAMINATION For most healthy women without medical complication , :the booking ex. should include the following . BP measurement(1 abdominal examination to record the size of the (2 . uterus

. recognition of any abdominal scars(3 measurement of height & weight for calculation of (4 BMI ,women with low BMI are at more risk of low birth weight &IUGR . Obese women are at greater risks of gestational DM ,preeclampsia ,need for C/S & . anesthetic difficulties Thorough examination must be carried out if there are symptoms of concern, eg . cardiovascular examination . when there is dyspnea or chest pain E)THE BOOKING INVESTIGATIONS full blood count : this screens for anaemia & (1 thrombocytopenia .blood group & Rh(2 rubella screening : rubella non immune women should (3 be advised to avoid contact with affected persons & . advised for immunization after the current pregnancy Hepatitis B : the presence of surface Ag.or 'e' (4 Ag.represent recently affected or carrier status . A baby born to a hepatitis B carrier should be actively & passively immunized . The health provider should take . precautions when dealing with body fluids HIV screen :the department of health guidelines now (5 recommend that all pregnant women should be offered . an HIV test at booking syphilis(6 haemoglobin study : for women who have an ethnic (7 . background or family history

screening for gestational DM : at booking but more (8 usefully performed at 28 weeks ,when the metabolic . changes of GDM become more detectable other routine inv. : cervical smear& vaginal swab are (9 not routine but indicated when the smear is overdue , the pt. is unlikely to attend postnatally , when there is abnormal symptoms as postcoital bleeding or abnormal . cervix on examination

SCREENING OF FETAL ABNORMALITIES

This is a routine aspect of ANC

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A)Screening for Down's syndrome : nuchal translucency US scan(11_13 weeks) & serum screening . (test (15_19 weeks B)NTD ( eg.anencephaly & spina bifida ) screening : by (maternal serum alpha fetoprotein (15_19 weeks C)Anomaly scan : detailed US scan (19_ 22 weeks) for structural congenital abnormality

FOLLOW UP VISITS

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The precise no. of visits is a contentious point & should be tailored to the individual .the minimum no. of visits recommended by the RCOG is five ,occurring at 12 , 20 , 28_32 , 36 & 40_41 weeks .A common pattern of ANC adopted in their first pregnancy is (4_ weekly visits from 20 weeks until 32 weeks , followed by fortnightly visits from 32 _36 weeks of pregnancy & weekly visits . thereafter

THE CONTENT OF FOLLOW _ UP VISITS

general questions regarding maternal well_ being (1 (enquiry regarding fetal movement (from 24 weeks (2 BP reading(3 urinalysis : for protein , blood & glugose (4 examination for oedema : common in pregnancy (in 80 (5 % of normal pregnancies )& insensitive marker for preeclampsia abdominal palpation for fundal height : if serially (6 done , it can detect abnormality in fetal growth & in . liquor volume auscultation of fetal heart : for reassurance (7 a full blood count & red cell antibodies screening is (8 . repeated at 28 & 36 weeks screening for gestational DM : at 28 weeks of (9 . gestation from 36 weeks ,fetal lie , presentation & engagement (10 should be assessed to decide the mode of delivery at 41 weeks of pregnancy , discussion regarding the (11 merits of induction of labour should occur because of . increase in perinatal morbidity & mortality

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