SHP Doctors Guidebook: ANTENATAL CARE

Updated as of June 2013

ANTENATAL CARE

Introduction

SHP provides basic antenatal care for our obstetric patients. Patient with high risk factors ought to be referred to
tertiary centres for follow up. Down syndrome screening should be discussed and referral to tertiary centres will be
needed if patient express interest of such tests.

Antenatal screening test including thalassemia screening must be done and abnormal results dealt with promptly.
Dating and screening ultrasounds should be arranged timely.

Routine Antenatal Care Algorithm

1st Antenatal checkup

- Checklist

High risk pregnancy Refer Tertiary Centre

Keen for Down Syndrome

Screening

Antenatal Blood test (package)

1. Thalassemia screen stage I
( FBC, HbH inclusion bodies) Abnormal Thalassemia screening
**
2. Hep B screening for either partner
3. VDRL
4. HIV
5. Blood group/ rhesus

Husbands MCV < 80 for either partner,

Thalassemia screen stage I proceed to Thalassemia stage 2
screening.**

Ultrasound
1.Dating ultrasound (11-14 weeks, <16
weeks)
2.Screening ultrasound (19-21 weeks)

Subsequent checkup 4 weekly till 28 weeks Refer Tertiary Centre

Blood test
OGTT @24-28 weeks
(for patients with risk factors)

**
Refer to section on thalassemia screening
Strictly for internal circulation only. To the best of our knowledge, the contents and materials featured are not copyrighted.
If you know otherwise, pls contact us at prime@singhealth.com.sg
Pg 195
SHP Doctors Guidebook: ANTENATAL CARE
Updated as of June 2013

First Visit

HISTORY

1. The general well-being of patient

a. nausea/vomiting

2. The present pregnancy

a. Establish last menstrual period (LMP), dating ultrasound should be done for all patients.
b. abdominal pain, PV bleeding

3. Past obstetric history

a. previous obstetric complications eg. miscarriages/abortions, PIH/ pre-eclampsia, gestational
diabetes; previous modes of delivery etc
b. previous fetal anomaly, chromosomal disorder etc

4. Medical and surgical history

a. hypertension, diabetes, thyroid disorders
b. abdominal surgery

PHYSICAL EXAMINATION

1. General oral cavity, pallor, goiter, heart and lungs auscultation, blood pressure, pedal edema

2. Breast examination detection of breast lumps

3. Abdomen fundal height, lie (long, transverse, oblique), presentation (cephalic, breech), engagement,
detection of fetal movement and heart sound

MEASUREMENTS

1. Weight
2. Blood pressure
3. Fundal height
4. Urine dipstix - detection of proteinuria

Strictly for internal circulation only. To the best of our knowledge, the contents and materials featured are not copyrighted.
If you know otherwise, pls contact us at prime@singhealth.com.sg
Pg 196
SHP Doctors Guidebook: ANTENATAL CARE
Updated as of June 2013

Investigations

1. Antenatal Screening Panel, which includes:

a. Thal stage 1 (Consists of FBC and HbH Inclusion bodies)
for patient and
husband (if this was not previously done)
please proceed to Thal stage 2 Screen (Hb electrophoresis and ferritin) if
a. MCV < 80 (refer to section on Thalassemia Screening)

b. HBs Ag, Anti-HBs

(If HBs Ag +ve, HBe Ag status would be performed)

c. VDRL (if +ve refer DSC and obstetrician)

d. HIV screening (if +ve refer CDC and obstetrician)

e. Blood group/rhesus status

All mothers (including those with no previous pregnancies) with rhesus negative status should be
referred to obstetrician for monitoring of rhesus incompatibility disease. Prophylactic anti-D
immunoglobulin could also be given to rhesus negative mothers to reduce the risk of fetal rhesus
incompatibility disease.

2. Ultrasound
a. Dating ultrasound to be done at 11-14 weeks
- for pregnancy dating
- exclusion of multiple pregnancy
- re-adjust working EDD to that derived from scan if it does not correspond to EDD derived from
LMP by 7 days or less

b. Screening Ultrasound to be scheduled at 19 21 weeks.

OTHERS

1. Down Syndrome Screening

a. Maternal Age > / = 35 at EDD refer to tertiary centre for Down Syndrome
counseling and screening.

b. Maternal Age < 35 at EDD patient to be informed of availability of Down

Syndrome screening tests. To refer to tertiary centre if patient is
keen.

(Refer to section on Down Syndrome Screening)

Strictly for internal circulation only. To the best of our knowledge, the contents and materials featured are not copyrighted.
If you know otherwise, pls contact us at prime@singhealth.com.sg
Pg 197
SHP Doctors Guidebook: ANTENATAL CARE
Updated as of June 2013

Management

PRIMARY CARE

1. Hematinics and multivitamins (e.g. Neogobion, Obimin)

st
2. Folate 5mg om should be given at least during the 1 trimester.
3. Scheduling next appointment
a. 4 weekly up till 28 weeks- patients to be referred to tertiary clinic at 28 weeks.

NON-URGENT REFERRAL TO OBSTETRICIAN

1. High risk pregnancy refer to the relevant section

2. Patients who are keen for Down Syndrome Screening
3. Patients with rhesus ve blood group

IMMEDIATE REFERRAL IF

1. Bleeding per vagina

2. Abdominal pain suspected of uterine origin
3. Leaking liquor
4. Decrease in fetal movement

Strictly for internal circulation only. To the best of our knowledge, the contents and materials featured are not copyrighted.
If you know otherwise, pls contact us at prime@singhealth.com.sg
Pg 198
SHP Doctors Guidebook: ANTENATAL CARE
Updated as of June 2013

Subsequent Visits (Till 28 Weeks Gestation)

HISTORY
1. Updates on general well-being of patient nausea/vomiting, appetite, activity level, lethargy, mental
state etc
2. Significant abdominal pain
3. PV bleeding
4. Presence and frequency of fetal movements if > 20 weeks gestation (could be as early as 18 weeks in
multiparous mothers)
5. Leg swelling and pain, chest pain and breathlessness or other symptoms of DVT

PHYSICAL EXAMINATION
1. General blood pressure, pedal edema
2. Abdomen fundal height, detection of fetal heart and movement

MEASUREMENTS (as in first visit) (Done by the midwife)

1. Weight
2. Blood pressure
3. Fundal height
4. Urine dipstix

INVESTIGATION
1. If risk factors for gestational diabetes are present, perform OGTT 24-28 weeks gestation.
2. Review of antenatal blood results
3. Review of ultrasound results
4. Ensure screening ultrasound has been done at 19 21 weeks

MANAGEMENT
st
1. Hematinics (Folate should be continued at least through 1 trimester)

REFERRAL TO OBSTETRICIAN
1. Complications (e.g. hypertension, GDM, abnormal lie, low-lying placenta) arise
2. Refer to obstetrician at 28 weeks gestation.

IMMEDIATE REFERRAL IF
1. Bleeding per vagina
2. Abdominal pain suspected of uterine origin
3. Leaking liquor
4. Decrease in fetal movement

Strictly for internal circulation only. To the best of our knowledge, the contents and materials featured are not copyrighted.
If you know otherwise, pls contact us at prime@singhealth.com.sg
Pg 199
SHP Doctors Guidebook: ANTENATAL CARE
Updated as of June 2013

Risk Factors For Gestational Diabetes Mellitus (GDM)

1. Family history of diabetes mellitus in first degree relatives

2. Marked obesity (pre-pregnancy weight > 80kg)
3. Personal history of previous GDM or large babies > 4kg
4. Age > 35 years
5. Previous poor obstetric outcome usually associated with DM, e.g. macrosomia, congenital
malformations, or intrauterine death

Patients who have factors (4) or (5) should be referred to the obstetrician for further management.

GDM is diagnosed with a 75g oral glucose tolerance test (OGTT). A 2-hour venous plasma of >=7.8mmol/L is
diagnostic of GDM. Random venous plasma level > = 11.1mmol/L on 2 successive occasions would also
confirm GDM without the need for OGTT

Management of glucosuria in pregnancy. If urine glucose is 1+ or more on 2 or more occasions, 1 month apart,
proceed with an OGTT test.

Strictly for internal circulation only. To the best of our knowledge, the contents and materials featured are not copyrighted.
If you know otherwise, pls contact us at prime@singhealth.com.sg
Pg 200