ANTENATAL CARE SYSTEMATIC MEDICAL SUPERVISION OF A FEMALE DURING PREGNANCY

ANC includes

HISTORY TAKING EXAMINATION ADVICE INVESTIGATION MEDICINE DIET & GENERAL ADVICE

AIMS OF ANC

TO SCREEN HIGH RISK CASES. TO PREVENT OR TO DETECT & TREAT ANY COMPLICATIONS AT THE EARLIEST. TO MAINTAIN THE HEALTH OF THE FEMALE THROUGHOUT PREGNANCY. TO EDUCATE MOTHER REGARDING THE PHYSIOLOGY OF PREGNANCY & LABOUR, TO REMOVE HER ANXIETY & FEAR OF CHILD BIRTH. TO SCREEN THE FETUS TO MONITOR FETAL GROWTH & ITS WELL BEING. TO DECIDE TIME, MODE & PLACE OF DELIVERY. TO GUIDE PARENTS IN INFANT & CHILD CARE. TO GIVE CONTRACEPTIVE ADVICE.

OBJECTIVES OF ANC
WOMAN ENTERS PREGNANCY WITH AN OPTIMAL STATE OF HEALTH. DELIVERY OF A HEALTHY BABY. MAINTAINANCE OF THE HEALTH OF THE MOTHER. Main aim is delivery of a healthy baby from a healthy mother.

WHO recommends minimum 4 ANC VISITS

1ST VISIT IN SECOND TRIMESTER AT AROUND 16 WEEKS. 2ND VISIT BETWEEN 24-28 WEEKS. 3RD VISIT AT 32 WEEKS. 4TH VISIT AT 36 WEEKS.

SCHEDULE FOR OPTIMAL ANC VISITS. ANC visits in developing countries like our are as follows -

ROUTINE CHECK UP IS DONE AT AN INTERVAL OF 4 WEEKS UPTO 28 WEEKS AND AT AN INTERVAL OF 2 WEEKS UPTO 36 WEEKS AND THEREAFTER WEEKLY TILL EDD.

Aims at first ANC visit

OBTAIN A BASELINE INFORMATION AGAINST WHICH THE SUBSEQUENT CHANGES ARE ASSESSED. ASSESS HEALTH STATUS OF THE MOTHER AND FETUS. SCREEN OUT HIGH RISK PREGNANCY.

SUBSEQUENT VISITS

ASSESS FETAL WELLBEING. ASSESS THE LIE, PRESENTATION & POSITION OF THE FETUS. ASSESS FOR ANAEMIA & PIH. SELECT TIME FOR USG & AMNIOCENTESIS IF REQUIRED. PLAN THE MODE OF DELIVERY.

ANC ADVICE

DIETARY ADVICE

DIET SHOULD BE LIGHT, NUTRITIOUS, EASILY DIGESTIBLE, RICH IN PROTEINS, MINERALS (iron) & VITAMINS. + I/2 LITRE OF MILK. + GREEN VEGETABLES & FRUITS.

SALT SHOULD BE JUST ENOUGH TO MAKE FOOD PALATABLE. Avoid excess salt in the diet.

SUPPLIMENTS REQUIRED DURING PREGNANCY

IRON 70-80 mg one capsule/day from second trimester. FOLIC ACID 5mg/day in the first trimester VITAMIN B12 100mg/day in the first trimester CALCIUM 1000mg/day from 20 weeks of pregnancy

PROTEIN

GENERAL ADVICE

8 to IO HOURS OF SLEEP ON AN AVERAGE ESPECIALLY LAST 6 WEEKS. CONTINUE USUAL ACTIVITIES THROUGHOUT PREGNANCY. INCREASE FLUIDS & FIBRE IN THE DIET TO PREVENT CONSTIPATON. RETRACTED NIPPLES NEED CORRECTION DURING PREGNANCY. AVOID COITUS IN THE FIRST TRIMESTER & LAST 6 WEEKS. NO SMOKING & ALCOHOL DURING PREGNANCY. TETATUS TOXOID IMMUNIZATION. ( Inj TT 0.5 ml IM 2 doses at an interval of 4-6 weeks) ADVICE REGARDING TRAVELLING AND WORK.

HIGH RISK PREGNANCY

ONE WHICH IS COMPLICATED BY FACTOR OR FACTORS THAT ADVERSELY AFFECTS THE PREGNANCY OUTCOME - MATERNAL OR FETAL OR BOTH.

ACCORDING TO WHO HIGH RISK PREGNANCY INCLUDES

ELDERLY PRIMI > 30 YEARS. SHORT STATURED PRIMI <145 cms. THREATENED ABORTION OR APH MALPRESENTATION PRE ECLAMPSIA AND ECLAMPSIA ANAEMIA ELDERLY GRAND MULTIPARA TWINS AND HYDRAMNIOS

PREVIOUS STILL BIRTH, IUFD, H/O MANUAL REMOVAL OF PLACENTA OR PROLONGED LABOUR H/O PREVIOUS CAESAREAN SECTION OR INSTRUMENTAL DELIVERY.

PREGNANCY ASSOCIATED WITH MEDICAL ILLNESS.

PROM. FEET OR CORD PROLAPSE

RETAINED PLACENTA
PUERPEREAL FEVER AND SEPSIS

ANTENATAL ASSESSMENT OF FETAL WELL BEING

IN EARLY PREGNANCY TO DETECT ANY FETAL CONGENITAL ANOMALIES

INDICATIONS FOR PRENATAL GENETIC SCREENING

MATERNAL AGE >35 YRS. STRONG F/H OF NEURAL TUBE DEFECTS. PREVIOUS CHILD HAVING NEURAL TUBE DEFECTS OR CHROMOSOMAL ANOMALIES. H/O RECURRENT ABORTIONS. ONE OR BOTH PARENTS ARE CARRIERS OF SEX LINKED OR AUTOSOMAL TRAITS. H/O VIRAL INFECTION IN EARLY PREGNANCY.

Investigations that are carried out

Biochemical tests Cytogenic tests Ultrasonography

BIOCHEMICAL TESTS
1. MATERNAL SERUM ALPHA FETOPROTEIN i.e. MSAFP IT INCREASES IN NEURAL TUBE DEFECTS, MULTIPLE PREGNANCY, IUFD,RENAL ANOMALIES. IT DECREASES IN DOWNS SYNDROME,GESTATIONAL TROPHOBLASTIC DISEASES.

2. TRIPLE TEST / TRIPLE MARKER TEST IT IS A COMBINED BIOCHEMIOCAL TEST WHICH INCLUDES MSAFP ( maternal serum alpha fetoprotein), hCG and UE3 (unconjugated estriol ).

Age of mother is considered.

AFP and UE3 ARE Low & , hCG is high in DOWNS SYNDROME. IT GIVES RELATIVE RATIO. TEST IS POSITIVE IF RATIO IS 1: 250 CONFIRMATION IS DONE BY AMNIOCENTESIS.

3. AChE - ACETYL CHOLINE ESTERASE INCREASES IN NEURAL TUBE DEFECTS.

4. INHIBIN A INCREASES IN DOWNS SYNDROME.

5. PAPP A PREGNANCY ASSOCIATED PLACENTAL PROTEIN A DECREASES IN DOWNS SYNDROME.

CYTOGENIC TESTS
1. CVS CHORIONIC VILLUS SAMPLING OR CVB CHORIONIC VILLUS BIOPSY IT IS DONE AT 10-12 WEEKS UNDER USG GUIDANCE AND TROPHOBLAST CELLS ARE OBTAINED. 2. AMNIOCENTESIS AT AROUND 14 16 WEEKS UNDER USG GUIDANCE. AMNIOTIC FLUID AND FETAL CELLS ARE OBTAINED. CORDOCENTESIS DONE AT AROUND 18-20 WEEKS , FETAL BLOOD CELLS ARE OBTAINED.

3.

ULTRASONOGRAPHY ANOMALY SCAN IT IS A SPECIALIZED SONOGRAPH WHERE ALL THE ORGANS OF FETUS ARE SCANNED A DETAIL STUDY OF THE FETUS IS CARRIED OUT. COLOUR DOPPLER Specialized sonography done to see the placental blood flow, blood flow through the umbilical vessels.

ASSESSMENT OF FETAL WELL BEING IN LATE PREGNANCY

1. CLINICAL EXAMINATION FUNDAL HEIGHT, WEIGHT GAIN, FHS. 2. BIOCHEMICAL TESTS. BASICALLY DONE FOR ASSSESSING PULMONARY MATURITY AMNIOCENTESIS IS DONE AND EXAMINED FOR LECITHIN/SPHINGOMYELIN RATIO. RATIO IS 1 AT 31-32 WEEKS 2 AT 35 WEEKS > 2 INDICATES PULMONARY MATURITY.

3. BIOPHYSICAL TESTS - FETAL KICK COUNT / FETAL MOVEMENT COUNT NORMAL 10 OR MORE MOVEMENTS IN 12 HOURS. MOVEMENTS MAY BE PERCEIVED WITH DIFFICULTY IN CASE OF HYDRAMNIOS, ANTERIOS PLACENTA, OBESITY, SMOKING, DRUG INTAKE. - NON STRESS TEST NST CONTINUOUS ELECTRONIC MONITORING OF FETAL HEART RATE.

CARDIOTOCOGRAPHY RECORDING FETAL MONEMENTS. THERE IS ACCELERATION IN FETAL HEART RATE WITH FETAL MOVEMENT. DOPPLER USG / COLOUR DOPPLER USG BLOOD FLOW THROUGH THE UMBILICAL VESSELS IS SEEN. BLOOD FLOW DECREASES IN PRE ECLAMPSIA AND IUGR.