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Antenatal Care Presented by: Team 1 Mohammed Alshehri – AU ID: 130127 Sultan Alsobayeg – AU

Antenatal Care

Antenatal Care Presented by: Team 1 Mohammed Alshehri – AU ID: 130127 Sultan Alsobayeg – AU

Presented by: Team 1

Mohammed Alshehri – AU ID: 130127 Sultan Alsobayeg – AU ID: 130351

Antenatal Care Presented by: Team 1 Mohammed Alshehri – AU ID: 130127 Sultan Alsobayeg – AU

Objectives

Preconception care: indications, advice What is antenatal care Aims of antenatal care The booking visit Dating the pregnancy Booking history, examination and investigations Screening for maternal diseases, fetal abnormalities Teratogenicity, teratogenic medications Genetic counselling Ultrasound: indications and timing Follow-up and frequency of visits Common/ minor pregnancy problems: hyperemesis, constipation, heartburn General advise: life style, nutrition

Preconception Care: Indications & Advice

Up to 30% of pregnant women begin traditional prenatal care in the second trimester, which is after the period of organogenesis

Improving the health of women before pregnancy is essential Aims of preconception care:

Avoid behaviors and exposures known to adversely affect pregnancy outcomes Provide an opportunity to inform women about pregnancy issues

Identify some of the risks of pregnancy for the mother and fetus and educate them about these risks

Institute appropriate interventions when possible, before conception

Preconception Care: Indications & Advice

A set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management

Preconception intervention is more important than prenatal intervention for prevention of congenital anomalies Prenatal care should begin before pregnancy & more than one visit Data shows that 4 out of 10 women report that their pregnancies are unplanned 1/2 of all pregnancies in USA are unplanned As a result preconception counseling is recommended for every woman of reproductive age Examples: obesity control, smoking cessation, exposure to toxins, HIV/AIDS screening and treatment, and genetic disorders screening

What is Antenatal Care?

The care provided for pregnant women & her unborn baby throughout a pregnancy

Before 10 weeks

Influences the outcome of the pregnancy

Patients are advised to follow up with regular visits

Providers: Obstetricians and Gynecologists, Family physicians and Midwives

Medical check up every four weeks up to 28 weeks gestation

Every 2 weeks until 36 weeks

Every week until delivery

An average of 7 to 11 visits

More visits may be required if complications arise

Aims of Antenatal Care

To educate mothers about pregnancy, childbirth and child care

To screen for and detect factors which might adversely affect the health of mother and/or fetus

To deal with minor pregnancy problems

To control pre-existing diseases to avoid exacerbations with adverse outcome on mother and/or fetus

Final aim: healthy mother and child

The Booking Visit

The Booking (first) visit is a very important component of antenatal care

In the first visit, basic medical information is collected to follow the patient throughout pregnancy

Subsequent visits are often scheduled about every four weeks during the first trimester & will probably be shorter than the first

Confirmation of pregnancy: WHAT IS REQUIRED? 1- Symptoms of pregnancy (amenorrhea, breast tenderness, nausea, increased frequency of urination etc.) 2- +ve βhCG in urine and serum 7 – 10 days after conception 3- US to confirm + date pregnancy

Dating the pregnancy: Precise dating is very important for both preterm gestations and post term deliveries

History & Physical Examination Investigations

Dating the Pregnancy

Menstrual EDD:

Using Naegele’s rule: LMP + 7 days + 9 months (or subtract 3 months)

This rule assumes a regular 28 day menstrual cycle with ovulation on the 14 th day and an accurate recollection of the LMP

Ultrasound dating

Accurate dating of pregnancy in women with: poor recollection, irregular cycles, and for early detection

Before 15-16 weeks minimal variation in fetal size; plotted on standard charts and gestation calculated accurately

If EDD predicted by dating scan differs from menstrual EDD by >7 days Go with scan EDD

Beyond 20 weeks Genetic and environmental factors cause significant variability  ↓ accuracy

Dating scan is also helpful and more accurate because not all women have a 28 day cycle, a regular cycle or accurate recollection. This also decreases the chances of labour induction for supposedly prolonged pregnancies or anxiety regarding supposedly preterm deliveries. Early detection of multiple pregnancies, screening for various diseases/abnormalities is another benefit of getting a dating scan

Ultrasound – “crown rump length”

Most accurate method

Crown-rump length (CRL) measurement of length of fetus from top of head (crown) to bottom of buttocks (rump)

• Ultrasound – “crown rump length” • Most accurate method • Crown - rump length (CRL)
• Ultrasound – “crown rump length” • Most accurate method • Crown - rump length (CRL)
• Ultrasound – “crown rump length” • Most accurate method • Crown - rump length (CRL)

AIM: identify risks

Age and racial origin:

History

Extremes of age  ↑ risk of pregnancy related complications

Certain racial groups carry risk of medical conditions Past medical history:

Chronic illnesses Treatment (rule out teratogens) Hospitalisations, surgeries and blood transfusions Past obstetric history:

GTPAL and details of each pregnancy Previous complications Method of delivery Outcome of each pregnancy (gender, well/not well etc.)

Past gynaecological history History of infertility or recurrent pregnancy loss Menstrual History Surgeries, infections etc Family history:

FHx of Type 2 DM +ve  ↑ risk of developing gestational diabetes Thromboembolic diseases linked to risk of DVT pulmonary embolism Chromosomal anomalies, single gene disorders etc Social History:

Smoking and alcohol exposure Non prescription drugs Social deprivation Neglect and abuse

Physical Examination

Introduce yourself, obtain consent, Wash your hands & obtain a chaperone for assistance

Height and weight/BMI

<19 BMI associated with low birth weight

>29 BMI associated with complications such as pregnancy induced hypertension, diabetes and macrosomia

Vital signs General physical exam Specific examination if indicated Abdominal exam Pelvic exam

Discharge

Cysts

Lesions (e.g. herpes)

Adnexal masses

Physical Examination • Introduce yourself, obtain consent, Wash your hands & obtain a chaperone for assistance

Fetal heart: can be heard by Doptone around 12 weeks

Place Doptone just above pubic symphysis and aim transducer towards feet/spine

Investigations

CBC; Hemoglobin, hematocrit and platelet count MCV <80 without the presence of iron deficiency anemia can indicate an

underlying sickle cell disease or thalassemia

ABO and Rh type: Direct Coomb’s test Hepatitis B surface antigen (HBsAg) STDs, gonorrhea and chlamydia Syphilis screening (VDRL, RPR) Rubella Titer HIV Urinalysis and culture: asymptomatic bacteriuria Targeted tests: Hb electrophoresis, sickle cell, infection Screen for diabetes – highly prevalent in our society Consider Thyroid function tests (TFT) – highly prevalent in our society

Screening for Maternal Diseases and Fetal Abnormalities

First and second trimester testing Can be invasive or non invasive tests Commonly used techniques:

Maternal serum screen (β-hCG, AFP, PAPP-A) Ultrasound Amniocentesis Chorionic Villus Sampling (CVS) Cordocentesis

Screening for Maternal Diseases and Fetal Abnormalities

Prenatal diagnostic testing performed when there is:

FHx genetic disease with known mutation and recurrence risk

Past ob Hx; Rh isoimmunization

Abnormal screening test (serum, or ultrasound)

Abnormality in ultrasound

Additional diagnostic testing for mothers who have:

Pre-existing maternal diseases (i.e., diabetes,

kidney disease, heart disease)

Toxemia

Abnormal amniotic fluid amounts

Abnormal fetal growth

Multiple pregnancy

Post-term pregnancy

First trimester screening:

Maternal age Fetal nuchal translucency (NT) thickness:

NT associated with chromosomal and congenital anomalies.

Maternal serum free β-hCG

(β-hCG  ↑ risk of Down syndrome)

Pregnancy associated plasma protein A (PAPP-A)

(PAPP-A

 ↑ risk of Down syndrome)

Nasal bone assessment on ultrasound can Down syndrome detection rate

Second trimester screening: “serum triple screening test”:

Alpha-fetoprotein (AFP) detection of neural tube defects hCG Unconjugated estriol (UE3)

MSAFP + hCG + UE3 Screen for Down syndrome MSAFP + hCG + UE3 Screen for trisomy 18

Teratogenicity

Tetracycline

Pregnancy category - D

Trimesters of risk - Second and third (20th gestational week or later)

Associated defects and complications - Dental staining

Teratogenicity

Warfarin

Pregnancy category - X

Trimesters of risk - First, second, and third

Associated defects and complications - Malformed intestines, hearing defects, absent ears

Teratogenicity

Thalidomide

Pregnancy category - X

Trimesters of risk - First, second, and third

Associated defects and complications - Deformities of the axial and appendicular skeleton

Genetic Counseling

Down's syndrome (between 11-14 weeks)

Thalassemia

Sickle cell anemia

Patau's syndromes

Genetic Counseling

Chorionic villus sampling (12 weeks):

A sample of placental tissue is obtained for analysis under ultrasonographic guidance

Genetic Counseling

Amniocentesis (15-22 weeks ):

The procedure consists of the aspiration of amniotic from an amniotic fluid pocket with a ultrasonographic guidance

Genetic Counseling • Amniocentesis ( 15-22 weeks ) : The procedure consists of the aspiration of

Genetic Counseling

Cordocentesis PUBS (20 weeks) :

The greatest advantage of this technique is that it provides a direct fetal sample, but still carry a high risk of fetal loss and placental abruption

Genetic Counseling • Cordocentesis PUBS (20 weeks) : The greatest advantage of this technique is that

Ultrasound

The basic obstetric ultrasound is categorized by the gestational age at which it is performed

First trimester:

1-Mainly to confirm the pregnancy 2- Nuchal translucency

3-Anencephalia

Ultrasound • The basic obstetric ultrasound is categorized by the gestational age at which it is

Ultrasound

Second trimester (Anatomy ultrasound):

1-Aneuploid

2-Placental evaluation 3-Fetal growth

Any trimester:

1-Fetal heart tones 2-Evaluating preterm labor 3-Determining fetal presentation

Ultrasound • Second trimester (Anatomy ultrasound): 1-Aneuploid 2-Placental evaluation 3-Fetal growth • Any trimester: 1-Fetal heart
Ultrasound • Second trimester (Anatomy ultrasound): 1-Aneuploid 2-Placental evaluation 3-Fetal growth • Any trimester: 1-Fetal heart

Follow Ups

The Traditional antenatal care includes a series of between 7 and 11 visits

A comprehensive physical examination should be performed at the first or second visit

Follow Ups

Typical frequency of visits in an uncomplicated pregnancy:

Every 4 weeks for the first 28 weeks Every 2 to 3 weeks between 28 and 36 weeks Weekly after 36 weeks

Psychosocial screening to evaluate any existing anxiety, depression and other aspects

Undergo influenza vaccination, tetanus toxoid and reduced diphtheria toxoid

Follow Ups

Ask about:

pain, fetal movement, contraction frequency, vaginal bleeding, loss of fluid or discharge, preeclampsia symptoms in addition to any other patient-provided complaints or concerns

Common Symptoms of Pregnancy

Hyperemesis Gravidarum:

Early in the first trimester

The pathogenesis of hyperemesis gravidarum is poorly understood. Hormonal and psychologic factors may play a role

Treatment of hyperemesis gravidarum focuses on replenishing fluids, electrolytes, vitamins, and minerals

Common Symptoms of Pregnancy

Gastroesophageal Reflux Disease (Heart Burn):

Both mechanical and intrinsic factors are involved in GERD

Fifty-two percent of pregnant women first experience GERD in their first trimester, 24-40% experience it in their second trimester, and 9% in their third trimester

Lifestyle modifications and pharmacologic management

Common Symptoms of Pregnancy

Constipation:

The etiology is multifactorial, with decreased small bowel motility, decreased motilin level, decreased colonic motility, increased absorption of water, and iron supplementations possible contributory factors

Stool softeners such as sodium docusate are probably safe. Stimulant laxatives are probably safe for intermittent use, but these agents should not be used regularly. Castor oil and mineral oil should not used in pregnancy

General Advice

Life Style ***Do your daily activities***

Nutrition ***Balanced diet + fluids + vitamins***

References

Uptodate.com Medscape.com Webmd.com Presentations of Alfaisal’s faculty Presentations of Dr Kurdi Student presentation from last year

The End

Thank you