Antenatal Care

Presented by: Team 1

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

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 womans 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 hCG 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 Naegeles 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 oflengthof fetus from top of head (crown) to
bottom of buttocks (rump)

AIM: identify risks

History

Age and racial origin:

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

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 Coombs 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 (-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,

Toxemia
Abnormal amniotic fluid amounts
Abnormal fetal growth
Multiple pregnancy
Post-term pregnancy

kidney disease, heart disease)

First trimester screening:

Maternal age
Fetal nuchal translucency (NT) thickness:
NT associated with chromosomal and congenital anomalies.

Maternal serum free -hCG

( -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
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

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

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

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, andiron 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 Alfaisals faculty
Presentations of Dr Kurdi
Student presentation from last year

The End

Thank you