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Definition: 
Embryo: 
Fetus: 
Gravidity 
Parity 
Abortion: 
Immature infant: 
Preterm/premature infant: 
Term: 
Post term 
Date/Post date 
Birth rate 
Fertility rate 
Neonatal period: 
I, II & III 
Perinatal period: 
Perinatal mortality rate: 
Maternal mortality rate:
Sign & symptoms of PRESUMPTIVE /PROBABLE manifestations 
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Pregnancy test: 
Biological 
Immunological 
Radioimmunoassay for HCG 
Serum vs urine
“”Antenatal care is the clinical assessment of mother and fetus 
during pregnancy, for the purpose of obtaining the best possible 
outcome for both the mother and the fetus” 
The aims of antenatal care: 
Assessment and management of maternal risk and symptoms 
Assessment and management of fetal risk 
Prenatal diagnosis and management of fetal abnormalities 
Diagnosis and management of perinatal complications 
Decision regarding timing and mode of delivery 
Education regarding pregnancy and childbirth 
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Frequency of antenatal visits 
 12 weeks –booking + viability uss 
 16 weeks-blood screening (MW) 
 18 weeks-dating &detailed uss 
 24 weeks- 
 28 weeks- FBS, auto ab 
 30 weeks 
 32 weeks- growth uss 
 34 weeks 
 36 weeks – 
 38 weeks 
 40 weeks 
 41 weeks - 
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booking visit (first visit): 
The aim: 
obtain a comprehensive history and physical examination 
establish the gestational age 
identify the maternal and foetal risk factors 
History: 
A FULL obstetric history particularly: 
LMP (last menstrual period) 
EDD (estimated delivery date) 
Past obstetric, gynaecological, medical and surgical history 
Family history 
Social history ( inquire about smoking, alcohol, drugs) 
Identify factors and categories which make patient high or low risk.
Assessment of gestational age: 
Nagel’s rule (EDD) : 
Subtract 3 months from the date of the last menstrual period and add 
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7 days( 14 days in Arabic months). 
If the cycle was longer than 28 days, the number of additional days 
are added to the days used in the rule 
Do the opposite if the cycle is shorter 
Biparietal diameter: accurate +/- 3 weeks ( useful between wks 7-12) 
Crown rump length: accurate +/- 1 week (useful between wks 7-12) 
Fundal height: correspond to gestational age in weeks 
.
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Measurement Symphyseal 
Fundal height 
 Evidence supports either palpation or S- F measurement 
at every AN visit to monitor fetal growth 
 measurement should start at the variable point (F) and 
continue to the fixed point (S) 
 SF measurement should be recorded in a consistent 
manner (therefore cms at RWH) 
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Fetal Presentation and 
Descent 
 Check presenting part beginning around 30 weeks 
 Descent of presenting part is important as term 
approaches 
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Auscultation of fetal heart 
 Listening to fetal heart is of no known clinical benefit, 
but may be of psychological benefit to mother 
(Consensus opinion) 
 Should be offered at each visit after about 20 weeks 
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Routine BP measurement 
 HT is defined when systolic BP is 140mmHg +/or DBP is 
90 mmHg or there is an incremental rise of 30 systolic 
or 15 diastolic 
 Automated devices & ambulatory devices should not be 
used (Mercury devises seem best) 
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Urinalysis by dipstick for 
proteinuria - evidence 
 high incidence of false +ve and - ve using dipsticks cf 24 
hr urine collection 
 reliable in detecting highly variable elevations in 
protein in pre-eclampsia 
 Gribble et al AJOG 1995; 173: 214-7 
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Urinalysis by dipstick forn 
proteinuria - evidence 
 no statistical differences in rates of PAH, fetal distress, 
abruptio placentae, neonatal outcome in those with 
absent, mild or marked proteinuria by dipstick 
 US and Canadian Guidelines recommend screening for 
pre-eclampsia by BP measurement rather than dipstick 
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Urinalysis by dipstick for 
proteinuria - guidelines 
 Routine screening for proteinuria in low risk pregnant 
women not recommended IV 
 assessment hypertensive pregnancies requires 
estimation of total protein in 24-hr collection IV 
 If detect hypertension then use dipstick for testing 
proteinuria 
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Routine weighing at A/N 
visits - evidence 
 weighing at every antenatal visit 
routine practice for many years 
 No conclusive evidence for weighing at 
each visit. Maternal weight not 
clinically useful screening tool for 
detection of IUGR, macrosomia or pre-eclampsia 
IV 
 Weighing at booking or other times 
may be indicated eg anaesthetic risk 
assessment (done BIV at RWH) or 
maternal weight concerns 
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Initial recommended tests 
 FBE 
 MCHC/MCV (Thal screen. Ferritin and 
Hb electrophoresis if low) 
 Blood group/Ab screen 
 HIV (level 1 evidence) 
 Hep B 
 Syphilis (ideally prior 16 weeks) 
 Rubella Abs 
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 Urine testing- either 2 step or 
MSU+dipstick 
 PAP if due 
Consider 
 Hep C 
 Ferritin 
 Vit D levels - common in patients at RWH 
 addit Thal screen 
 dating US 
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Hepatitis C screening 
 Should be offered to all at increased risk 
 history of injecting drugs 
 partner who injected drugs 
 tattoo or piercing 
 been in prison 
 blood t/f later positive for Hep C 
 long-term dialysis or organ transplant before 7/92 
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Prenatal testing 
Down screening 
 Screening - : early US, 15-17 week MSST, Early 
combined screening(first trimester MSST and early US) 
 diagnostic testing - CVS, amniocentesis 
Other testing according to history eg for CF, Fragile X, 
Thalassaemia, Huntington's disease 
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Prenatal screening for Down’s 
syndrome 
 All women should be offered screening irrespective of 
age III/IV 
 counselling given by appropriately trained staff and 
specific to age of each woman III/IV 
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Down syndrome screening 
 Screening should 
 include accurate dating by 1st T u/s IV 
 either by 2nd T biochem, or nuchal translucency alone or 
combination III 
 notify result irrespective of risk in understandable format 
II 
 if increased risk should be offered further counselling and 
diagnostic testing within 72 hrs or ASAP IV 
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Down’s syndrome screening 
 Quality of counselling is of primary importance, non-directional, 
if chooses screening, should be single-step 
III 
 Nuchal translucency should be performed at 11-14 
weeks by trained operators and risks derived in 
conjunction with gestation and maternal age IV 
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Other recommended tests 
 26 weeks (at hospital) 
 Gestational diabetes screening - 
 AB screen on all women 
 36 weeks 
 GBS screen 
 (Ab if RH -ve has been ceased) 
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Screening for GDM 
 In absence of high level evidence to either support or 
abandon screening reasonable to 
 not offer screening 
 selectively offer screening to all with risk factors 
 offer screening to all 
 if screening do so between 24-28 weeks 
 RWH screen all women at 26 weeks 
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Prevention of Early Onset GBS 
 Swabs should be taken between 35-37 weeks’ III 
 Intrapartum antibiotics recommended if 
 <37 weeks’ 
 ruptured membranes >18 before delivery 
 maternal temperature ³38 C 
 previous GBS colonisation, bacteruria or infant with GBS III 
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Antenatal anti-D prophylaxis 
 Prophylactic Anti-D at 28 and 34 
weeks’ gestation 
 No level I evidence 
 Level II and III evidence would suggest 
that the 1.5 percent immunisation 
rate could be reduced to 0.1-0.2% 
through antenatal prophylaxis (Huchet 
et al, 1987;Bowman and Pollock, 1978; 
Hermann et al, 1974) 
 www.health.gov.au/nhmrc/publicatio 
ns/pdf/wh27.pdf 
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Investigation: 
routine test: 
Blood group and Rh type ( if positive, appropriate management) 
CBC 
Urine analysis- to prevent UTI affecting pregnancy) 
MSU 
HBs Ag ( if a mother has it, 70-90% chance of foetus getting it, 
90% chance of being chronic carrier. Prevent by treating newborn 
of HBs AG+ve mother with B immune globulin and hep B 
vaccine) 
Rubella 
Syphilis 
U/S: 
Determine foetal crown rump length and thus gestational age 
Identify multiple gestation 
Identify gross abnormalities/ markers of genetic disease. 
Cervical cytology
2-Screening tests: 
Anaemia 
Gestational DM (best carried out between 24 and 28 weeks, observe 1 hr 
after 50g glucose solution. A reading of 126 mg/dl or greater is abnormal, 
according to the amended WHO recommendations 1999 regarding DM, 
as is HbAlc of greater than 90%. In these cases proceed to glucose 
tolerance test) 
Antibodies 
Triple test: Alpha feto protein in normal serum, oestriol, HGG 
( to detect neural tube defect or chromosomal defect, 16-18 weeks) 
Hb electrophoresis 
Tuberculin skin testing 
Urine culture- for glucose, ketones and protein, bacilli 
Cervical culture: N gonorrhoea, group B streptococci, 
Chlamydia trachomatis, Mycoplasma hominis 
Toxoplasma antibody test 
HIV 
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HIV: Voluntary Counseling 
and Testing 
 Voluntary HIV counseling and testing should be 
available to every pregnant woman--for public health 
reasons as well as for the benefit to the individual 
woman. 
 Pre and post-test counseling is an essential part of 
managing HIV in pregnancy. 
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Source: WHO and UNAIDS 1999.
Benefits of Voluntary HIV 
Counseling and Testing 
1) If the HIV test is positive, the woman can 
get early counseling and treatment 
2)Allows appropriate follow-up and treatment 
of child 
3)Enables a woman to make decisions 
regarding continuation of the pregnancy 
and future fertility 
4)May allow the institution of anti-retroviral 
(ARV) therapy 
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Source: WHO and UNAIDS 1999.
Benefits of Voluntary HIV Counseling and 
Testing continued 
5) Provides the opportunity to 
implement strategies that attempt 
to prevent transmission to the child 
6) Can inform partner and enable him 
to get counseling and testing 
7) Women can take precautions to 
prevent transmission to partners 
8) If the HIV test is negative, the 
woman can be guided in 
appropriate HIV prevention 
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Source: WHO and UNAIDS 1999.
Syphilis 
 Maternal-fetal transmission may 
be as high as 80%. 
 Incidence of adverse effects on 
the fetus/infant due to untreated 
maternal syphilis reported in some 
studies was: 
Spontaneous abortion – 20% 
Perinatal death – 30% 
Congenital syphilis – 25% 
Source: WHO 1991. 
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Syphilis continued 
 A study in Zambia found syphilis to be the 
single most common cause of fetal wastage. 
The adverse outcomes of syphilis were 
halved by a fairly incomplete program of 
screening and treatment. 
Sources: Hira et al 1990; Tinker and Koblinsky 1993. 
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Syphilis continued 
 Even where prevalance is relatively low 
(i.e., as in most industrialized countries) an 
antenatal syphilis screening program is a 
cost-effective intervention. 
 Initiation of treatment should occur at the 
same visit as the screening. 
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Source: Wang and Smaill 1989.
Tuberculosis 
 Infants born to women with tuberculosis (TB) have an increased risk 
of morbidity and mortality in the neonatal period. 
Source: Figueroa-Damian and Arredondo-Garcia 2001. 
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Severe anemia 
 Mild or moderate anemia is not correlated with adverse 
pregnancy outcomes 
 Severe anemia, however, (hgb <7 g/dL or hct <20%) is 
associated with increased preterm delivery, inadequate 
intrauterine growth, increased perinatal mortality and 
increased maternal mortality. 
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Severe anemia continued 
 Providers can screen for anemia by 
1)Hemoglobin (hgb) by thin film/smear 
2)Hematocrat (hct) test 
3)Hemoglobin Color Scale, or 
4) Clinical observation of the inferior conjunctiva 
of the eye, the nail beds and the palm. If any of 
these are pale, the woman is severely anemic. 
Other symptoms include shortness of breath 
and signs of heart failure. 
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Tetanus Toxoid 
 Tetanus toxoid is 
 An effective, stable, cheap toxoid 
which has been available for > 50 years 
and is produced in many developing 
countries. 
 Effective in preventing neonatal 
tetanus (NNT), which causes 
approximately half a million 
deaths/year) and maternal tetanus, 
which is estimated to cause 30,000 
deaths annually. 
Sources: Fauveau V et al 1993; Bennett JV 2000. 
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Iron Deficiency 
 Globally among all populations, iron 
deficiency (and its manifestation in anemia) 
is the single most prevalent nutrient 
deficiency condition. The World Health 
Organization (WHO) estimates put anemia 
prevalence at 52% among pregnant women. 
Source: MotherCare, John Snow, Inc. 2000. 
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Iron Folate Supplements 
 The International Nutritional Anemia Consultative 
Group, WHO and UNICEF have endorsed the 
following guidelines: 
1) All women should consume daily iron folate 
supplements for 6 months during pregnancy. 
2) Where anemia prevalence is <40%, women should 
receive supplements of 60 mg iron and 400 
micrograms of folate 
3) In areas where anemia prevalence is high among 
pregnant women (³40%), women should continue 
the same dosage for 3 months into postpartum. 
Sources: Stoltzfus and Dreyfuss 1998; McDonagh 1996. 
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3-Specific nutritional advice: 
0.4 mg Folic Acid per day ( it prevents tube defects) 
30 mg ferrous iron 
60 mg ferrous iron 2 times a day ( anaemic patients) 
Supplement copper and zinc in anaemic patients 
Avoid Vitamin A in huge amounts as it is teratogenic 
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Nutrition Requirements 
Good antenatal nutrition includes: 
 Meeting the caloric needs 
 Eating foods which supply specific micronutrients 
 Providing micronutrient supplementation 
An underweight mother increases the 
likelihood of a low birth weight (LBW) baby; 
low iron intake contributes to anemia. 
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Models of antenatal care 
 At each visit midwives and doctors should offer 
information, consistent advice, clear explanations and 
provide opportunity to ask questions III/IV 
 More likely to be satisfied with A/N care when perceive 
care givers are kind, supportive, courteous, respectful, 
recognise individual needs IV 
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Complications Cannot Be 
Reliably Predicted 
 No formula or scoring system can reliably distinguish those who will 
develop complications from those who will not. 
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Complication Readiness is 
KNeepyal tStou dSyurvival 
 Less than 50% of families of women who died in 
pregnancy, delivery or postpartum, recognized the 
problem. 
 36% decided within 2 hours to seek care and get 
transport. 
 15% decided in 2 to 23 hours to seek care and get 
transport. 
 29% made the decision and arranged transport 1 to 
8 or more days after recognition of a life-threatening 
complication. 
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Source: MOH, Nepal 1998.
Complication Readiness is 
Key to Survival continued 
 The interval from onset to death for 
antepartum hemorrhage can be 
approximately 12 hours. 
 The interval from onset to death for 
postpartum hemorrhage can be two hours. 
 The hours required for making 
arrangements (which could have been 
made prior to the emergency) may define 
the line between survival and mortality. 
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Sources: Maine 1991; MOH, Nepal 1998.
Danger Signals 
 Families of pregnant women need to know how to recognize the signs 
of complications as well as what to do and where to get help 
 In Nepal, less than 50% of families of women who died recognized the 
problem. 
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Source: MOH, Nepal 1998.
On subsequent visits 
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Check: 
oBp 0 urine analysis 0 weight? 
Ask for : 
0 FM 0 Maternal complaints 
Examine: 
0 abdomen/obstetric 0 listen/see FH USS if required 
Advice: 
Treatment of complaint & health education
Antenatal care and high risk assessment1
 1. Infections: 
13/12/2003 
Syphilis 
Hepatitis 
.H.I.V 
Rubella 
:Blood disorders. 2 
Sickle cell 
Thalassaemia 
:Fetal anomalies. 3 
Structural e.g. N.T.D 
:Chromosomal abnormalities. 4 
Down’s 
T18 
T13
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 Non Invasive: 
 B-HCG …. Urine 14 days post ovulation, serum 7-9 days ….. 
doubling time….. 
 Alpha feto protein. 
 Triple test: AFP, Unconjugated oestriol & B-HCG 
 Ultra Sound scan 
 Invasive: 
 Amniocentesis 
 Chorionic villus biopsy 
 Chordocentesis
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 Indications of use: 
 pregnancy location 
 viability 
 fetal number 
 dating 
 anomaly 
 placental localization, amniotic fluid 
 fetal growth and wellbeing 
 during invasive procedures
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 Amniocentesis: 
 carried at 15-18 wks. Failure rate < 1%.. Culture time 10- 
12 days 
 For chromosomal analysis: Down’s etc… 
 Miscarriage rate 0.5-1%.... Experience and USS 
 Anti-D
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 Fetal blood sampling: 
 Ultra sound guided. Cord insertion into the placenta 
 Only in specialist centres 
 indications: 
 Rh iso-immunisation 
 non-immune hydrops 
 Fetal infection 
 Rapid karyotyping in some IUGR 
 Anti-D 
 Fetal loss ~ 1%.
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 Assessment of gestational age and fetal growth: 
 menstrual history unreliable in up to 45% of women 
 serial fundal height measurement provides a guide to fetal growth 
 USS: crown-rump length before 14 weeks 
 USS: BPD serial measurement every 2 weeks for fetal growth. 
Unreliable after 28 weeks for dating 
 USS: head/abd ratio, 2 weeks serial HC & AC for fetal growth .. IUGR 
AC< but initially HC ~. 
 USS: femur length, more precise guide to gestational age than BPD 
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 Principles: 
 the ideal scheme to assess FWB should: 
Take account of cycles of normal fetal behavior 
 detect impending harm accurately and in time to intervene to 
prevent it 
 give reassurance preferably up to 7 days 
 avoid causing unnecessary anxiety 
 allow detection of specific causes e.g hypoxia, infection, malf’n 
 produce measurable benefits in reducing perinatal loss/injury 
 such system is likely to involve tests which assess several 
fetal systems, CVS, NS,, RS and use >1 modality
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 Fetal Movement Count: 
 Fetal Heart Recording….. CTG 
Biophysical Profile {BPP} scoring 
Doppler studies
 BPP uses FHR monitor and real time USS to assess: 
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 fetal breathing movement 
 discrete body or limb movement 
 fetal tone 
 FHR 
 amniotic fluid volume 
 Amniotic fluid volume is most important 
 Fetal breathing movement is the first to disappear in asphyxia 
 7 days reassurance in low risk, only 24 hours in high risk preg
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Clinical Indications for Doppler Studies 
 most useful in assessing IUGR 
 identify only the sub-group which is hypoxemic bec/of 
inadequate placental function and may be abnormal for up to 18 
weeks before any fetal problem is observed 
 no proven role in population screening for increased risk of 
pre-eclampsia or IUGR 
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Antenatal care and high risk assessment1

  • 2. 13/12/200 3 Definition: Embryo: Fetus: Gravidity Parity Abortion: Immature infant: Preterm/premature infant: Term: Post term Date/Post date Birth rate Fertility rate Neonatal period: I, II & III Perinatal period: Perinatal mortality rate: Maternal mortality rate:
  • 3. Sign & symptoms of PRESUMPTIVE /PROBABLE manifestations 13/12/200 3 Pregnancy test: Biological Immunological Radioimmunoassay for HCG Serum vs urine
  • 4. “”Antenatal care is the clinical assessment of mother and fetus during pregnancy, for the purpose of obtaining the best possible outcome for both the mother and the fetus” The aims of antenatal care: Assessment and management of maternal risk and symptoms Assessment and management of fetal risk Prenatal diagnosis and management of fetal abnormalities Diagnosis and management of perinatal complications Decision regarding timing and mode of delivery Education regarding pregnancy and childbirth 13/12/200 3
  • 5. Frequency of antenatal visits  12 weeks –booking + viability uss  16 weeks-blood screening (MW)  18 weeks-dating &detailed uss  24 weeks-  28 weeks- FBS, auto ab  30 weeks  32 weeks- growth uss  34 weeks  36 weeks –  38 weeks  40 weeks  41 weeks - 13/12/200 3
  • 6. 13/12/200 3 booking visit (first visit): The aim: obtain a comprehensive history and physical examination establish the gestational age identify the maternal and foetal risk factors History: A FULL obstetric history particularly: LMP (last menstrual period) EDD (estimated delivery date) Past obstetric, gynaecological, medical and surgical history Family history Social history ( inquire about smoking, alcohol, drugs) Identify factors and categories which make patient high or low risk.
  • 7. Assessment of gestational age: Nagel’s rule (EDD) : Subtract 3 months from the date of the last menstrual period and add 13/12/200 3 7 days( 14 days in Arabic months). If the cycle was longer than 28 days, the number of additional days are added to the days used in the rule Do the opposite if the cycle is shorter Biparietal diameter: accurate +/- 3 weeks ( useful between wks 7-12) Crown rump length: accurate +/- 1 week (useful between wks 7-12) Fundal height: correspond to gestational age in weeks .
  • 9. Measurement Symphyseal Fundal height  Evidence supports either palpation or S- F measurement at every AN visit to monitor fetal growth  measurement should start at the variable point (F) and continue to the fixed point (S)  SF measurement should be recorded in a consistent manner (therefore cms at RWH) 13/12/200 3
  • 10. Fetal Presentation and Descent  Check presenting part beginning around 30 weeks  Descent of presenting part is important as term approaches 13/12/200 3
  • 11. Auscultation of fetal heart  Listening to fetal heart is of no known clinical benefit, but may be of psychological benefit to mother (Consensus opinion)  Should be offered at each visit after about 20 weeks 13/12/200 3
  • 12. Routine BP measurement  HT is defined when systolic BP is 140mmHg +/or DBP is 90 mmHg or there is an incremental rise of 30 systolic or 15 diastolic  Automated devices & ambulatory devices should not be used (Mercury devises seem best) 13/12/200 3
  • 13. Urinalysis by dipstick for proteinuria - evidence  high incidence of false +ve and - ve using dipsticks cf 24 hr urine collection  reliable in detecting highly variable elevations in protein in pre-eclampsia  Gribble et al AJOG 1995; 173: 214-7 13/12/200 3
  • 14. Urinalysis by dipstick forn proteinuria - evidence  no statistical differences in rates of PAH, fetal distress, abruptio placentae, neonatal outcome in those with absent, mild or marked proteinuria by dipstick  US and Canadian Guidelines recommend screening for pre-eclampsia by BP measurement rather than dipstick 13/12/200 3
  • 15. Urinalysis by dipstick for proteinuria - guidelines  Routine screening for proteinuria in low risk pregnant women not recommended IV  assessment hypertensive pregnancies requires estimation of total protein in 24-hr collection IV  If detect hypertension then use dipstick for testing proteinuria 13/12/200 3
  • 16. Routine weighing at A/N visits - evidence  weighing at every antenatal visit routine practice for many years  No conclusive evidence for weighing at each visit. Maternal weight not clinically useful screening tool for detection of IUGR, macrosomia or pre-eclampsia IV  Weighing at booking or other times may be indicated eg anaesthetic risk assessment (done BIV at RWH) or maternal weight concerns 13/12/200 3
  • 18. Initial recommended tests  FBE  MCHC/MCV (Thal screen. Ferritin and Hb electrophoresis if low)  Blood group/Ab screen  HIV (level 1 evidence)  Hep B  Syphilis (ideally prior 16 weeks)  Rubella Abs 13/12/200 3
  • 19.  Urine testing- either 2 step or MSU+dipstick  PAP if due Consider  Hep C  Ferritin  Vit D levels - common in patients at RWH  addit Thal screen  dating US 13/12/200 3
  • 20. Hepatitis C screening  Should be offered to all at increased risk  history of injecting drugs  partner who injected drugs  tattoo or piercing  been in prison  blood t/f later positive for Hep C  long-term dialysis or organ transplant before 7/92 13/12/200 3
  • 21. Prenatal testing Down screening  Screening - : early US, 15-17 week MSST, Early combined screening(first trimester MSST and early US)  diagnostic testing - CVS, amniocentesis Other testing according to history eg for CF, Fragile X, Thalassaemia, Huntington's disease 13/12/200 3
  • 22. Prenatal screening for Down’s syndrome  All women should be offered screening irrespective of age III/IV  counselling given by appropriately trained staff and specific to age of each woman III/IV 13/12/200 3
  • 23. Down syndrome screening  Screening should  include accurate dating by 1st T u/s IV  either by 2nd T biochem, or nuchal translucency alone or combination III  notify result irrespective of risk in understandable format II  if increased risk should be offered further counselling and diagnostic testing within 72 hrs or ASAP IV 13/12/200 3
  • 24. Down’s syndrome screening  Quality of counselling is of primary importance, non-directional, if chooses screening, should be single-step III  Nuchal translucency should be performed at 11-14 weeks by trained operators and risks derived in conjunction with gestation and maternal age IV 13/12/200 3
  • 25. Other recommended tests  26 weeks (at hospital)  Gestational diabetes screening -  AB screen on all women  36 weeks  GBS screen  (Ab if RH -ve has been ceased) 13/12/200 3
  • 26. Screening for GDM  In absence of high level evidence to either support or abandon screening reasonable to  not offer screening  selectively offer screening to all with risk factors  offer screening to all  if screening do so between 24-28 weeks  RWH screen all women at 26 weeks 13/12/200 3
  • 27. Prevention of Early Onset GBS  Swabs should be taken between 35-37 weeks’ III  Intrapartum antibiotics recommended if  <37 weeks’  ruptured membranes >18 before delivery  maternal temperature ³38 C  previous GBS colonisation, bacteruria or infant with GBS III 13/12/200 3
  • 28. Antenatal anti-D prophylaxis  Prophylactic Anti-D at 28 and 34 weeks’ gestation  No level I evidence  Level II and III evidence would suggest that the 1.5 percent immunisation rate could be reduced to 0.1-0.2% through antenatal prophylaxis (Huchet et al, 1987;Bowman and Pollock, 1978; Hermann et al, 1974)  www.health.gov.au/nhmrc/publicatio ns/pdf/wh27.pdf 13/12/200 3
  • 29. 13/12/200 3 Investigation: routine test: Blood group and Rh type ( if positive, appropriate management) CBC Urine analysis- to prevent UTI affecting pregnancy) MSU HBs Ag ( if a mother has it, 70-90% chance of foetus getting it, 90% chance of being chronic carrier. Prevent by treating newborn of HBs AG+ve mother with B immune globulin and hep B vaccine) Rubella Syphilis U/S: Determine foetal crown rump length and thus gestational age Identify multiple gestation Identify gross abnormalities/ markers of genetic disease. Cervical cytology
  • 30. 2-Screening tests: Anaemia Gestational DM (best carried out between 24 and 28 weeks, observe 1 hr after 50g glucose solution. A reading of 126 mg/dl or greater is abnormal, according to the amended WHO recommendations 1999 regarding DM, as is HbAlc of greater than 90%. In these cases proceed to glucose tolerance test) Antibodies Triple test: Alpha feto protein in normal serum, oestriol, HGG ( to detect neural tube defect or chromosomal defect, 16-18 weeks) Hb electrophoresis Tuberculin skin testing Urine culture- for glucose, ketones and protein, bacilli Cervical culture: N gonorrhoea, group B streptococci, Chlamydia trachomatis, Mycoplasma hominis Toxoplasma antibody test HIV 13/12/200 3
  • 31. HIV: Voluntary Counseling and Testing  Voluntary HIV counseling and testing should be available to every pregnant woman--for public health reasons as well as for the benefit to the individual woman.  Pre and post-test counseling is an essential part of managing HIV in pregnancy. 13/12/200 3 Source: WHO and UNAIDS 1999.
  • 32. Benefits of Voluntary HIV Counseling and Testing 1) If the HIV test is positive, the woman can get early counseling and treatment 2)Allows appropriate follow-up and treatment of child 3)Enables a woman to make decisions regarding continuation of the pregnancy and future fertility 4)May allow the institution of anti-retroviral (ARV) therapy 13/12/200 3 Source: WHO and UNAIDS 1999.
  • 33. Benefits of Voluntary HIV Counseling and Testing continued 5) Provides the opportunity to implement strategies that attempt to prevent transmission to the child 6) Can inform partner and enable him to get counseling and testing 7) Women can take precautions to prevent transmission to partners 8) If the HIV test is negative, the woman can be guided in appropriate HIV prevention 13/12/200 3 Source: WHO and UNAIDS 1999.
  • 34. Syphilis  Maternal-fetal transmission may be as high as 80%.  Incidence of adverse effects on the fetus/infant due to untreated maternal syphilis reported in some studies was: Spontaneous abortion – 20% Perinatal death – 30% Congenital syphilis – 25% Source: WHO 1991. 13/12/200 3
  • 35. Syphilis continued  A study in Zambia found syphilis to be the single most common cause of fetal wastage. The adverse outcomes of syphilis were halved by a fairly incomplete program of screening and treatment. Sources: Hira et al 1990; Tinker and Koblinsky 1993. 13/12/200 3
  • 36. Syphilis continued  Even where prevalance is relatively low (i.e., as in most industrialized countries) an antenatal syphilis screening program is a cost-effective intervention.  Initiation of treatment should occur at the same visit as the screening. 13/12/200 3 Source: Wang and Smaill 1989.
  • 37. Tuberculosis  Infants born to women with tuberculosis (TB) have an increased risk of morbidity and mortality in the neonatal period. Source: Figueroa-Damian and Arredondo-Garcia 2001. 13/12/200 3
  • 38. Severe anemia  Mild or moderate anemia is not correlated with adverse pregnancy outcomes  Severe anemia, however, (hgb <7 g/dL or hct <20%) is associated with increased preterm delivery, inadequate intrauterine growth, increased perinatal mortality and increased maternal mortality. 13/12/200 3
  • 39. Severe anemia continued  Providers can screen for anemia by 1)Hemoglobin (hgb) by thin film/smear 2)Hematocrat (hct) test 3)Hemoglobin Color Scale, or 4) Clinical observation of the inferior conjunctiva of the eye, the nail beds and the palm. If any of these are pale, the woman is severely anemic. Other symptoms include shortness of breath and signs of heart failure. 13/12/200 3
  • 40. Tetanus Toxoid  Tetanus toxoid is  An effective, stable, cheap toxoid which has been available for > 50 years and is produced in many developing countries.  Effective in preventing neonatal tetanus (NNT), which causes approximately half a million deaths/year) and maternal tetanus, which is estimated to cause 30,000 deaths annually. Sources: Fauveau V et al 1993; Bennett JV 2000. 13/12/200 3
  • 41. Iron Deficiency  Globally among all populations, iron deficiency (and its manifestation in anemia) is the single most prevalent nutrient deficiency condition. The World Health Organization (WHO) estimates put anemia prevalence at 52% among pregnant women. Source: MotherCare, John Snow, Inc. 2000. 13/12/200 3
  • 42. Iron Folate Supplements  The International Nutritional Anemia Consultative Group, WHO and UNICEF have endorsed the following guidelines: 1) All women should consume daily iron folate supplements for 6 months during pregnancy. 2) Where anemia prevalence is <40%, women should receive supplements of 60 mg iron and 400 micrograms of folate 3) In areas where anemia prevalence is high among pregnant women (³40%), women should continue the same dosage for 3 months into postpartum. Sources: Stoltzfus and Dreyfuss 1998; McDonagh 1996. 13/12/200 3
  • 43. 3-Specific nutritional advice: 0.4 mg Folic Acid per day ( it prevents tube defects) 30 mg ferrous iron 60 mg ferrous iron 2 times a day ( anaemic patients) Supplement copper and zinc in anaemic patients Avoid Vitamin A in huge amounts as it is teratogenic 13/12/200 3
  • 44. Nutrition Requirements Good antenatal nutrition includes:  Meeting the caloric needs  Eating foods which supply specific micronutrients  Providing micronutrient supplementation An underweight mother increases the likelihood of a low birth weight (LBW) baby; low iron intake contributes to anemia. 13/12/200 3
  • 45. Models of antenatal care  At each visit midwives and doctors should offer information, consistent advice, clear explanations and provide opportunity to ask questions III/IV  More likely to be satisfied with A/N care when perceive care givers are kind, supportive, courteous, respectful, recognise individual needs IV 13/12/200 3
  • 47. Complications Cannot Be Reliably Predicted  No formula or scoring system can reliably distinguish those who will develop complications from those who will not. 13/12/200 3
  • 48. Complication Readiness is KNeepyal tStou dSyurvival  Less than 50% of families of women who died in pregnancy, delivery or postpartum, recognized the problem.  36% decided within 2 hours to seek care and get transport.  15% decided in 2 to 23 hours to seek care and get transport.  29% made the decision and arranged transport 1 to 8 or more days after recognition of a life-threatening complication. 13/12/200 3 Source: MOH, Nepal 1998.
  • 49. Complication Readiness is Key to Survival continued  The interval from onset to death for antepartum hemorrhage can be approximately 12 hours.  The interval from onset to death for postpartum hemorrhage can be two hours.  The hours required for making arrangements (which could have been made prior to the emergency) may define the line between survival and mortality. 13/12/200 3 Sources: Maine 1991; MOH, Nepal 1998.
  • 50. Danger Signals  Families of pregnant women need to know how to recognize the signs of complications as well as what to do and where to get help  In Nepal, less than 50% of families of women who died recognized the problem. 13/12/200 3 Source: MOH, Nepal 1998.
  • 51. On subsequent visits 13/12/200 3 Check: oBp 0 urine analysis 0 weight? Ask for : 0 FM 0 Maternal complaints Examine: 0 abdomen/obstetric 0 listen/see FH USS if required Advice: Treatment of complaint & health education
  • 53.  1. Infections: 13/12/2003 Syphilis Hepatitis .H.I.V Rubella :Blood disorders. 2 Sickle cell Thalassaemia :Fetal anomalies. 3 Structural e.g. N.T.D :Chromosomal abnormalities. 4 Down’s T18 T13
  • 54. 13/12/200 3  Non Invasive:  B-HCG …. Urine 14 days post ovulation, serum 7-9 days ….. doubling time…..  Alpha feto protein.  Triple test: AFP, Unconjugated oestriol & B-HCG  Ultra Sound scan  Invasive:  Amniocentesis  Chorionic villus biopsy  Chordocentesis
  • 56. 13/12/200 3  Indications of use:  pregnancy location  viability  fetal number  dating  anomaly  placental localization, amniotic fluid  fetal growth and wellbeing  during invasive procedures
  • 59. 13/12/200 3  Amniocentesis:  carried at 15-18 wks. Failure rate < 1%.. Culture time 10- 12 days  For chromosomal analysis: Down’s etc…  Miscarriage rate 0.5-1%.... Experience and USS  Anti-D
  • 60. 13/12/200 3  Fetal blood sampling:  Ultra sound guided. Cord insertion into the placenta  Only in specialist centres  indications:  Rh iso-immunisation  non-immune hydrops  Fetal infection  Rapid karyotyping in some IUGR  Anti-D  Fetal loss ~ 1%.
  • 63.  Assessment of gestational age and fetal growth:  menstrual history unreliable in up to 45% of women  serial fundal height measurement provides a guide to fetal growth  USS: crown-rump length before 14 weeks  USS: BPD serial measurement every 2 weeks for fetal growth. Unreliable after 28 weeks for dating  USS: head/abd ratio, 2 weeks serial HC & AC for fetal growth .. IUGR AC< but initially HC ~.  USS: femur length, more precise guide to gestational age than BPD 13/12/200 3
  • 64. 13/12/200 3  Principles:  the ideal scheme to assess FWB should: Take account of cycles of normal fetal behavior  detect impending harm accurately and in time to intervene to prevent it  give reassurance preferably up to 7 days  avoid causing unnecessary anxiety  allow detection of specific causes e.g hypoxia, infection, malf’n  produce measurable benefits in reducing perinatal loss/injury  such system is likely to involve tests which assess several fetal systems, CVS, NS,, RS and use >1 modality
  • 65. 13/12/200 3  Fetal Movement Count:  Fetal Heart Recording….. CTG Biophysical Profile {BPP} scoring Doppler studies
  • 66.  BPP uses FHR monitor and real time USS to assess: 13/12/200 3  fetal breathing movement  discrete body or limb movement  fetal tone  FHR  amniotic fluid volume  Amniotic fluid volume is most important  Fetal breathing movement is the first to disappear in asphyxia  7 days reassurance in low risk, only 24 hours in high risk preg
  • 68. Clinical Indications for Doppler Studies  most useful in assessing IUGR  identify only the sub-group which is hypoxemic bec/of inadequate placental function and may be abnormal for up to 18 weeks before any fetal problem is observed  no proven role in population screening for increased risk of pre-eclampsia or IUGR 13/12/200 3

Notas del editor

  1. Source: WHO and UNAIDS. 1999. HIV in Pregnancy: A Review, pp. 27-31. Geneva, Switzerland.
  2. Source: WHO and UNAIDS. 1999. HIV in Pregnancy: A Review, pp. 27-31. Geneva, Switzerland.
  3. Source: WHO and UNAIDS. 1999. HIV in Pregnancy: A Review, pp.27-31. Geneva, Switzerland.
  4. Source: World Health Organization Programme of Maternal and Child Health and Family Planning Unit. 1991. WHO Consultation on Maternal and Perinatal Infections, 28 November – 2 December 1988 report. WHO/MCH/91.10. WHO: Geneva, Switzerland.
  5. Sources: Hira SK et al. 1990. Syphilis intervention in pregnancy: Zambian demonstration project. Genitourinary Medicine 66(3): 159-164;Tinker A and MA Koblinsky. 1993. Making Motherhood Safe, pp. 99-100, World Bank: Washington, DC.
  6. Source: Wang E and F Smaill. 1989. Infection in pregnancy, in Effective Care in Pregnancy and Childbirth. Chalmers I, MW Enkin and MJNC Keirse (eds), pp.534-564. Oxford University Press: Oxford, UK.
  7. Source: Figueroa-Damian R and JL Arredondo-Garcia. 2001. Neonatal outcome of children born to women with tuberculosis. Archives of Medical Research 32(1): 66-69.
  8. Sources: The LINKAGES Project. 2000. Maternal Nutrition: Issues and Interventions. A computer-based slide presentation for advancing maternal nutrition. Academy for Educational Development: Washington, DC; Stoltzfus RJ and ML Dreyfuss. 1998. Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia. INACG/WHO/UNICEF: Washington, DC.
  9. Sources: Fauveau V et al. 1993. Maternal tetanus: Magnitude, epidemiology, and potential control measures. International Journal of Gynecology and Obstetrics 40(1): 3-12; Bennett JV. 2000. Memo from author, The role of topical antimicrobials, to persons interested/involved in control of neonatal tetanus (NNT), 14 February.
  10. Source: MotherCare, John Snow, Inc. (JSI). September 2000. Issues in Programming for Maternal Anemia. MotherCare/JSI: Arlington, Virginia.
  11. Sources: Stoltzfus RJ and ML Dreyfuss. 1998. Guidelines for the use of iron supplements to prevent and treat iron deficiency anemia. INACG/WHO/UNICEF: Washington,DC; McDonagh M: 1996. Is antenatal care effective in reducing maternal morbidity and mortality? Health Policy and Planning 11(1): 1-15.
  12. The source listed below discusses the difficulties in implementing an effective risk scoring system. Source: Rooney C. 1992. Antenatal Care and Maternal Health: How effective is it? A review of the evidence, pp. 12-16. WHO: Geneva, Switzerland.
  13. Note: Optional slides 24 and 25, if used, should always be used together. In Nepal, a recent study showed that less than 50% of families of women who died in pregnancy, delivery or postpartum, recognized the problem. In rural situations in the developing world, as many as 12 to15 hours may elapse between the decision to seek treatment and the beginning to travel towards that treatment. Source: Ministry of Health (MOH). His Majesty’s Government of Nepal. 1998. Maternal Mortality and Morbidity Study, p. 29. MOH: Kathmandu, Nepal. This same study in Nepal found that of those families who did decide to seek care, 36% decided within 2 hours to seek care and get transport; 15% decided in 2 to 23 hours to seek care and get transport; while 29% made the decision and arranged transport 1 to 8 or more days after recognition of a life-threatening complication. Source: Ministry of Health (MOH). His Majesty’s Government of Nepal. 1998. Maternal Mortality and Morbidity Study, p. 31. MOH: Kathmandu, Nepal.
  14. Note: Optional slides 24 and 25, if used, should always be used together. Life-depleting hours can be lost from the time a complication that needs treatment is recognized through the time arrangements have been made for all the elements that must be in place for the woman to reach help. Considering that the interval from onset to death for antepartum hemorrhage can be approximately 12 hours, while the interval from onset to death for postpartum hemorrhage can be two hours, the hours required for making arrangements (which could have been made prior to the emergency) may define the line between survival and mortality. Sources: Maine D. 1991. Safe Motherhood Programs: Options and Issues. Center for Population and Family Health, p. 42. Columbia University: New York; Ministry of Health (MOH), His Majesty’s Government of Nepal. 1998. Maternal Mortality and Morbidity Study, pp. 27-28. Kathmandu, Nepal. Birth planning and complication readiness prior to the development of a complication is key to survival.
  15. Source: Ministry of Health (MOH). His Majesty’s Government of Nepal. 1998. Maternal Mortality and Morbidity Study, p. 29. MOH: Kathmandu, Nepal.