Important aspects of antenatal care

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Important aspects of antenatal care

  1. 1. IMPORTANT ASPECTS OF ANTENATAL CARE CME Conducted by ATLAS HOSPITAL, RUWI MUSCAT
  2. 2. NICE/RCOG GUIDELINES – JUNE 2010 Pregnancy is a normal physiological process & any interventions offered should have known benefits & be acceptable to the pregnant women Current models of ante-natal care originated in the early 20th century. The pattern of visits recommended at that time (monthly until 30 wks, then fortnightly to 36 wks and then weekly until delivery) is still recognisable today
  3. 3. AIMS OF ANTENATAL CARE Monitoring the progress of pregnancy with minimum interference Guidance to the expectant mother Early detection of any deviation from normal Institution of corrective measures wherever possible Preparation of the mother for labour & delivery
  4. 4. PRENATAL CARE The ideal initial prenatal care visit occurs before conception with a pre-conceptive visit. A pre-conceptive visit allows modification of behavioral choices, medication, and optimizing medical concerns before conception.
  5. 5. FIRST VISIT – 10 WEEKSANC BEGINS AS SOON AS PREGNANCY ISCONFIRMED CONFIRMATION OF PREGNANCY – UPT HISTORY TAKING GENERAL & SYSTEMIC EXAMINATION INVESTIGATIONS – Hb, RBS, Ur, Blood Group, HIV, VDRL, HbsAg , Sickling Test USG –Confirming viability & number Estimation of GA & EDD (10–13wks)
  6. 6. Advice - Do’s And Dont’s DIET WORK & EXERCISE – Continue working till the end & moderate exercise COMMON SYMPTOMS – Morning sickness, Heartburn, LBA, Frequency, Vg Discharge, Constipation SEXUAL INTERCOURSE – safe MEDICATIONS – Folic acid & calcium ALCOHOL INTAKE - <1-2 UK units/wk (1 u= half a pint of ordinary strength lager/beer, or one shot [25 ml] of spirits. One small [125 ml] glass of wine =1.5 UK units) SMOKING – Quit-LBW, IUGR DRIVING & TRAVEL – Car (seat belts) & Air travel (36wks), travel abroad & related vaccinations
  7. 7. Seat Belt in pregnant lady – the right way!
  8. 8. SCREENING FOR MATERNAL DISEASES ANEMIA – Booking – 11 gm% 28wks – 10.5 gm% No need for routine Iron supplements SICKLE CELL DISEASE - Sickling test ALLO-ANTIBODIES - ICT - Routine anti-D prophylaxis at 28 & 36 wks to all non-sensitised pregnant women Women should be screened for atypical red cell allo antibodies (Kidd, Duffy, Anti-C) in early pregnancy & at 28 weeks, regardless of their rhesus D status
  9. 9. SCREENING FOR FETAL ANOMALIES  DOWN’S SYNDROME- Nuchal Thickness - performed end of first trimester (13w0d-13w6d) – increased >6 mm  COMBINED TEST – NT + HCG + PAPP-A (11w- 13w6d)  TRIPLE/QUADRUPLE TEST 15-20wks.  CONTINGENT SCREENING measuring free β- hCG & PAPP-A in all pts at 10 wks -those with low risk are screened negative- remainder NT - 13 wks - low risk are screened negative-others offered marker assays & diagnostic tests.  ANOMALY SCAN - 18w 0d-20w 6d – Optional
  10. 10. TRIPLE MARKER TEST Performed between the 15th & 18th wk. AFP (fetus), HCG (placenta), and Estriol (both) High AFP levels - neural tube defects, anencephaly, mistaken dates. Low AFP & Estriol & High HCG -Trisomy 21 (Down) Trisomy 18 (Edwards) or any other type of chromosome abnormality.
  11. 11. QUADRUPLE TEST Pts registering in late 2nd trimester-22wks AFP (fetal liver), Estriol (placenta+fetal liver),HCG (placenta),Inhibin-A (placenta) High AFP levels - open neural tube defect, mistaken dates or twins. Low AFP levels - high risk for Down syndrome. High HCG and Inhibin-A levels - increased risk Down syndrome. Low Estriol - high risk for Down syndrome
  12. 12. SCREENING FOR INFECTIONS Asymptomatic bacteriuria - persistent bacterial colonisation of the urinary tract without symptoms. After the initial screening, patients only need to be screened for UTI infections if they are symptomatic HIV – MTCT- more than 35% reduced to 5% with ART with ZT(300mg)+NVP(200mg)+3TC(150mg) twice daily-14 wks till BF & 6wks for infant after BF The combination of ART, LSCS and avoiding breast feeding can further reduce the transmission to 1%. Latest guidelines – Continue ART + Breast feeding
  13. 13. SCREENING FOR INFECTIONS HEPATITIS–B - Screening for HBsAg, new sample-confirmatory testing & testing for e-markers to know if baby will need Ig along with vaccine postnatally RUBELLA - susceptibility screening offered early to identify women at risk of contracting rubella infection and vaccinate in the postnatal period. SYPHILLIS- TPHA if VDRL is positive Mother-to-child transmission is associated with neonatal death, congenital syphilis, stillbirth and preterm birth
  14. 14. SCREENING FOR CLINICAL CONDITIONSGESTATIONAL DIABETES RBS at booking - less than 130 mg/dl or 7.2 mmol/l OGCT - 1 hr after 50 gm of glucose - 24wks – h/o GDM–16wks-< 140mg/dl or 7.8 mmol/l GTT– 75 gm of glucose and 03 days of diet rich in carbohydrates. Fasting – 104 mg/dl or 5.8 mmol/l 2 hr after glucose – 140 mg/dl or 7.8 mmol/l A 2 hr 75 g OGTT is used as the gold standard diagnostic test and is assumed to be 100% sensitive and specific
  15. 15. PRE-ECLAMPSIA Pre-eclampsia is a complex disorder with widespread endothelial damage in all organs, thus presenting signs and symptoms may be more varied than just high BP & proteinuria Blood pressure measurement and urinalysis for protein–each visit. Hypertension single diastolic BP of 110 mmHg or any consecutive readings of 90 mmHg on more than one occasion at least 4 hours apart. Proteinuria 02 clean catch samples-4 hours apart with 2+ proteinuria by dipstick are significant. 300 mg protein in a 24 hour sample
  16. 16. PLACENTA PREVIA Low-lying placentae - not an uncommon finding on early trimester scans Most low-lying placentae detected at the routine scan generally resolve by the time the baby is born. Only a woman whose placenta extends over the internal cervical os should be offered another trans-abdominal scan at 32 weeks. If the trans-abdominal scan is unclear, a trans- vaginal scan should be performed.
  17. 17. MONITORING FETAL WELL BEING Clinical Examination – Symphysis-Fundal height – after 24wks (difference of more than 2 cms is significant) Daily Fetal Movement Count – DFMC–10/12 hrs or 3 in one hr – one hr post meals. Ultrasound – not accurate in assessing fetal growth in later trimesters Doppler Studies - in suspected IUGR CTG/NST– valid only after 32 weeks Biophysical Profile – Movement, tone, HR (NST), Breathing, AFI – Normal score 8 or more Modified Biophysical Profile – NST + AFI
  18. 18. VACCINATIONS Tetanus Toxoid - 02 doses Killed/Inactivated/Toxoids can be given . Live vaccines are contraindicated Not Given - BCG, Cholera, Japanese Encephalitis, Measles , Mumps, Rubella, Typhoid, Varicella Give only if essential as safety in pregnancy has not been documented - Hepatitis A & E Influenza Meningococcal OPV Rabies Diphtheria Yellow fever
  19. 19. MANAGEMENT OF COMMON SYMPTOMS IN PREGNANCY NAUSEA & VOMITTING More in primigravidas & multiple pregnancies Cause - First/Increased exposure to HCG No harm to fetus - Generally settles by 16-20wks Diet - Avoid oily & spicy food Small frequent meals Home remedies – Ginger & lemon Medications - T. Pyridoxine - twice daily Severe cases – Inj. Metoclopramide
  20. 20. HEARTBURN Effect of progesterone - reduced tone of lower esophageal sphincter Diet modifications – reduce spicy food & eat small and frequent meals at short intervals Postural modifications – avoid bending & lying down immediately after meals Medications–H2 receptor blockers - Ranitidine Proton Pump Inhibitors - Omez ® Antacids - Gelusil®
  21. 21. CONSTIPATION Effect of Progesterone – Relaxes musculature reduces tone & motility of smooth muscles Diet modification – High fibre diet Plenty of water More fruits & vegetables Medications – Mild Laxatives–Lactulose Herbolax ® Liquid Paraffin
  22. 22. VAGINAL DISCHARGE Due to vascular congestion & increased activity of cervical mucus secreting glands No treatment required Watch for – Change of colour Foul Smell Associated Pruritis Painful or burning micturitionAbove signs indicate infection in which case the same will have to be treated accordingly
  23. 23. BACKACHE Initially due to pelvic organ congestion & later due to strained pelvic supports & exaggerated lumbar lordosis Lifestyle – as active as possible Support- Lower back when sitting Abdominal bump when lying down Non-pharmacological - Back massage - Hot fomentation Drugs - Unrelenting cases - Analgesics - Balms/gels for LA
  24. 24. HAEMORRHOIDS & VARICOSE VEINS Due to vascular congestion Effect of Progesterone No effective treatment in pregnancy Avoid constipation Diet advice – high fibre, plenty of water Leg elevation & avoid prolonged periods of standing Compression stockings Medications – Laxatives, creams & Flavinoids Hirudoid cream
  25. 25. POST-DATISM At 40 wks of gestation, only 58% of women had delivered, 74% by 41 wks and 82% by 42 wks Perinatal mortality & morbidity is increased if duration of pregnancy is more than 42 wks. Sweeping/Stripping of membranes – 41 wks – likelihood of spontaneous onset of labour in 48 hrs 41-42 weeks – Twice weekly NST, USG for AFI 42 weeks – Induction of labour & delivery
  26. 26. INTERVENTIONS NOT ROUTINELY RECOMMENDED Repeated maternal weighing. Breast or pelvic examination. Iron or vitamin A supplements. Routine Doppler ultrasound in low-risk pregnancies. Ultrasound estimation of fetal size for suspected LGA Routine screening for preterm labour. Routine screening for cardiac anomalies using NT. Routine fetal-movement counting. Routine auscultation of the fetal heart. Routine antenatal electronic cardio-tocography. Routine ultrasound scanning after 24 weeks
  27. 27. THANKS

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