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ANTENATAL SCREENING
Reference Material
• New WHO guidelines on antenatal care –
Systematic review BJOG 2016;123:519-28
• Guidelines by Government of western
Australia
• SOGC guideline on Prenatal Screening
• RCOG / NICE Guidelines
OUR PUBLICATION AT FIGO
ABSTRACT
FIGO GUIDELINES PRESENT 8
GOOD PRACTICE ADVISES
• 1.SCREENING FOR CHROMOSOMAL ABNORMALITIES
AND NIPD
• 2.PRECONCEPTIONAL FOLIC ACID FOR THE
PREVENTION OF NEURAL TUBE DEFECTS
• 3.CERVICAL LENGTH AND PROGESTERONE FOR THE
PREDICTION AND PREVENTION OF PRETERM BIRTH
• 4. & 5.MAGNISIUM SULPHATE USE IN OBSTETRICS
• 6.ULTRASOUND EXAMINATION IN PREGNANCY
• 7.THYROID DISEASE IN PREGNANCY
• 8.HYPERGLYCEMIA IN PREGNANCY
WHY SCREEN ?
Why Screen ?
1.Triage mothers to High Risk & Low Risk
2.Prevent Maternal Complications
3.Screen the fetus for
• Chromosomal errors
• Structural Defects
• Growth abnormalities
4.Decide the time and mode of safe
delivery
ADD SCREENING FOR N.C.D.HERE
THE PYRAMID OF ANTENATAL CARE
Post delivery continued screening
Routine Antenatal Care 1990s…….
Early scan to diagnose
pregnancy & dating
Fetal defects
22-24 wks
Anomaly scan
Routine Antenatal Care 2005
11-14 wks
Fetal defects
20-23 wks
P I P I P
The great
Ob syndrome
Routine Antenatal Care 2010
11-13+6 wks
Fetal defects
Chemical markers Major
Cardiac defects
Uterine artery Doppler
20-23 wks
Anomaly scan
FOGSI OLD CHECK LIST OF 2009,MODIFIED IN 2017 AT FOGSI T.O.G.
First Trimester
Second Trimester
Third Trimester
FIRST TRIMESTER
Screening is VOLUNTARY
Screening should be made UNIVERSAL
 SCREENING SHOULD BE OFFERED TO
EVERYONE
 Screening should be DONE only to women willing
for the same
 Those who decline screening may not be offered this
tests and decision should be documented.
FIRST TRIMESTER
Body Mass Index – If high
•Prevent further weight gain
•Institute Life style modifications
•Medical Therapy – Metformin
•Nutrition Therapy – High fibre diet
•Daily Exercise
•Prepare for safe delivery
General Examination
• Heart – Murmurs
• Lungs – Rhonchi
• Breast – Lumps / Nipples
• Abdomen – Scars / Lumps
• Per Speculum – Discharge / Polyp / Erosion
LBC / HPV
• Anus – Sentinel Pile
Blood Pressure
• Hypertension – BP in both arms
Sitting position
Dissappearance of korotkov
• Hypotension – increase sodium/ potassium intake
• Screening test for PIH
 Placental Growth Factor (PlGF)
 S Flt
 s endoglin
 Uterine artery doppler flow indices
Screening for Anaemia
• Complete Blood count
• Peripheral Smear
• If Microcytic Hypochromic
Iron studies – Ferritin / Total Iron / TIBC
Haemoglobin Electrophoresis
• If Normocytic / Macrocytic
Serum Vitamin B12
Serum / Red cell Folate
Reticulocyte count
Blood group & Rhesus Antibodies
• If Rhesus Negative
• Partners Blood group – If negative –
• If positive – Indirect Coombs test
• If positive – Cordocentesis & fetal blood
transfusion with Rh negative blood at
periodic intervals
• Deliver at 34 weeks
Endocrine Screening
• Thyroid function test
• If abnormal, thyroid antibodies
• In PCO – screen for GDM early (HbA1C)
• If galactorrhea – Prolactin
• Serum Vitamin D
• Relaxin ?
Infection Screen
• Complete blood count /ESR
• Rubella antibodies
• Urine routine & microscopy
• Mid stream urine culture
• High Vaginal / Endo cervical swab /Wet Prep /
Vaginal pH / Chlamydia antibodies
(SOLVS + FVU PCR)
• HIV / Hep B / Hep C / VDRL
Biochemical
Screening
Watch
carefully
the picture
Where do all these markers come
from?
(adrenals)
(liver)
Various Integrated screening in
strategies (1st and 2nd trim)
Main strategies:
• Fully Integrated
• Step-wise sequential
• Contingent screening
1st trimester:
NT, PAPP-A
No risk estimate
2nd trimester:
Fb-hCG, AFP, uE3, (± Inhibin)
Final risk estimate:
All markers
1st trimester:
NT, PAPP-A, Fb-hCG
Risk estimate
2nd trimester:
Fb-hCG, AFP, uE3, (± Inhibin)
Final risk estimate:
All markers
CVS
NIPT
High risk
Low risk
1st trimester:
NT, PAPP-A, Fb-hCG
Risk estimate
2nd trimester:
Fb-hCG, AFP, uE3, (± Inhibin)
Final risk estimate:
All markers
CVS
NIPT
HR
Borderline risk
No further
screening
LR
First trimester screening for
Preeclampsia
Maternal serum PIGF,
Mean arterial Blood pressure
- Implantation
- Maternal artery remodelling
Detection rate – 90%
0
10
20
30
Falsepositive(%)
Doppler
12%
30%
PP13
9%
Doppler
& PP13
New Screening Protocol for Trisomy 21 + PE + ONTDs
in Indian Scenario
Viability Scan: 6-8 weeks
LOW RISK HIGH RISK
NIPT
Anomaly scan at 19 weeks
with genetic sonogram
Amniocentesis
CVS
LOW RISKHIGH RISKLOW RISK HIGH RISK
Non Invasive Prenatal Testing (NIPT)
• NIPT – 9 weeks onwards
• At least 4% fetal fraction to be identified
• Twin Pregnancy – confusing results
• Vanishing twin – confusing results
• If positive – CVS / Amniocentesis
CVS
•11-14 weeks
•Transcervical
•Check for chorionic villi under
microscope
•Risk of miscarriage 1%
•Need is obviated now due to NIPT
Amniocentesis
•15-18 weeks
•Risk of miscarriage < 1%
•To confirm diagnosis in positive
integrated screen and/or positive NIPT
•To screen known carriers for
chromosomally abnormal fetus
FIRST TRIMESTER
SCREENING FOR
CHROMOSOMAL
ANOMALIES
Screening in the 1st trimester
• Time window: 8 - 14 weeks
• Ultrasound Marker:
• NT
• Biochemical markers:
• PAPP-A
• Fb-hCG
• Marker combination:
• Combined test: NT, PAPP-A, Fb hCG
Screening for Trisomy 21 at 11- 14 weeks
2-stage (contingency) screening- UK system
USG (N.T.) AND DUAL MARKER FOR ALL
Fetal NT and
free BhCG and
PAPP-A at 12 wks
Very high risk
Very low risk
CVS
Reassure
Borderline
risk
Further
screening
Nasal bone
DV, TR
Screening for Trisomy 21 at 11- 14 weeks for
India
2-stage (contingency) screening proposed
RISK ESTIMATE BY ONLY USG N.T. AND OTHER MARKERS
Fetal NT
Nasal bone and
ductus venosus
tricuspid
regurgitation at 12
wks
Very high risk
Very low risk
CVS
Reassure
Borderline
risk
Further
screening
Free B hCG
PAPP-A
THIS WILL SAVE
TIME
MONEY
OPTIMUM USE OF OUR
SKILL
DOUBLE MARKER
TEST
Scan 20w NIPT
• MA + NIPT(OPTIONAL)
• Dual Marker
• NT + NB + TR + DV
First
trimester
• Quad Marker
• Genetic Sonogram
Second
trimester
Integrated 1st and 2nd
trimester screening
DR – 97%
FPR – 2.5%
SO PROPOSAL IS INDIAN
CONTINGENT SCREEN
OR
INTEGRATED FIRST AND
SECOND TRIMESTER
SCREEN
COMBINED FIRST TRIMESTER SCREEN
FOR RISK ESTIMATE…….
FOLLOWED BY COMBINED 2ND
TRIMESTER RISK SCREENING
99
COMBINED SCREENING & RISK ESTIMATION IN FIRST
TRIMESTER
100099
1LOW LEVELS PREDICT PRE ECCLAMPSIA
2 LOW RISK NO FURTHER TEST (1 : 1000)
INTERMEDIATE RISK (100 : 999) TO PROCEED TO SECOND TRIMESTER SCREENING VS NIPT
HIGH RISK (1 : 99) TO GO FOR CVS / NIPT
ANTENATAL CHECKLIST
First Trimester Recommended Preferable
weight BMI
Blood pressure Mean Arterial Pressure
Haemoglobin Complete blood count/ Peripheral smear /
Hb Electrophoresis / HPLC
Blood group ABO & Rh (both partners)
Urine routine MSU culture
VDRL/ Hep B / HIV HCV / Rubella IgG
TSH Thyroid function test / Thyroid Antibodies
Vitamin D
DIPSI test 75gms 2 hours blood sugar Hb A1C / OGTT/ 6 point blood sugar test
Dating scan + NT
Double marker (free beta
HCG + PAPP A1 )
(Contingent Screen2
Cervical length
Uterine artery Doppler
NIPT
Placental Growth Factor
(PLGF)
Per speculum exam Pap Smear, Bacterial vaginosis &
Chlamydia screen
Greater opportunity to secure a healthy pregnancy and healthy child,
with 1st Trimester evaluation
WHY CHOOSE BE HAPPY FIRST
TRIMESTER PREGNANCY CHECK?
 All the advantages of 1T screening:
Earlier reassurance and early
intervention if required
 Enhanced performance for 1T
combined aneuploidy screening:
To enable to higher DR or lower FPR
 4 marker biochemistry:
Aneuploidy risk on par with 2T Quad
 Some significant Fetal structural
abnormalities
 Pre-term Pre-eclampsia:
Identify a high risk group, who would
benefit from Aspirin
First Trimester
Second Trimester
Third Trimester
SECOND TRIMESTER
SCREENING
CERVICAL LENGTH SCREENING
ROUTINE TO PREVENT PRETERM
LABOUR AND FOR GUIDELINE FOR
CX STITCH
• ASYMPTOMATIC SINGLETON PREGNANCY A TVS CL <25
MM IN SECOND TRIMESTER
• SCREEN AT 11-13 WEEKS AND THEN AT 22-22 WEEKS
RECENT EVIDENCE SAYS CX STITCH DOES NOT HELP AND
PROGESTERONE MAY BE THE ONLY TREATMENT OPTION
HERE.ROUTINE MCDONALD STITCH PRACTISE SHOULD BE
INDIVIDUALISED
SECOND
TRIMESTER
Second Trimester Recommended Preferable
18-24 weeks Repeat bloods (Hb /
blood sugar / TSH) &
urine test as indicated
Quadruple OR Triple
marker
NIPT
Anomaly scan 3D/4D scan/ Fetal
Echo
Uterine artery
Doppler
Cervical length
DIPSI screen 75 gms 2
hour blood sugar
6 Points Blood
Sugar HbA1C
Sequential Screening
•Quadruple marker – 15-18 weeks
•NIPT 9 week onwards
•Amniocentesis – 15 week onwards
COMBINED 2ND TRIMESTER SCREENING
ANOMALY SCAN
Screening for GDM
• HbA1C
• DIPSI one step screen 75 gms 2
hour
• Cut off of 140 mg/dl
• At 24 to 28 weeks
• Repeat at 32 weeks in high risk
women i.e Polyhydramnios /
previous GDM / Parents &
siblings diabetic
Screening for PIH
• Blood Pressure BOTH ARMS SITTING
• Water Retention – edema / rapid weight
gain
• Micro albuminuria
• Spot test – Urine Protein /Creatinine
ratio
• Ratio of PlGF / sFlt
• LDH raised in HELLP Syndrome
• Renal artery doppler
Vaccination
• Tetanus Toxoid – ONE DOSE
• Tdap –SECOND DOSE AT 24 WEEKS
• Influenza vaccine 24 weeks onwards
• hpB can be given if not immunised
• Targetted Vaccine in case of travel to
endemic areas
• Post partum – HPV vaccine
First Trimester
Second Trimester
Third Trimester
THIRD TRIMESTER
SCREEN
Abbreviations
Hb Haemoglobin GCT- Glucose Challenge Test
TSH Thyroid stimulating hormone OGTT Oral glucose tolerance test
HbA1C Haemoglobin A1C NT Scan- Nuchal Translucency
Scan,
NIPT Non invasive prenatal testing PAPP A- Pregnancy Associated
plasma protein A
PlGF Placental growth factor VDRL Venereal disease reference
HCV Hepatitis C virus Hep B hepatitis B virus
HIV Human Immune defeciency virus HPLC high performance liquid
chromatography
Third
Trimester
Recommended Preferable
24 weeks
onwards
Repeat DIPSI Screen
TSH/Hb/Urine
HbA1C
Growth scan with liquor volume
& placental localisation
Fetal Doppler
velocimetry
Fetal movement count
(6 in 2 hours)
CTG (NST)
Modified
biophysical
Score
Doppler
velocimetry
THIRD TRIMESTER
INFECTION SCREEN
• GBS – Is routine screening required prior to
delivery ?
• Pelvic assessment – Does it improve your
decision for normal delivery ?
• Pelvic relaxation techniques / exercises like
walking / squatting / butterfly
NON USG SCREENING
FOR FETAL WELL
BEING
CARDIOTOCOGRAPHY
Cardiotocography
• Non Stress test vs Oxytocin Stress test
• When to start ? Post viability period 30
weeks
• How often to do ? Once a week
• What are the omnious signs –
Lack of BTB variation
Variable deaccelerations of cord
compression
Late deacceleration of fetal hypoxia
• Supplement with ST waveform analysis
• Fetal cord blood pH during labour
KICK CHART
Recording
•Every kick / roll is 1 movement
•Count 10 movements everyday
•Should be around 6 in 1 hour
•If < 6 movements in 2 hours
•Call doctor & come for CTG / USS
assessment
About baby’s movements
An active baby is usually a healthy baby. You
will feel your baby stretch, kick, roll and turn
every day. Some babies are more active than
others. All babies have periods of sleep during
which they are not as active. You will get to
know your baby’s pattern of movements and
when your baby is most active.
You should feel your baby’s movements
throughout the day, each day from 28 weeks of
pregnancy until the baby is born.
When during my pregnancy should I count
my baby’s movements?
Your health care provider may ask you
to count your baby’s movements once
every day.
If you think there is a decrease in your
baby’s movements this is an important sign that
your baby may not be well. Count your baby’s
movements to be sure that you feel at least 6
movements in 2 hours.
Reference:
Society of Obstetricians and Gynaecologists of Canada (2007).
Fetal Health Surveillance : Antepartum and Intrapartum Consensus
Guideline. Journal of Obstetrics and Gynaecology Canada. 29(9).
FETAL MOVEMENT
COUNT CHART
PLEASE BRING THIS CHART WITH YOU EACH
TIME YOU SEE THE DOCTOR/MIDWIFE
IMPORTANT PHONE NUMBERS:
DOCTOR:
MIDWIFE:
HOSPITAL:
DUE DATE:
OTHER INSTRUCTIONS:
For 24-hour nurse advice and health information call
Health Link Alberta:
1-866-408- LINK (5465)– Toll Free
In Calgary call 403-943- LINK (5465)
In Edmonton call 780-408-LINK (5465)
ADDRESS:
NAME:
HS0001-132 (2012/11)
How do I count my baby’s movements?
• Get into a comfortable position – lying on
your side or sitting. Place one or both of your
hands on your abdomen.
• Count each time that you feel your baby
move. If you feel many movements all at
once, count each movement that you feel.
• Write down the date and the time that you
start counting on the fetal movement chart.
• Make a mark on the chart each time your baby
moves.
• Stop counting when you have counted 6
movements.
• Write down the time you stopped counting.
• Do not count for more than 2 hours
What if I don’t feel 6 movements in 2 hours?
Count your baby’s movements once a day. You
should feel 6 or more movements in 2 hours.
If you count fewer than 6 movements in 2 hours
do not wait. Go to the hospital or birthing unit.
Your baby’s heart rate and movements will be
checked using a fetal monitor. This is called a
non-stress test or NST.
If you live too far from a hospital or birthing
unit, immediately contact your health care
provider for advice.
TWEAK Screening for alcoholism
• T – Tolerance (No of drinks one can hold)
• W- Worry about drinking
• E – Eye opener
• A - Amnesia
• K/C – Cut down on drinking
• To screen for fetal alcohol syndrome
• Antepartum fetal surveillance is the assessment of
fetal well being in utero before the onset of labor
• Early detection of fetus at risk so that timely
management to prevent further deterioration
• Also find out normal fetuses and avoid unnecessary
interventions
• Very high negative predictive value
• Very low positive predictive value
FETUS AT RISK
• PRE TERM
• POST TERM
• IUGR
• THICK MECONIUM
WITH SCANTY
FLUID
• INTRAUTERINE
INFECTION
• INTRAPARTUM
BLEEDING
INJUDICIOUS USE OF
OXYTOCIN
EPIDURAL IN A CASE WITH
SOME COMPROMISE
DIFFICULT INSTRUMENTAL
DELIVERY/ MACROSOMIA/
MALPRESENTATION
ACUTE EVENTS (CORD
PROLAPSE, ABRUPTION,
SCAR RUPTURE)
SUSPICIOUS/ ABNORMAL
ADMISSION TEST
FETUS AT
RELATIVE RISK
Admission assessment
Are any risk factors present?
Maternal problems
• Previous LSCS
• Pre-eclampsia
• Post-term pregnancy (>42
weeks)
• Prolonged membrane rupture
(>24 hours)
• Induced labour
• APH
• Other maternal disease
Fetal problems
• Growth restriction
• Prematurity
• Oligohydramnios
• Abnormal dopplers
• Multiple pregnancy
• Meconium stained liquor
• Breech presentation
INDICATION OF FETAL SURVEILLANCE
•Maternal conditions
• Hypertension
• Diabetes mellitus
• Heart Disease
• Chronic renal disease
• Acute febrile illness
• Pneumonia /asthma
• Epilepsy
• Collagen vascular disease
• Sickle cell disease
• Antiphospholipid syndrome
• Drug Abuse
• FETAL CONDITIONS
• Fetal growth restriction
• Rh isoimmunisation
• Fetal Cardiac arrythmia
• Hydrops fetalis
• Fetal infections
• PREGNANCY RELATED CONDITIONS
• Preeclampsia
• Multiple pregnancy
• Post term pregnancy
• Decreased fetal movements
• Abnormal placentation
• Placental abruption
• Oligohydramnios
• Polyhydramnios
• Unexplained stillbirth in a previous pregnancy
• Cholestasis of pregnancy
• PROM
• Poorly controlled Gestational Diabetes mellitus
The Various Methods of Antepartum
Fetal Surveillance
1) Clinical assessment by uterine growth
2) Fetal movement count by the mother
3) Ultrasound for fetal growth
4) Non stress test and cardiotocography
5) Vibroacoustic stimulation test
6) Contraction stress test
7) Nipple stimulation test
8) Biophysical profile
9) Modified biophysical profile
10) Doppler studies
11) Fetal lung maturation studies
12) Placental grading
Check list made a few years back…….NOW TO BE MODIFIED
SCREENING IN PREGNANCY
At booking (Recommended 3ANC) [Preferable 5]
General Physical exam Heart / Lungs / Breast /
Abdomen
In all trimesters
• Maternal weight /BMI
• Blood Pressure / Mean Arterial Pressure
• Urine dipstick (albumin sugar)
1LOW LEVELS PREDICT PRE ECCLAMPSIA
2 LOW RISK NO FURTHER TEST (1 : 1000)
INTERMEDIATE RISK (100 : 999) TO PROCEED TO SECOND TRIMESTER SCREENING VS NIPT
HIGH RISK (1 : 99) TO GO FOR CVS / NIPT
ANTENATAL CHECKLIST
First Trimester Recommended Preferable
weight BMI
Blood pressure Mean Arterial Pressure
Haemoglobin Complete blood count/ Peripheral smear /
Hb Electrophoresis / HPLC
Blood group ABO & Rh (both partners)
Urine routine MSU culture
VDRL/ Hep B / HIV HCV / Rubella IgG
TSH Thyroid function test / Thyroid Antibodies
Vitamin D
DIPSI test 75gms 2 hours blood sugar Hb A1C / OGTT/ 6 point blood sugar test
Dating scan + NT
Double marker (free beta
HCG + PAPP A1 )
(Contingent Screen2
Cervical length
Uterine artery Doppler
NIPT
Placental Growth Factor
(PLGF)
Per speculum exam Pap Smear, Bacterial vaginosis &
Chlamydia screen
Second Trimester Recommended Preferable
18-24 weeks Repeat bloods (Hb /
blood sugar / TSH) &
urine test as indicated
Quadruple OR Triple
marker
NIPT
Anomaly scan 3D/4D scan/ Fetal
Echo
Uterine artery
Doppler
Cervical length
DIPSI screen 75 gms 2
hour blood sugar
6 Points Blood
Sugar HbA1C
Abbreviations
Hb Haemoglobin GCT- Glucose Challenge Test
TSH Thyroid stimulating hormone OGTT Oral glucose tolerance test
HbA1C Haemoglobin A1C NT Scan- Nuchal Translucency
Scan,
NIPT Non invasive prenatal testing PAPP A- Pregnancy Associated
plasma protein A
PlGF Placental growth factor VDRL Venereal disease reference
HCV Hepatitis C virus Hep B hepatitis B virus
HIV Human Immune defeciency virus HPLC high performance liquid
chromatography
Third
Trimester
Recommended Preferable
24 weeks
onwards
Repeat DIPSI Screen
TSH/Hb/Urine
HbA1C
Growth scan with liquor volume
& placental localisation
Fetal Doppler
velocimetry
Fetal movement count
(6 in 2 hours)
CTG (NST)
Modified
biophysical
Score
Doppler
velocimetry
FIRST TRIMESTER
COMBINED SCREENING & RISK ESTIMATION IN FIRST
TRIMESTER
SECOND
TRIMESTER
COMBINED 2ND TRIMESTER SCREENING
THIRD TRIMESTER
Abbreviations
Hb Haemoglobin GCT- Glucose Challenge Test
TSH Thyroid stimulating hormone OGTT Oral glucose tolerance test
HbA1C Haemoglobin A1C NT Scan- Nuchal Translucency
Scan,
NIPT Non invasive prenatal testing PAPP A- Pregnancy Associated
plasma protein A
PlGF Placental growth factor VDRL Venereal disease reference
HCV Hepatitis C virus Hep B hepatitis B virus
HIV Human Immune defeciency virus HPLC high performance liquid
chromatography
Third
Trimester
Recommended Preferable
24 weeks
onwards
Repeat DIPSI Screen
TSH/Hb/Urine
HbA1C
Growth scan with liquor volume
& placental localisation
Fetal Doppler
velocimetry
Fetal movement count
(6 in 2 hours)
CTG (NST)
Modified
biophysical
Score
Doppler
velocimetry
Preconception advises and screening
• BMI
• BP
• SCREEN FOR INFECTIONS (RUBELLA)
• BLOOD GLUCOSE
• PCO AND OTHER ENDORINE :TSH/ PRL
• ROUTINE BLOOD TESTS
• THALLASIMEA SCREEN
PRECONCEPTION ADVICES
• LIFESTYLE
• GARBH SANSKAR SPIRITUAL
• DIET
• EXERCISE/YOGA/MEDITATION
• FOLIC ACID SUPPLIMENTATION
• ANEMIA CORRECTION IF DETECTED
• CORRECTION OF ENDOCRINE FACTORS
• VACCINATE FOR RUBELLA/HPV AND OTHERS
Why vaccinate women ???
• Vaccination
before during and after pregnancy
helps protect women from serious infections .
• It can also help in improving the women’s health in
general .
• It is an important preventable measure which should be
adopted rationally
• Ideally, all women should be
up-to-date with their
vaccinations before they
become pregnant.
• It is known that approximately
50 percent of all pregnancies
are unplanned
• it is important to keep women
of reproductive age current
with immunizations,
regardless of whether they are
actively trying to conceive.
Adolescent vaccination recommendations
MMR (2),Hep B ,Hep A ,HPV,
tetanus,diphtheria , influenza and VAR(2)
catch up vaccination is recommended
from 11 years onwards.
Typhoid and cholera vaccination can be
given seasonally.
VACCINES OF THE TEENAGE GIRL
• Catch up vaccinations for Hepatitis B, Tetanus, diphtheria
acellular pertussis(Tdap),typhoid, Influenza, rubella and
HPV are recommended in the adolescent age group.
• The medical history of prior affliction with these diseases
should be elicited.
• Previous adverse effects of immunizations especially
allergies should be noted.
PRECONCEPTION
COUNSELING /PREGNANCY
PLANNING
Preconceptional counseling /pregnancy
planning
• FOGSI recommends vaccination counseling as apartof
pre-pregnancy counseling .(unvaccinated women)
• History of occurrence of vaccine preventable diseases,
previous vaccinations administered and allergic reactions
to vaccinations must be recorded.
• 3.1Rubella ,Hepatitis B and Varicella vaccination should
be given preferably during postmenstrual period
• 3.2 Pregnancy should be deferred for 3 months in case of
Rubella vaccine
Maternal Nutrition Overview
• At no other time in woman’s life is nutrition so
important as before, during and after pregnancy
• Preconception nutrient needs
• Pregnancy increased nutrient demands
• Lactation nutrient needs
Overall care during pregnancy and lactation
Intervention - Preconception
•Visit to doctor
•Change in lifestyle
•Diet and nutrition
• Weight control
• Use of vitamins or other supplements
• Eating habits, such as a vegetarian diet or fasting
•Keeping fit
•Medical conditions
http://www.acog.org/publications/patient_education/bp056.cfm
Principles – Antenatal advice
• Regular health check up
• Maintain or improve health
status to optimum status till
delivery by judicious advice
regarding diet, drugs and
hygiene
• Improve and tone up
psychology by explaining
principal changes & events
likely to occur during
pregnancy and labour
Dutta D.C. Text book of obs, 2004
Diet
• Starting a healthy diet before pregnancy
• Diet - Quantity and quality
• Basic and extra nutrients for
• Maintenance of maternal health
• Needs of growing fetus
• Strength and vitality required during labour
• Successful lactation
• Special concerns
http://www.acog.org/publications/patient_education/
bp001.cfm
Dutta D.C. Text book of obs, 2004
Planning healthy meals
• Include all food groups
in diet
• Vegetables & fruits
• Milk and dairy foods
• Cereals & Grains
• Meat, beans, and eggs
• Fats and oils
MEAL PLANNING FOR PREGNANT WOMEN
Calories
Protein
Calcium
Iron
Vitamin A
Thiamin
Riboflavin
Niacin
Pyridoxine
Ascorbic Acid
Folic Acid
Vitamin B12
Magnesium
Zinc
Vitamin D
Iodine
Omega3fattyacid
+350 kcal
+23 gm
+1200 mg
+35 mg
+800 g
+0.2 mg
+0.3 mg
+2 mg
2.5 mg
60 mg
500 mg
1.2 g
210 mg
12 mg
400 IU
200 g
200 mg
RDA for pregnant women
Special concerns
• Caffeine
• Limited intake during pregnancy
• Excess caffeine can interfere with sleep and contribute to nausea and
light-headedness
• Can increase urination and lead to dehydration
• Vegetarian diets – low intake of iron, vitamin B12, vitamin
D
• Pica
• Strong urge to eat nonfood items such as clay, ice, laundry starch, or
cornstarch
• May affect intake of nutrients and can lead to constipation and anemia
Supplementary nutrition
• Personal food preferences, lifestyle habits
and special needs may affect the intake of
nutrients
• Essential vitamins lacking in diet or
destroyed during cooking
• Nutritional supplements are one of the
ways to fill the nutritional gap that may be
arising due to improper diet
• It fills the gap by providing the vitamins,
minerals, and other substances that may
be missing out
Vital nutrients in breast milk
• Breast milk provides all the nutrients a
baby needs to grow well for the first six
months of life. The key nutrients in breast
milk support the optimal growth and
development of the baby and all organs
and systems.
• Breast milk contains:
• DHA and AA - building blocks of brain & eye
development
• Taurine & choline - support overall mental
development & functioning.
• Calcium and vitamin D for bone development
• Many protective factors that protect the infant from
infections
• Fat, protein and carbohydrate, which are easily
digested and absorbed
Company Conf
Mother’s nutrition influences the composition and
quality of breast milk
• The nutritional needs of a
breastfeeding mother is high -
increased demand for Energy,
Vitamins C, B12
• Nutrients consumed by mother is
transferred to the growing baby to
support its growth and development.
• Nutritional deficiencies may develop
during this period and affect both
mothers and infants
• Maintaining a diet of fruits,
vegetables, whole grains, lean
meats, and dairy products regularly
will help to meet nutritional needs
“The doctor of the future will give no medicine, but will
interest his patient in the care of the human frame, in
diet and
in the cause and prevention of disease” –
Thomas Edison.
Abbreviations
• Hb Haemoglobin
• GCT- Glucose Challenge Test
• TSH Thyroid stimulating hormone
• OGTT Oral glucose tolerance test
• HbA1C Haemoglobin A1C
• NT Scan- Nuchal Translucency Scan,
• NIPT Non invasive prenatal testing
• PAPP A- Pregnancy Associated plasma protein A
• PlGF Placental growth factor
• VDRL Venereal disease reference
• HCV Hepatitis C virus
• Hep B hepatitis B virus
• HIV Human Immune defeciency virus
• HPLC high performance liquid chromatography
thank you
AIMS OF OBSTETRICAL CARE IS
so both are safe and Happy
Thank you

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ADBHUT MATRATVA ANTENATAL SCREENING

  • 2. Reference Material • New WHO guidelines on antenatal care – Systematic review BJOG 2016;123:519-28 • Guidelines by Government of western Australia • SOGC guideline on Prenatal Screening • RCOG / NICE Guidelines
  • 5. FIGO GUIDELINES PRESENT 8 GOOD PRACTICE ADVISES • 1.SCREENING FOR CHROMOSOMAL ABNORMALITIES AND NIPD • 2.PRECONCEPTIONAL FOLIC ACID FOR THE PREVENTION OF NEURAL TUBE DEFECTS • 3.CERVICAL LENGTH AND PROGESTERONE FOR THE PREDICTION AND PREVENTION OF PRETERM BIRTH • 4. & 5.MAGNISIUM SULPHATE USE IN OBSTETRICS • 6.ULTRASOUND EXAMINATION IN PREGNANCY • 7.THYROID DISEASE IN PREGNANCY • 8.HYPERGLYCEMIA IN PREGNANCY
  • 7. Why Screen ? 1.Triage mothers to High Risk & Low Risk 2.Prevent Maternal Complications 3.Screen the fetus for • Chromosomal errors • Structural Defects • Growth abnormalities 4.Decide the time and mode of safe delivery
  • 8. ADD SCREENING FOR N.C.D.HERE THE PYRAMID OF ANTENATAL CARE Post delivery continued screening
  • 9.
  • 10.
  • 11.
  • 12. Routine Antenatal Care 1990s……. Early scan to diagnose pregnancy & dating Fetal defects 22-24 wks Anomaly scan
  • 13. Routine Antenatal Care 2005 11-14 wks Fetal defects 20-23 wks P I P I P The great Ob syndrome
  • 14. Routine Antenatal Care 2010 11-13+6 wks Fetal defects Chemical markers Major Cardiac defects Uterine artery Doppler 20-23 wks Anomaly scan
  • 15. FOGSI OLD CHECK LIST OF 2009,MODIFIED IN 2017 AT FOGSI T.O.G.
  • 18.
  • 19. Screening is VOLUNTARY Screening should be made UNIVERSAL  SCREENING SHOULD BE OFFERED TO EVERYONE  Screening should be DONE only to women willing for the same  Those who decline screening may not be offered this tests and decision should be documented.
  • 20.
  • 22. Body Mass Index – If high •Prevent further weight gain •Institute Life style modifications •Medical Therapy – Metformin •Nutrition Therapy – High fibre diet •Daily Exercise •Prepare for safe delivery
  • 23. General Examination • Heart – Murmurs • Lungs – Rhonchi • Breast – Lumps / Nipples • Abdomen – Scars / Lumps • Per Speculum – Discharge / Polyp / Erosion LBC / HPV • Anus – Sentinel Pile
  • 24. Blood Pressure • Hypertension – BP in both arms Sitting position Dissappearance of korotkov • Hypotension – increase sodium/ potassium intake • Screening test for PIH  Placental Growth Factor (PlGF)  S Flt  s endoglin  Uterine artery doppler flow indices
  • 25. Screening for Anaemia • Complete Blood count • Peripheral Smear • If Microcytic Hypochromic Iron studies – Ferritin / Total Iron / TIBC Haemoglobin Electrophoresis • If Normocytic / Macrocytic Serum Vitamin B12 Serum / Red cell Folate Reticulocyte count
  • 26. Blood group & Rhesus Antibodies • If Rhesus Negative • Partners Blood group – If negative – • If positive – Indirect Coombs test • If positive – Cordocentesis & fetal blood transfusion with Rh negative blood at periodic intervals • Deliver at 34 weeks
  • 27. Endocrine Screening • Thyroid function test • If abnormal, thyroid antibodies • In PCO – screen for GDM early (HbA1C) • If galactorrhea – Prolactin • Serum Vitamin D • Relaxin ?
  • 28. Infection Screen • Complete blood count /ESR • Rubella antibodies • Urine routine & microscopy • Mid stream urine culture • High Vaginal / Endo cervical swab /Wet Prep / Vaginal pH / Chlamydia antibodies (SOLVS + FVU PCR) • HIV / Hep B / Hep C / VDRL
  • 31. Where do all these markers come from? (adrenals) (liver)
  • 32. Various Integrated screening in strategies (1st and 2nd trim) Main strategies: • Fully Integrated • Step-wise sequential • Contingent screening 1st trimester: NT, PAPP-A No risk estimate 2nd trimester: Fb-hCG, AFP, uE3, (± Inhibin) Final risk estimate: All markers 1st trimester: NT, PAPP-A, Fb-hCG Risk estimate 2nd trimester: Fb-hCG, AFP, uE3, (± Inhibin) Final risk estimate: All markers CVS NIPT High risk Low risk 1st trimester: NT, PAPP-A, Fb-hCG Risk estimate 2nd trimester: Fb-hCG, AFP, uE3, (± Inhibin) Final risk estimate: All markers CVS NIPT HR Borderline risk No further screening LR
  • 33. First trimester screening for Preeclampsia Maternal serum PIGF, Mean arterial Blood pressure - Implantation - Maternal artery remodelling Detection rate – 90% 0 10 20 30 Falsepositive(%) Doppler 12% 30% PP13 9% Doppler & PP13
  • 34.
  • 35. New Screening Protocol for Trisomy 21 + PE + ONTDs in Indian Scenario Viability Scan: 6-8 weeks LOW RISK HIGH RISK NIPT Anomaly scan at 19 weeks with genetic sonogram Amniocentesis CVS LOW RISKHIGH RISKLOW RISK HIGH RISK
  • 36. Non Invasive Prenatal Testing (NIPT) • NIPT – 9 weeks onwards • At least 4% fetal fraction to be identified • Twin Pregnancy – confusing results • Vanishing twin – confusing results • If positive – CVS / Amniocentesis
  • 37. CVS •11-14 weeks •Transcervical •Check for chorionic villi under microscope •Risk of miscarriage 1% •Need is obviated now due to NIPT
  • 38. Amniocentesis •15-18 weeks •Risk of miscarriage < 1% •To confirm diagnosis in positive integrated screen and/or positive NIPT •To screen known carriers for chromosomally abnormal fetus
  • 40. Screening in the 1st trimester • Time window: 8 - 14 weeks • Ultrasound Marker: • NT • Biochemical markers: • PAPP-A • Fb-hCG • Marker combination: • Combined test: NT, PAPP-A, Fb hCG
  • 41. Screening for Trisomy 21 at 11- 14 weeks 2-stage (contingency) screening- UK system USG (N.T.) AND DUAL MARKER FOR ALL Fetal NT and free BhCG and PAPP-A at 12 wks Very high risk Very low risk CVS Reassure Borderline risk Further screening Nasal bone DV, TR
  • 42. Screening for Trisomy 21 at 11- 14 weeks for India 2-stage (contingency) screening proposed RISK ESTIMATE BY ONLY USG N.T. AND OTHER MARKERS Fetal NT Nasal bone and ductus venosus tricuspid regurgitation at 12 wks Very high risk Very low risk CVS Reassure Borderline risk Further screening Free B hCG PAPP-A THIS WILL SAVE TIME MONEY OPTIMUM USE OF OUR SKILL DOUBLE MARKER TEST Scan 20w NIPT
  • 43. • MA + NIPT(OPTIONAL) • Dual Marker • NT + NB + TR + DV First trimester • Quad Marker • Genetic Sonogram Second trimester Integrated 1st and 2nd trimester screening DR – 97% FPR – 2.5%
  • 44. SO PROPOSAL IS INDIAN CONTINGENT SCREEN OR INTEGRATED FIRST AND SECOND TRIMESTER SCREEN COMBINED FIRST TRIMESTER SCREEN FOR RISK ESTIMATE……. FOLLOWED BY COMBINED 2ND TRIMESTER RISK SCREENING
  • 45. 99
  • 46.
  • 47. COMBINED SCREENING & RISK ESTIMATION IN FIRST TRIMESTER 100099
  • 48. 1LOW LEVELS PREDICT PRE ECCLAMPSIA 2 LOW RISK NO FURTHER TEST (1 : 1000) INTERMEDIATE RISK (100 : 999) TO PROCEED TO SECOND TRIMESTER SCREENING VS NIPT HIGH RISK (1 : 99) TO GO FOR CVS / NIPT ANTENATAL CHECKLIST First Trimester Recommended Preferable weight BMI Blood pressure Mean Arterial Pressure Haemoglobin Complete blood count/ Peripheral smear / Hb Electrophoresis / HPLC Blood group ABO & Rh (both partners) Urine routine MSU culture VDRL/ Hep B / HIV HCV / Rubella IgG TSH Thyroid function test / Thyroid Antibodies Vitamin D DIPSI test 75gms 2 hours blood sugar Hb A1C / OGTT/ 6 point blood sugar test Dating scan + NT Double marker (free beta HCG + PAPP A1 ) (Contingent Screen2 Cervical length Uterine artery Doppler NIPT Placental Growth Factor (PLGF) Per speculum exam Pap Smear, Bacterial vaginosis & Chlamydia screen
  • 49. Greater opportunity to secure a healthy pregnancy and healthy child, with 1st Trimester evaluation WHY CHOOSE BE HAPPY FIRST TRIMESTER PREGNANCY CHECK?  All the advantages of 1T screening: Earlier reassurance and early intervention if required  Enhanced performance for 1T combined aneuploidy screening: To enable to higher DR or lower FPR  4 marker biochemistry: Aneuploidy risk on par with 2T Quad  Some significant Fetal structural abnormalities  Pre-term Pre-eclampsia: Identify a high risk group, who would benefit from Aspirin
  • 50.
  • 53. CERVICAL LENGTH SCREENING ROUTINE TO PREVENT PRETERM LABOUR AND FOR GUIDELINE FOR CX STITCH • ASYMPTOMATIC SINGLETON PREGNANCY A TVS CL <25 MM IN SECOND TRIMESTER • SCREEN AT 11-13 WEEKS AND THEN AT 22-22 WEEKS RECENT EVIDENCE SAYS CX STITCH DOES NOT HELP AND PROGESTERONE MAY BE THE ONLY TREATMENT OPTION HERE.ROUTINE MCDONALD STITCH PRACTISE SHOULD BE INDIVIDUALISED
  • 55. Second Trimester Recommended Preferable 18-24 weeks Repeat bloods (Hb / blood sugar / TSH) & urine test as indicated Quadruple OR Triple marker NIPT Anomaly scan 3D/4D scan/ Fetal Echo Uterine artery Doppler Cervical length DIPSI screen 75 gms 2 hour blood sugar 6 Points Blood Sugar HbA1C
  • 56. Sequential Screening •Quadruple marker – 15-18 weeks •NIPT 9 week onwards •Amniocentesis – 15 week onwards
  • 59. Screening for GDM • HbA1C • DIPSI one step screen 75 gms 2 hour • Cut off of 140 mg/dl • At 24 to 28 weeks • Repeat at 32 weeks in high risk women i.e Polyhydramnios / previous GDM / Parents & siblings diabetic
  • 60. Screening for PIH • Blood Pressure BOTH ARMS SITTING • Water Retention – edema / rapid weight gain • Micro albuminuria • Spot test – Urine Protein /Creatinine ratio • Ratio of PlGF / sFlt • LDH raised in HELLP Syndrome • Renal artery doppler
  • 61. Vaccination • Tetanus Toxoid – ONE DOSE • Tdap –SECOND DOSE AT 24 WEEKS • Influenza vaccine 24 weeks onwards • hpB can be given if not immunised • Targetted Vaccine in case of travel to endemic areas • Post partum – HPV vaccine
  • 64. Abbreviations Hb Haemoglobin GCT- Glucose Challenge Test TSH Thyroid stimulating hormone OGTT Oral glucose tolerance test HbA1C Haemoglobin A1C NT Scan- Nuchal Translucency Scan, NIPT Non invasive prenatal testing PAPP A- Pregnancy Associated plasma protein A PlGF Placental growth factor VDRL Venereal disease reference HCV Hepatitis C virus Hep B hepatitis B virus HIV Human Immune defeciency virus HPLC high performance liquid chromatography Third Trimester Recommended Preferable 24 weeks onwards Repeat DIPSI Screen TSH/Hb/Urine HbA1C Growth scan with liquor volume & placental localisation Fetal Doppler velocimetry Fetal movement count (6 in 2 hours) CTG (NST) Modified biophysical Score Doppler velocimetry
  • 66. INFECTION SCREEN • GBS – Is routine screening required prior to delivery ? • Pelvic assessment – Does it improve your decision for normal delivery ? • Pelvic relaxation techniques / exercises like walking / squatting / butterfly
  • 67. NON USG SCREENING FOR FETAL WELL BEING
  • 69. Cardiotocography • Non Stress test vs Oxytocin Stress test • When to start ? Post viability period 30 weeks • How often to do ? Once a week • What are the omnious signs – Lack of BTB variation Variable deaccelerations of cord compression Late deacceleration of fetal hypoxia • Supplement with ST waveform analysis • Fetal cord blood pH during labour
  • 71. Recording •Every kick / roll is 1 movement •Count 10 movements everyday •Should be around 6 in 1 hour •If < 6 movements in 2 hours •Call doctor & come for CTG / USS assessment
  • 72. About baby’s movements An active baby is usually a healthy baby. You will feel your baby stretch, kick, roll and turn every day. Some babies are more active than others. All babies have periods of sleep during which they are not as active. You will get to know your baby’s pattern of movements and when your baby is most active. You should feel your baby’s movements throughout the day, each day from 28 weeks of pregnancy until the baby is born. When during my pregnancy should I count my baby’s movements? Your health care provider may ask you to count your baby’s movements once every day. If you think there is a decrease in your baby’s movements this is an important sign that your baby may not be well. Count your baby’s movements to be sure that you feel at least 6 movements in 2 hours. Reference: Society of Obstetricians and Gynaecologists of Canada (2007). Fetal Health Surveillance : Antepartum and Intrapartum Consensus Guideline. Journal of Obstetrics and Gynaecology Canada. 29(9). FETAL MOVEMENT COUNT CHART PLEASE BRING THIS CHART WITH YOU EACH TIME YOU SEE THE DOCTOR/MIDWIFE IMPORTANT PHONE NUMBERS: DOCTOR: MIDWIFE: HOSPITAL: DUE DATE: OTHER INSTRUCTIONS: For 24-hour nurse advice and health information call Health Link Alberta: 1-866-408- LINK (5465)– Toll Free In Calgary call 403-943- LINK (5465) In Edmonton call 780-408-LINK (5465) ADDRESS: NAME: HS0001-132 (2012/11) How do I count my baby’s movements? • Get into a comfortable position – lying on your side or sitting. Place one or both of your hands on your abdomen. • Count each time that you feel your baby move. If you feel many movements all at once, count each movement that you feel. • Write down the date and the time that you start counting on the fetal movement chart. • Make a mark on the chart each time your baby moves. • Stop counting when you have counted 6 movements. • Write down the time you stopped counting. • Do not count for more than 2 hours What if I don’t feel 6 movements in 2 hours? Count your baby’s movements once a day. You should feel 6 or more movements in 2 hours. If you count fewer than 6 movements in 2 hours do not wait. Go to the hospital or birthing unit. Your baby’s heart rate and movements will be checked using a fetal monitor. This is called a non-stress test or NST. If you live too far from a hospital or birthing unit, immediately contact your health care provider for advice.
  • 73. TWEAK Screening for alcoholism • T – Tolerance (No of drinks one can hold) • W- Worry about drinking • E – Eye opener • A - Amnesia • K/C – Cut down on drinking • To screen for fetal alcohol syndrome
  • 74. • Antepartum fetal surveillance is the assessment of fetal well being in utero before the onset of labor • Early detection of fetus at risk so that timely management to prevent further deterioration • Also find out normal fetuses and avoid unnecessary interventions • Very high negative predictive value • Very low positive predictive value
  • 75. FETUS AT RISK • PRE TERM • POST TERM • IUGR • THICK MECONIUM WITH SCANTY FLUID • INTRAUTERINE INFECTION • INTRAPARTUM BLEEDING INJUDICIOUS USE OF OXYTOCIN EPIDURAL IN A CASE WITH SOME COMPROMISE DIFFICULT INSTRUMENTAL DELIVERY/ MACROSOMIA/ MALPRESENTATION ACUTE EVENTS (CORD PROLAPSE, ABRUPTION, SCAR RUPTURE) SUSPICIOUS/ ABNORMAL ADMISSION TEST FETUS AT RELATIVE RISK
  • 76. Admission assessment Are any risk factors present? Maternal problems • Previous LSCS • Pre-eclampsia • Post-term pregnancy (>42 weeks) • Prolonged membrane rupture (>24 hours) • Induced labour • APH • Other maternal disease Fetal problems • Growth restriction • Prematurity • Oligohydramnios • Abnormal dopplers • Multiple pregnancy • Meconium stained liquor • Breech presentation
  • 77. INDICATION OF FETAL SURVEILLANCE •Maternal conditions • Hypertension • Diabetes mellitus • Heart Disease • Chronic renal disease • Acute febrile illness • Pneumonia /asthma • Epilepsy
  • 78. • Collagen vascular disease • Sickle cell disease • Antiphospholipid syndrome • Drug Abuse • FETAL CONDITIONS • Fetal growth restriction • Rh isoimmunisation • Fetal Cardiac arrythmia
  • 79. • Hydrops fetalis • Fetal infections • PREGNANCY RELATED CONDITIONS • Preeclampsia • Multiple pregnancy • Post term pregnancy • Decreased fetal movements • Abnormal placentation • Placental abruption
  • 80. • Oligohydramnios • Polyhydramnios • Unexplained stillbirth in a previous pregnancy • Cholestasis of pregnancy • PROM • Poorly controlled Gestational Diabetes mellitus
  • 81. The Various Methods of Antepartum Fetal Surveillance 1) Clinical assessment by uterine growth 2) Fetal movement count by the mother 3) Ultrasound for fetal growth 4) Non stress test and cardiotocography 5) Vibroacoustic stimulation test 6) Contraction stress test 7) Nipple stimulation test 8) Biophysical profile 9) Modified biophysical profile 10) Doppler studies 11) Fetal lung maturation studies 12) Placental grading
  • 82. Check list made a few years back…….NOW TO BE MODIFIED
  • 83. SCREENING IN PREGNANCY At booking (Recommended 3ANC) [Preferable 5] General Physical exam Heart / Lungs / Breast / Abdomen In all trimesters • Maternal weight /BMI • Blood Pressure / Mean Arterial Pressure • Urine dipstick (albumin sugar)
  • 84. 1LOW LEVELS PREDICT PRE ECCLAMPSIA 2 LOW RISK NO FURTHER TEST (1 : 1000) INTERMEDIATE RISK (100 : 999) TO PROCEED TO SECOND TRIMESTER SCREENING VS NIPT HIGH RISK (1 : 99) TO GO FOR CVS / NIPT ANTENATAL CHECKLIST First Trimester Recommended Preferable weight BMI Blood pressure Mean Arterial Pressure Haemoglobin Complete blood count/ Peripheral smear / Hb Electrophoresis / HPLC Blood group ABO & Rh (both partners) Urine routine MSU culture VDRL/ Hep B / HIV HCV / Rubella IgG TSH Thyroid function test / Thyroid Antibodies Vitamin D DIPSI test 75gms 2 hours blood sugar Hb A1C / OGTT/ 6 point blood sugar test Dating scan + NT Double marker (free beta HCG + PAPP A1 ) (Contingent Screen2 Cervical length Uterine artery Doppler NIPT Placental Growth Factor (PLGF) Per speculum exam Pap Smear, Bacterial vaginosis & Chlamydia screen
  • 85. Second Trimester Recommended Preferable 18-24 weeks Repeat bloods (Hb / blood sugar / TSH) & urine test as indicated Quadruple OR Triple marker NIPT Anomaly scan 3D/4D scan/ Fetal Echo Uterine artery Doppler Cervical length DIPSI screen 75 gms 2 hour blood sugar 6 Points Blood Sugar HbA1C
  • 86. Abbreviations Hb Haemoglobin GCT- Glucose Challenge Test TSH Thyroid stimulating hormone OGTT Oral glucose tolerance test HbA1C Haemoglobin A1C NT Scan- Nuchal Translucency Scan, NIPT Non invasive prenatal testing PAPP A- Pregnancy Associated plasma protein A PlGF Placental growth factor VDRL Venereal disease reference HCV Hepatitis C virus Hep B hepatitis B virus HIV Human Immune defeciency virus HPLC high performance liquid chromatography Third Trimester Recommended Preferable 24 weeks onwards Repeat DIPSI Screen TSH/Hb/Urine HbA1C Growth scan with liquor volume & placental localisation Fetal Doppler velocimetry Fetal movement count (6 in 2 hours) CTG (NST) Modified biophysical Score Doppler velocimetry
  • 87.
  • 89. COMBINED SCREENING & RISK ESTIMATION IN FIRST TRIMESTER
  • 93. Abbreviations Hb Haemoglobin GCT- Glucose Challenge Test TSH Thyroid stimulating hormone OGTT Oral glucose tolerance test HbA1C Haemoglobin A1C NT Scan- Nuchal Translucency Scan, NIPT Non invasive prenatal testing PAPP A- Pregnancy Associated plasma protein A PlGF Placental growth factor VDRL Venereal disease reference HCV Hepatitis C virus Hep B hepatitis B virus HIV Human Immune defeciency virus HPLC high performance liquid chromatography Third Trimester Recommended Preferable 24 weeks onwards Repeat DIPSI Screen TSH/Hb/Urine HbA1C Growth scan with liquor volume & placental localisation Fetal Doppler velocimetry Fetal movement count (6 in 2 hours) CTG (NST) Modified biophysical Score Doppler velocimetry
  • 94. Preconception advises and screening • BMI • BP • SCREEN FOR INFECTIONS (RUBELLA) • BLOOD GLUCOSE • PCO AND OTHER ENDORINE :TSH/ PRL • ROUTINE BLOOD TESTS • THALLASIMEA SCREEN
  • 95. PRECONCEPTION ADVICES • LIFESTYLE • GARBH SANSKAR SPIRITUAL • DIET • EXERCISE/YOGA/MEDITATION • FOLIC ACID SUPPLIMENTATION • ANEMIA CORRECTION IF DETECTED • CORRECTION OF ENDOCRINE FACTORS • VACCINATE FOR RUBELLA/HPV AND OTHERS
  • 96. Why vaccinate women ??? • Vaccination before during and after pregnancy helps protect women from serious infections . • It can also help in improving the women’s health in general . • It is an important preventable measure which should be adopted rationally
  • 97. • Ideally, all women should be up-to-date with their vaccinations before they become pregnant. • It is known that approximately 50 percent of all pregnancies are unplanned • it is important to keep women of reproductive age current with immunizations, regardless of whether they are actively trying to conceive.
  • 98. Adolescent vaccination recommendations MMR (2),Hep B ,Hep A ,HPV, tetanus,diphtheria , influenza and VAR(2) catch up vaccination is recommended from 11 years onwards. Typhoid and cholera vaccination can be given seasonally.
  • 99. VACCINES OF THE TEENAGE GIRL • Catch up vaccinations for Hepatitis B, Tetanus, diphtheria acellular pertussis(Tdap),typhoid, Influenza, rubella and HPV are recommended in the adolescent age group. • The medical history of prior affliction with these diseases should be elicited. • Previous adverse effects of immunizations especially allergies should be noted.
  • 101. Preconceptional counseling /pregnancy planning • FOGSI recommends vaccination counseling as apartof pre-pregnancy counseling .(unvaccinated women) • History of occurrence of vaccine preventable diseases, previous vaccinations administered and allergic reactions to vaccinations must be recorded. • 3.1Rubella ,Hepatitis B and Varicella vaccination should be given preferably during postmenstrual period • 3.2 Pregnancy should be deferred for 3 months in case of Rubella vaccine
  • 102. Maternal Nutrition Overview • At no other time in woman’s life is nutrition so important as before, during and after pregnancy • Preconception nutrient needs • Pregnancy increased nutrient demands • Lactation nutrient needs
  • 103. Overall care during pregnancy and lactation
  • 104. Intervention - Preconception •Visit to doctor •Change in lifestyle •Diet and nutrition • Weight control • Use of vitamins or other supplements • Eating habits, such as a vegetarian diet or fasting •Keeping fit •Medical conditions http://www.acog.org/publications/patient_education/bp056.cfm
  • 105. Principles – Antenatal advice • Regular health check up • Maintain or improve health status to optimum status till delivery by judicious advice regarding diet, drugs and hygiene • Improve and tone up psychology by explaining principal changes & events likely to occur during pregnancy and labour Dutta D.C. Text book of obs, 2004
  • 106. Diet • Starting a healthy diet before pregnancy • Diet - Quantity and quality • Basic and extra nutrients for • Maintenance of maternal health • Needs of growing fetus • Strength and vitality required during labour • Successful lactation • Special concerns http://www.acog.org/publications/patient_education/ bp001.cfm Dutta D.C. Text book of obs, 2004
  • 107. Planning healthy meals • Include all food groups in diet • Vegetables & fruits • Milk and dairy foods • Cereals & Grains • Meat, beans, and eggs • Fats and oils
  • 108. MEAL PLANNING FOR PREGNANT WOMEN Calories Protein Calcium Iron Vitamin A Thiamin Riboflavin Niacin Pyridoxine Ascorbic Acid Folic Acid Vitamin B12 Magnesium Zinc Vitamin D Iodine Omega3fattyacid +350 kcal +23 gm +1200 mg +35 mg +800 g +0.2 mg +0.3 mg +2 mg 2.5 mg 60 mg 500 mg 1.2 g 210 mg 12 mg 400 IU 200 g 200 mg RDA for pregnant women
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  • 116. Special concerns • Caffeine • Limited intake during pregnancy • Excess caffeine can interfere with sleep and contribute to nausea and light-headedness • Can increase urination and lead to dehydration • Vegetarian diets – low intake of iron, vitamin B12, vitamin D • Pica • Strong urge to eat nonfood items such as clay, ice, laundry starch, or cornstarch • May affect intake of nutrients and can lead to constipation and anemia
  • 117. Supplementary nutrition • Personal food preferences, lifestyle habits and special needs may affect the intake of nutrients • Essential vitamins lacking in diet or destroyed during cooking • Nutritional supplements are one of the ways to fill the nutritional gap that may be arising due to improper diet • It fills the gap by providing the vitamins, minerals, and other substances that may be missing out
  • 118. Vital nutrients in breast milk • Breast milk provides all the nutrients a baby needs to grow well for the first six months of life. The key nutrients in breast milk support the optimal growth and development of the baby and all organs and systems. • Breast milk contains: • DHA and AA - building blocks of brain & eye development • Taurine & choline - support overall mental development & functioning. • Calcium and vitamin D for bone development • Many protective factors that protect the infant from infections • Fat, protein and carbohydrate, which are easily digested and absorbed
  • 119. Company Conf Mother’s nutrition influences the composition and quality of breast milk • The nutritional needs of a breastfeeding mother is high - increased demand for Energy, Vitamins C, B12 • Nutrients consumed by mother is transferred to the growing baby to support its growth and development. • Nutritional deficiencies may develop during this period and affect both mothers and infants • Maintaining a diet of fruits, vegetables, whole grains, lean meats, and dairy products regularly will help to meet nutritional needs
  • 120. “The doctor of the future will give no medicine, but will interest his patient in the care of the human frame, in diet and in the cause and prevention of disease” – Thomas Edison.
  • 121. Abbreviations • Hb Haemoglobin • GCT- Glucose Challenge Test • TSH Thyroid stimulating hormone • OGTT Oral glucose tolerance test • HbA1C Haemoglobin A1C • NT Scan- Nuchal Translucency Scan, • NIPT Non invasive prenatal testing • PAPP A- Pregnancy Associated plasma protein A • PlGF Placental growth factor • VDRL Venereal disease reference • HCV Hepatitis C virus • Hep B hepatitis B virus • HIV Human Immune defeciency virus • HPLC high performance liquid chromatography
  • 123. AIMS OF OBSTETRICAL CARE IS so both are safe and Happy