Antenatal care screening and common disease during pregnancy

1. Antenatal care screening

2. ANC goals
•To ensure the woman and her child are as healthy as
possible during pregnancy.
•Good birth outcome.
•Identify high risk pregnancy/ possible complications.
•Decrease infant and maternal mortality rate.

3. Recommended WT
gain
Rate of WT gain in
2nd &3rd
trimester
Recommended
total WT gain
KG/W Total KG
<18.5 0.5 12.5-18 KG
18.5-24.9 0.4 11.5-16KG
25-29.9 0.3 7-11.5KG
> 30 or equal 0.2 5-9 KG
THE RECOMMENDED WT GAIN IN PREGNANCY

4. Daily dietary requirements for common nutrients
 Calories: increase 100 kcal/day in the first trimester
 and 300 kcal/d in second and third trimester (15%), or
about 2200 cal/day
 Protein: an additional 10 to 30 gm /day (about 75
gm/day) Calcium: 1200 mg / day
 Float: 400 mcg/day Iron : 30 to 60 mg (300 mg
ferrous sulfate heptahydrate, 180 mg ferrous fumarate or
500 mg of ferrous gluconate.)

5. ANC visits
Monthly up to 32 weeks
Every two weeks until 36 weeks
weekly after 36 weeks till delivery.

6. Focused ANC 4 visits model out lined in WHO clinical
guidelines with additional 2 visits as needed
1st visit
8-12 weeks
2nd visit
24-26 weeks
3rd visit
32 weeks
4th visit
36-38 week
Confirm
pregnancy and
EDD, classify for
basic ANC 4 visits
or more
specialized care.
Screen , treat and
give preventive
measures
Develop a birth
and emergency
plan.
Advice and
counsel.
Assess maternal
and fetal well
being.
Exclude PIH and
anemia .
Preventive
measures.
Review and modify
birth and
emergency plan .
Advice and
counsel.
Assess maternal
and fetal well
being.
Exclude PIH and
anemia, multiple
pregnancies .
Preventive
measures.
Review and modify
birth and
emergency plan .
Advice and
counsel.
Assess maternal
and fetal well
being.
Exclude PIH and
anemia multiple
pregnancies ,
malpresentation .
Preventive
measures.
Review and modify
birth and
emergency plan .
Advice and
counsel.

7. 1st visit
8-12 weeks
2nd visit
24-26 weeks
3rd visit
32 weeks
4th visit
36-38 week
History
( ask ,
check ,
records)
Assess significant
symptoms.
Take psychosocial,
medical and OB hx.
Confirm pregnancy
and calculate EDD.
Classify all women
(in some cases after
test results)
Assess significant
symptoms.
Check record for
previous
complications
and treatment
during the
pregnancy. Re-
classification if
needed
Assess significant
symptoms.
Check record for
previous
complications
and treatment
during the
pregnancy. Re-
classification if
needed
Assess
significant
symptoms.
Check record for
previous
complications
and treatment
during the
pregnancy. Re-
classification if
needed
Ex.
(look,
listen,
feel)
Complete general
and Ob examination
,BP,(weight)
(pelvic examination)
(fundal height
>20w) ,
BP,(weight)
,fetal growth and
movements
Anemia
Anemia ,
BP,(weight fundal
ht),
,fetal growth and
multiple
pregnancies
Anemia ,BP,(wt
,fundal ht)
,fetal growth .
Movements
multiple
pregnancies,
(fetal lie by Abd
palpation)

8. Elements ANC visit
Accurate GA .
Identification of high risk pregnancy.
Deal with common complaints.
Screen for :
Anemia
GDM, STI, Genetic, TORCH
Co-morbidies
Monitoring Fetal well-being
Counseling and prevention
Referral
Screening
Treatment
Education &
Counseling
Psychological
support

9. HIGH RISK PREGNANCY

10. First Visit History

11. =
General examination
● Vital signs ● Breast ● Thyroid:
Current guidelines recommend targeted screening by
TSH measurement for women at high risk ?????
-History of thyroid disease
-Type 1 DM
-Current or past use of thyroid therapy
-Family history of autoimmune thyroid disease
-Symptoms of disease in pregnancy
● there is no evidence that universal testing during
pregnancy improves outcomes (not recommended)
● If the TSH level is abnormal, a free thyroxin test may
be useful

13. Physical examination
● Abdominal exam: scars? enlarged uterus? masses?
● LL edema / varicosities
● Dental assessment
● Pelvic exam :Routine antenatal pelvic examination
does not accurately assess gestational age, nor does it
accurately predict preterm birth or cephalopelvic
disproportion. It is not recommended. [B]

14. Components of Routine Prenatal
Examinations

15. Investigations
• Urine dipstick
• ABO / rhesus D status
• Screening for anemia & Hbopathies
• Rubella susceptibility
• FBS
• HBV*
• Toxoplasmosis / VDRL
• Early US for GA
•Screening for asymptomatic bacteriuria.

16. ASYMPTOMATIC BACTERIURIA
Asymptomatic bacteriuria complicates 2% to 7% of pregnancies.
All pregnant women should be screened between 11 and 16
weeks’ gestation and treated, if positive, to reduce the risk of
recurrent urinary tract infection, pyelonephritis, and preterm
labor

17. Infectious Diseases
BACTERIAL VAGINOSIS
Universal screening is not supported by current evidence.
A recent systematic review found that screening and
subsequent treatment of infection does not prevent
delivery before 37 weeks’ gestation, but decreases the
risk of low birth weight and premature rupture of
membranes (AAFP 2014)

18. RUBELLA
Women should be screened for rubella immunity during
the first prenatal visit and before conception when
vaccination is safe.
All women who are nonimmune should be offered
vaccination postpartum to prevent congenital rubella
syndrome in subsequent pregnancies.
Vaccination should not be given during pregnancy, but
may be given during lactation
Infectious Diseases

19. VARICELLA
Maternal varicella (chickenpox) can have significant fetal effects,
including congenital varicella syndrome (low birth weight and limb,
ophthalmologic, and neurologic abnormalities)
Neonatal varicella; infection can occur from approximately five days
before to two days after birth
Infectious Diseases

20. Women who test negative for immunoglobulin G should avoid
exposure to varicella during pregnancy and be offered
vaccination postpartum.
After a significant exposure, varicella-zoster immune globulin
therapy may be considered
Infectious Diseases

21. INFLUENZA
Physicians should recommend that all pregnant women receive
vaccination for influenza.
Pregnant women may be at higher risk of influenza complications
than the general population.
Household contacts of pregnant women should also be offered
vaccination

22. TETANUS AND PERTUSSIS
Women should receive a diphtheria, tetanus, and pertussis
(Tdap) vaccine during each pregnancy. (CDC adult immunization
2014& AAFP 2014)
The best time for vaccination is between 27 and 36 weeks’
gestation (CDC adult immunization 2014& AAFP 2014)

23. (AAFP)Routine screening for
other infections, including
toxoplasmosis,
cytomegalovirus, and
parvovirus, Trichomonas ,
Gonorrhea and Herpes is not
recommended during
pregnancy.

24. Ultra
sound
It is the standard of care in most U.S.
communities to offer a single
ultrasound examination at 18 to 20
weeks' gestation, even if dating
confirmation is not needed.11 This is the
optimal time for fetal anatomic
screening.
A randomized trial comparing routine
screening ultrasonography (between 15
and 22 weeks and again at 31 to 35
weeks) performed only for medical
indications showed no difference in
perinatal outcomes (e.g., fetal or
neonatal death, neonatal morbidity).

25. Ultra
sound A recent Cochrane review, however,
showed that ultrasonography before
24 weeks reduces missed multiple
gestation and inductions for
postterm pregnancies.
In our hospital maximum 3 us visits
1-at 8 – 12 wk screening, confirm
date,intra extra uterine.
2-after 20 w fetal anatomy ,multiple
gestation .
3-for lei presentation.

26. Psychosocial screening
•The U.S. Preventive
Services Task Force
(USPSTF) recommends
screen women of
childbearing age for
intimate partner violence,
such as domestic violence,
and provide intervention
services or a referral if a
woman screens positive.
•(ACOG) supports depression
screening during pregnancy.
Complications include
prematurity, low birth
weight, neurodevelopmental
delays, maternal/ infant
bonding.

27. Second visit at 26 gestational age
● Wt/BP/urine for proteinuria.
● Measure fundal height /correlate with calc GA
● Fetal movement
● GDM screening*
● Offer 2nd screening for anemia*
● Investigate Hb level below 10.5 g/100 ml and consider iron
supplements.
●Offer anti-D prophylaxis to women who are rhesus D-negative

28. Third visit at 32 weeks
Review, discuss and record the results of screening tests undertaken at 26 W.
Fetal movement
BP/urine for proteinuria.
Measure fundal height /correlate with calc GA
Give specific information on:
preparation for labour and birth, including the birth plan, recognizing active
labour and coping with pain.
Screening for G B streptococcal infection

29. GROUP B STREPTOCOCCUS
All pregnant women should be offered screening at 35
to 37 weeks’ gestation
Treatment with intrapartum antibiotic prophylaxis
(penicillin, or clindamycin if allergic)

30. Fourth visit at 38 weeks
BP /urine for proteinuria.
Measure fundal height
Fetal movement
Give specific information on:
options for management of prolonged pregnancy
Preparation for labor.
Importance of post natal care and arrange for home visits.
Role of the husband

31. At 41 weeks
BP /urine for proteinuria.
Measure fundal height
Fetal movement
Further discussion of management of prolonged
pregnancy

33. Medical conditions in pregnancy

34. Alloimmunization
RH incompatibility

35. ● Risk of developing alloimmunization in RhD-negative woman
carrying RhD-positive fetus
● Testing for ABO blood group and RhD antibodies performed
early in pregnancy
● Rho(D) immune globulin, 300 mcg, is recommended for
nonsensitized women at 28 weeks’ gestation, and again within 72
hours of delivery if the infant has RhD-positive blood.
Alloimmunization

36. Rho(D) immune globulin administered if the risk of fetal-to-
maternal transfusion is increased in
● Chorionic villus sampling
● Amniocentesis
● Abdominal trauma
● Bleeding in the second or third trimester
Alloimmunization is uncommon before 12 weeks’ gestation so
women with a threatened early spontaneous abortion may be
offered Rho(D) immune globulin, 50 mcg
Alloimmunization

37. Anemia
● IDA associated with
Increased risk of preterm labor
intrauterine growth retardation
perinatal depression.
● All pregnant women should be screened for anemia
early in pregnancy and treated with supplemental iron
if indicated.
● USPSTF found insufficient evidence to recommend
for or against routine iron supplementation.

38. ● Multivitamins alone have no benefit over iron and folate
supplementation.
● Pregnant women with anemia other than IDA or who do not
respond to iron supplementation within four to six weeks should
be evaluated for other conditions, including malabsorption,
ongoing blood loss, thalassemia, or other chronic diseases
Anemia

39. Thyroid disease
Women with overt hypothyroidism, are at increased risk
of
pregnancy loss
Preeclampsia
low birth weight and fetal demise or stillbirth.
placental abruption, hypertensive disorders& IUGR
Levothyroxine 2.33 µg/kg/day for overt hypothyroidism
to achieve a goal TSH level less than 2.5 mIU per L.
Diagnosed before pregnancy The levothyroxine dosage is typically
increased in the first (and sometimes in the second) trimester of
pregnancy, with a possible total increase of 30% to 50%

40. Case
A 31 year old pregnant in 10 weeks
referred to your clinic for evaluation
of her lab and management .
T4 15 (9 –24)
TSH 6.2 (0.5 – 5)
What you will do ?
levothyroxine doses:
TSH < 4.2 mIU/L 1.20 µg/kg/day
TSH > 4.2 to 10 1.42 µg/kg/day

41. Thyroid disease
Hyperthyroidism is associated with pregnancy loss,
preeclampsia, low birth weight, thyroid storm,
prematurity, and congestive heart failure
Treated with propyl thiouracil (PTU) 100 450 mg/d in the
first trimester only in the second and third trimester
treated with methimozol 10-40mg/d

42. All psychotropic medications cross the
placenta, are present in amniotic fluid, and
can enter breast milk.
Studies have shown a relapse rate of 68
percent in women who discontinue
antidepressant therapy during pregnancy..
Psychotic disorder

43. Untreated maternal depression is associated
with increased rates of adverse outcomes
(e.g., premature birth, low birth weight,
fetal growth restriction, postnatal
complications), especially when depression
occurs in the late second to early third
trimesters.
However, the potential risks associated with
SSRI use must be weighed against the risk of
relapse if treatment is discontinued. SSRI
should be individualized.

44. •At present, FDA does not find sufficient evidence to
conclude that SSRI use in pregnancy causes PPHN,
and therefore recommends that health care
providers treat depression during pregnancy as
clinically appropriate.( rare heart and lung condition
known as persistent pulmonary hypertension of the
newborn (PPHN).

45. ACOG Releases Guideline on
Gestational Diabetes 2015
Insulin is the preferred medication for pregestational type 1
and type 2 diabetes not adequately controlled with diet,
exercise, and metformin.

47. Chronic Hypertension
•BP ≥ 140 /90
mmHg one of
them or both .
•Present before
20th week of
pregnancy or
persists longer
then 12 weeks
postpartum.
Avoid treatment in women with
uncomplicated mild essential HTN as
blood pressure may decrease as
pregnancy progresses.
initiate therapy for persistent 150/100
mmHg, or signs of hypertensive end-
organ damage.
Medication choices = Oral
methyldopa and labetalol.
Time of delivery < 160/110 mmHg
after 37 weeks.

48. < 150100 no ttt
> 150100 With oral labetalol† as first-line treatment
to goal less than 150 80–100 mmHg
Preeclampsia
–New onset of HTN and
proteinuria after 20
weeks
–Proteinuria of 0.3 g or
greater in a 24-hour urine
specimen
–Preeclampsia before 20
weeks, think MOLAR
PREGNANCY!
–Time of delivery mild or
moderate HTN at 34+0
to 36+6 weeks
depending on maternal
and fetal condition.
–Sever before 34 w
Gestational Hypertension
Mild hypertension
without proteinuria.
Develops in late
pregnancy, after 20 weeks
gestation.
Resolves by 12 weeks
postpartum.
Can progress onto
preeclampsia. Time of
delivery < 160/110 mmHg
after 37 weeks.

49. HYPERTENSION IN PREGNANCY
Preeclampsia in a previous pregnancy , chronic hypertension, low
dietary calcium (less than 700 mg) increase risk of preeclampsia
. Calcium supplementation for women with low dietary calcium
reduces the risk of preeclampsia by 30% to 50%.
Low-dose aspirin from 12 to 36 weeks’ gestation reduces
preeclampsia by 20% in women with a history of preeclampsia

50. Common questions for which you will need
to have an answer
Activity and exercise: moderation
Sexual activity: no problem if pregnancy progresses normally
Diet: balanced diet
Bathing and swimming: no high speed sports or jet skis
Dentition: a dental check-up is recommended, any work is OK
Immunizations: avoid live virus vaccines MMR V
Travel: frequent stops to stretch
Employment: no contraindication if pregnancy is normal

51. References
•ACOG
•AAFP
•CDC