E. Atypical HUS (aHUS) 1. Epidemiology. aHUS is much less common than STEC-HUS. 2. Etiology a. Drugs (e.g., oral contraceptives, cyclosporine, tacrolimus) or pregnancy may cause aHUS. b. Inherited aHUS occurs with both autosomal dominant and autosomal recessive inheritance patterns, although not all patients have identifiable mutations. These genetic mutations cause chronic, excessive activation of complement, which also leads to platelet activation, endothelial cell damage, and systemic thrombotic microangiopathy. 3. Clinical features. Clinical findings are similar to those of STEC-HUS. Diarrhea may also be present, and severe proteinuria and hypertension are more consistently found. The clinical course is generally more severe with multiorgan damage. 4. Management. Treatment is supportive. Inciting medications, if any, must be stopped immediately. 5. Prognosis. Some patients have a chronic relapsing course (recurrent HUS). All patients with aHUS have a higher risk of progression to ESRD than patients with STEC-HUS.

1. ANTENTAL CARE
DR.AlaaAbbas

2. Goals OF ANTENATAL CARE
1- EARLY, ACCURATE ESTIMATION OF GA .
2-IDENTIFICATION OF PREGNENCIES AT INCREASED RISK OF
MATERNAL OR FETAL MORBIDITY AND MORTALITY.
3-ONGOING EVALUATION OF MATERNAL AND FETAL
WELLBEING STATUS .
4-ANTICIPATION OF PROBLEMS , WITH INTERVENTION (IF
POSSIBLE ) TO PREVENT OR MINIMIZE MORBIDITY AND
MORTALITY .
5- HEALTH PROMOTION,EDUCATION AND SUPPORT .

3. Antenatal care comprises of :
1.Registration of pregnancy
2. History taking
3. Antenatal examinations [general and obstetrical]
4. Laboratory investigations
5. Health education

4. • In an uncomplicated pregnancy, there should be 10 appointments
for nulliparous women and 7 appointments for parous women.
• women should receive written information about the number,
timing and content of antenatal appointments.
• Each antenatal appointment should have a structure and a focus.

5. THE FIRST VISIT
• History taking
• Examination
• Investigation

6. History
•
Demographic details
Name
Age
Occupation
Make a note of ethnic background
•
Past obstetric history
List the previous pregnancies and their outcomes in
order, any complications
•
Gynaecological history
Periods: regularity
Contraceptive history
Previous gynaecological surgery
•
Past medical and surgical history
Relevant medical problems
Any previous operations
•
Psychiatric history
• Postpartum blues or depression
• Depression unrelated to pregnancy
• Major psychiatric illness
•
Family history
• Diabetes, hypertension, genetic problems, etc.
•
Social history
• Smoking/alcohol/drugs
• Marital status
• Occupation, partner’s occupation
•
Drugs
• All medication including over-the-counter
medication
• Folate supplementation

7. Give specific information on:
• Folic acid supplements
• Food hygiene
• Lifestyle modification

8. Booking appointment (ideally by 10 weeks)
CONFIRMATION OF PREGNENCY :
*SYMPTOMS OF PREGNENCY ( BREAST TENDERNESS,NAUSEA , AMENORRHEA , URINARY
FREQUENCY )
*+ VE URINE OR SERUM PREGNENCY TEST
Identify women who may need additional care and plan pattern of care.
Determine risk factors for pre-eclampsia and gestational diabetes.
Offer early scan for gestational age assessment
Offer screening for Down‟s syndrome.

9. DATING THE PREGNENCY
•
1ST DAY OF LMP
•
DATING BY USS : 1ST OR EARLY 2ND TRI IS MORE CCURATE
esp. if irregular or uncertain of LMP
USS to determine GA using:
CRL measurement between 10 weeks 0 days and 13 weeks 6 days
HC if CRL is above 84 mm
OTHER BENEFITS OF USS :
*EARLY DETECTON OF MULTIPLE PREGNENCIES
*DETECTION OF ASYMPTOMATIC FAILED INTRAUTERINE PREGNENCY

10. BOOKING EXAMINATION
*Accurate measurement of blood pressure.
*Abdominal examination to record the size of the uterus.
* Recognition of any abdominal scars indicative of previous surgery.
*Measurement of height and weight for calculation of the BMI.

11. BOOKING INVESTIGATIONS and SCREENING
• * CBC :ANEMIA &THROMBOCYTOPENIA
• ABO, RH
• * SCREENED FOR ATYPICAL RED CELL ALLOANTIBODIES
• * URINE ANALYSIS: TO DETERMINE AND TTT ASYMPTOMATIC BACTERIUREA, THIS REDUCE RISK OF PYELOEPHRITIS
• * Rubella : to identify women at risk of infection and to enable vaccination in the postnatal period
• * HBsAG: IF + VE: decrease transmission by active immunization (vaccine) & passive with HBIG
• Syphilis *
• * Chlamydia : if < 25 y.o
• No evidence support screening for :GBS.

12. SCREENING DOWN SYNDROME
*The chance INCREASED with Advanced maternal age
*When a woman is offered a diagnostic test she should be informed of:
*Other chromosomal abnormalities, not just Down’ s syndrome, may be identified
*Information about screening for Down’ s syndrome should be given should include:
-the screening pathway
-the fact that screening does not provide a definitive diagnosis
-information about chorionic villus sampling and amniocentesis and risk associated
with them
-balanced and accurate information about Down’ s syndrome.

13. Incidence of down syndrome according to age
• at 35 yrs 1 : 350
• At 37 yrs 1 : 250
• At 40 yrs 1 :100
• At 45 1 : 30

14. Screening for Down s syndrome
* At 11–14 weeks: 85%
1. nuchal translucency (NT)(above 3.0 mm, or above the 99th percentile for
the gestational age)
2. combined test (NT + HCG(inc) + pregnancy associated plasma protein-A(inc))
IF +VE CVS
* At 15 – 20 weeks:80%
Quadruple test (hCG, ESTRIOL, AFP, inhibin A)
IF +VE AMNIOSENTISIS
* INTEGRATED TEST: 94%

15. • 16 weeks
*Review, discuss and record the results of screening tests.
*Investigate Hb < 11 mg/dl and consider iron sup.
* BP , urine dip
Give specific information on:
Detailed anomaly scan.
Offer quadriple test for DS if not yet done .

16. Anomaly scan: 18 to 20 weeks
Scan should be performed between 18 +0 and 20 +6 to detect
structural anomalies.
For a woman whose placenta extends across the internal cervical os,
offer another scan at 32 weeks

17. Gestational diabetes
Screening for gestational diabetes (24-28 WEEKS)
Risk factors for GDM
BMI > 30 kg/m2
Previous macrosomic baby >4.5 kg
Previous GDM
Family history of diabetes (first-degree relative)

18. •
28 weeks
Checks and tests
Measure blood pressure and test urine for proteinuria.
CBC, atypical antibodies and Offer anti-D prophylaxis to women
who are rhesus D-negative
Measure and plot symphysis–fundal height

20. 31 weeks for nulliparous women
Checks and tests
Review, discuss and record the results of screening tests undertaken
at 28 weeks.
Measure blood pressure and test urine for proteinuria.
Measure and plot symphysis–fundal height.

21. 34 weeks
Checks and tests
Review, discuss and record the results of screening tests undertaken at 28
weeks.
Measure blood pressure and test urine for proteinuria.
Measure and plot symphysis–fundal height.
Give specific information on:
plan for labour and birth, , recognizing active labour and coping with
pain.

22. 36 weeks
Checks and tests
Measure blood pressure and test urine for proteinuria.
Measure and plot symphysis–fundal height.
Check the position of the baby, PRESENTING PART with ABD palpation
and uss .
If breech, offer external cephalic version.
Give specific information (at or before 36 weeks) on:
breastfeeding
care of the new baby, vitamin K prophylaxis and newborn screening tests
postnatal self-care, awareness of „baby blues‟ and postnatal depression

23. • 38 weeks
Checks and tests
Measure blood pressure and test urine for proteinuria.
Measaure and plot symphysis–fundal height.
Give specific information on:
options for management of prolonged pregnancy

24. • 40 weeks for nulliparous women
Checks and tests
Measure blood pressure and test urine for proteinuria.
Measure and plot symphysis–fundal height.
Further discussion of management of prolonged pregnancy

25. • For women who have not given birth by 41 weeks:
offer a membrane sweep
offer induction of labour
measure blood pressure and test urine for proteinuria
measure and plot symphysis–fundal height.
• From 42 weeks,
offer women who decline induction of labour increased monitoring (at
least twice-weekly cardiotocography and ultrasound examination of
maximum amniotic pool depth)

26. • Lifestyle advice
Working during pregnancy
The majority of women can be reassured that it is safe to continue
working during pregnancy.
A woman’ s occupation should be ascertained to identify those at
increased risk through occupational exposure

27. Nutritional supplements
• folic acid, before conception and up to 12 weeks, reduces
the risk of having a baby with NTD.
• Iron supplementation should not be offered routinely to all
pregnant women. It may have unpleasant maternal side effects.
• vitamin A supplementation > 700 micrograms may be teratogenic
and should be avoided.
• liver and liver products may also contain high levels of vitamin A.
• vit. D 10 micrograms per day.

28. Exercise in pregnancy
beginning or continuing a moderate course of exercise during pregnancy
is not associated with adverse outcomes.
There is dangers of certain activities: contact sports, high-impact sports
and that may Result in abdominal trauma, falls or excessive joint stress.
Sexual intercourse in pregnancy
sexual intercourse in pregnancy is not known to be associated with any
adverse outcomes

29. Alcohol and smoking in pregnancy
Avoid drinking alcohol in the first 3 months of pregnancy because it may be
associated with an increased risk of miscarriage.
If choose to drink alcohol no more than 1 to 2 UK units once or twice a week
Informed about the specific risks of smoking during pregnancy (low birth
weight and preterm birth).
Advice and support on how to stop smoking

30. Air travel during pregnancy
long-haul air travel is associated with an increased risk of VTE,
wearing compression stockings is effective at reducing the risk.
Car travel during pregnancy
informed about the correct use of seatbelts that is, three-point
seatbelts ‘above and below the bump, not over it’ .

31. Management of common symptoms of pregnancy
Nausea and vomiting in early pregnancy
nausea and vomiting are not usually associated with a poor pregnancy
outcome.
the following interventions effective in reducing symptoms:
1. Non pharmacological:
ginger, P6 (wrist) acupressure
2. pharmacological:
antihistamines.

33. • Heartburn
Offer information regarding lifestyle and diet modification, antacids .
• Constipation
Offer information regarding diet modification, such as bran or wheat fiber
Haemorrhoids
Offer information concerning diet modification.
If clinical symptoms remain troublesome, standard hemorrhoid creams
should be considered.
•
Varicose veins
varicose veins are a common symptom of pregnancy that will not cause
harm compression stockings can improve the symptoms but will not
prevent varicose veins from emerging.

34. • Vaginal discharge
increase in vaginal discharge is a common physiological change that occurs
during pregnancy.
If this is associated with itch, soreness, offensive smell or pain on passing urine
there maybe an infective cause and investigation should be considered.
Backache
exercising in water, massage and group or individual back care classes might
help.

35. • Cardiotocography
The evidence does not support the routine use of antenatal CTG
for fetal assessment in women with an uncomplicated pregnancy
• Ultrasound assessment in the third trimester
The evidence does not support the routine use of scan after 24
week

36. Thank you