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Lecture 3 Antenatal Care

The document outlines the aims and practices of antenatal care, focusing on optimizing pregnancy outcomes, health screening, and managing minor ailments. It details the process for calculating estimated due dates, documenting pregnancy history, and scheduling visits based on risk levels. Additionally, it covers dietary advice, risk assessments, recommended supplements, and considerations for medications during pregnancy.

Education◦
Antenatal care
Aim of antenatal care • To optimize pregnancy outcomes for women and babies. • To prevent, detect and manage those factors that adversely affect the health of mother and baby. • To provide advice, reassurance, education and support for the woman and her family. • To deal with the ‘minor ailments’ of pregnancy. • To provide general health screening
Dating the pregnancy by LMP • Assuming the cycle is regular ,the EDD is calculated by taking the date of the LMP, counting forward by 9 months and adding 7 days. • If the cycle is longer than 28 days, add the difference between the cycle length and 28 to compensate
Examples on EDD • A patient with regular cycle of 28 days her LMP was on 1.2.2020 Her EDD is : 8/10/2020 • A patient with a cycle of 35 days on 1.2.2020 , we add 9 months and 7 days plus the 7 days difference from the 28 days (14 days ) EDD = 15.10.2020 • A patient with a cycle of 21 days , her LMP on 1.2.2020 her LMP will be by adding only 9 months , EDD = 1.10.2020
How to write gravida and para on history ? • Gravida (G ) is how many times she got pregnant , whatever the outcome was . • Para (p) is all deliveries happened after 23+6 weeks (live or not ) • Plus : are the miscarriages happened (before 24 weeks ) whatever the location was
Examples ….. • A patient who is pregnant 16 weeks now , she has one son who is 12years old and a daughter who is 9 years old , she had 2 miscarriages the first was in the first trimester and was completely miscarried and the other missed abortion of at 15 weeks who had a medical termination of pregnancy for it , the patient told you that she had one stillbirth at 30 weeks GA and one infant who was died when he was 3 years of age due to congenital heart disease . • By asking her on a small 3 scars on her abdomen she told you she had a surgery for one ectopic pregnancy when her tube was removed laparoscopically
G8P4+3
Leopold maneuvers
Antenatal visits • In low risk multiparas women 7 visits are recommended • In low risk primigravida 10 visits are recommended
Antenatal visit (NHS ) First trimester Second trimester 3rd trimester Dating booking 10-13+6 weeks 16 weeks visit 28 weeks visit (Hb and growth ) Education Full history , LMP , dating , NT 18-21 weeks visit (detailed anomalies scan ) 34 week visit (anti D ) Screening test of aneuploidy Hb , multiple gestation ? Full history , LMP , dating , NT Additional visit at 25 weeks for Primigravidas 38 week visit ( council about prolonged pregnancy) Maternal screening tests 41 week visit (membrane sweeping and book for induction of labor ) Additional visits for PG at 25 and 31 weeks
Other schedules for visits • Monthly in the first 7 months (30 weeks ) • Twice weekly in the 8th and 9th month (till 38 weeks ) • Once weekly after that (38 weeks and above )
First visit • Screening to detect high risk population by history examination and proper investigations , review of medications if was not done prenatally Risks for GDM , PET , IUGR and the need for timed tests and modified supplements and medications (to be discussed later ) • Pregnancy dating by LMP and most accurately ultrasound (CRL )  (to be discussed later in role of ultrasound in obstetrics )
Weight assessment • BMI should be measured in the first visit • For normal weight women (BMI 18.5–24.9 kg/m2) the recommended total weight gain in pregnancy is 11–16 kg • for overweight women (BMI 25–29.9 kg/m2) 7–11 kg • for obese (≥30 kg/m2) women 5–9 kg
Effect of obesity • Difficult ultrasound (more undetected congenital anomalies ) • GDM , PET , VTE • Difficult anesthesia • Difficult fetal monitoring • More cs and difficult instrumental deliveries • Wound infections • Postnatal depression • Macrosomia • Still birth and miscarriage • Fetal injuries and shoulder dystocia • Childhood obesity
General pregnancy dietary advice • Do not eat for two; maintain your normal portion size and try and avoid snacks. • Eat fiber-rich foods such as oats, beans, lentils, grains, seeds, fruit and vegetables as well as whole grain bread, brown rice and pasta. • Base your meals on starchy foods such as potatoes, bread, rice and pasta, choosing whole grain where possible. • Restrict intake of fried food, drinks and confectionary high in added sugars, and other foods high in fat and sugar. • Eat at least five portions of a variety of fruit and vegetables each day. • Dieting in pregnancy is not recommended but controlling weight gain in pregnancy is advocated • Caffeine intake less than 200 mg/ day • Avoid undercooked food and soft cheese ,pate ,undercooked food
Advice on smoking • Increases the risk of : SGA ABRUPTIO PLACENTA OVERALL PERINATAL MORTALITY
General exercise advice • Aerobic and strength conditioning exercise in pregnancy is considered safe and beneficial. • NOT scuba diving !!
Booking tests and infection screening • Bp assessment (at first visit and every visit ) • CBC (booking , 28 weeks and additional at 20-24 if multiple gestation ) • BG and Rh status (booking and 28 weeks to detect sensitization ) • Infections hepatitis B , syphilis , HIV • MSU every visit to detect asymptomatic bacteriuria (midstream urine ) • Ultrasound scan : dating(10-13+6 weeks ) , number of sacs , fetal heart … • First trimester screening test
Other test in specific situations • OGTT for GDM if she had GDM in previous pregnancy • Thalassemia and sickle cell disease in high risk ethnic groups • Rubella IgG (not anymore in UK )
Supplements • Folic acid 400 mcg for all ideally 3 months before pregnancy till 12 weeks • Higher folic acid supplementation (5 mg ) if DM , sickle cell ,on AED, thalassemia , history of NTD (family , personal , sons ) • Vitamin D : 10 mcg (400iu ) for all • Higher dose of it D (1000 iu ) if : obese ,dark skin, not exposed to sun , history of PET (calcium and vit D 800 iu )
PET risk assessment Aspirin 75 mg should be given if one major or more than one moderate risk starting from 12 weeks and before 20 weeks
Risk assessment IUGR Major risk Serial growth scan from 26 weeks 3 or more minor risks Uterine artery doppler at 20-24 weeks Low risk SFH
Second trimester • Detailed anomalies scan 20-22 week • GDM screening (24-28 weeks ) • Second trimester aneuploidy screening • Fetal growth for high risk population
GDM screening • BMI above 30 kg/m2 • previous macrosomic baby weighing 4.5 kg or above • previous gestational diabetes • family history of diabetes (first-degree relative with diabetes) • Ethnic group of a high prevalence of diabetes: South Asian, black Caribbean, Middle Eastern
OGTT • all previous population categories should be screened using 2 hour 75 g OGTT test at 24-28 weeks • Patients with a history of GDM should be screened as soon as possible GDM diagnosed if one of the reading is abnormal : Fasting more than 5.3 mmol (95 mg-dl) 2 hours more than 7.8 mmol (140 mg-dl )
Medications in pregnancy
Vaccines
Important teratogenic drugs • Anticonvulsants • Antibiotics • Anticoagulants • Antimetabolites • Antipsychotics • Androgens • Acne drugs • Alcohol • Anti hypertensives
Teratogenic drugs • Phenytoin , phenobarbital , valproic acid (fetal hydantoin syndrome ) • Warfarin (stippled epiphysis ,hypoplastic nasal bone , heart ) • ACE inhibitors (lisinopril) and ARBs (losartan) : renal and oligohydramnios • Isotretinoin (neurological and facial ) • Lithium : ebstein anomaly • Androgens : androgenizing a female fetus • Chemotherapy (IUGR , sterility ….) • Radiotherapy (leukemia , pregnancy loss , neurodevelopmental ,IUGR ,loss ) • Fetal alcohol syndrome
Teratogenic antibiotics Antibiotic effect Chloramphenicol Gray baby syndrome (cardiac collapse ) Tetracycline Teeth staining Trimethoprim Neural tube defect (antifolate) Aminoglycosides (streptomycin) Ototoxic (8th nerve ) nephrotoxic Nitrofurantoin and sulfonamides 3rd trimester (hemolysis , kernicterus ) Quinolone (ciprofloxacin ) C Cartilage