Antenatal care Dr. Sara Isam Eldin Definition: Antenatal care refers to the care that is given to an expected mother from time of conception is confirmed until the beginning of labor. The aims of antenatal care are: 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. Advice, reassurance and education Reassurance & explanation of pregnancy symptoms: 1. 2. 3. 4. 5. 6. 7. 8. 9. Nausea Heartburn Constipation Shortness Of Breath Dizziness Swelling Back-ache Abdominal Discomfort Headaches Mostly these represent the physiological adaptation of her body to the pregnancy and are often called the ‘minor complaints’ of pregnancy. Information regarding smoking, alcohol consumption and the use of drug during pregnancy (both legal and illegal) is extremely important. Woman also need advice on work, exercise, sexual intercourse and maternity benefit. Parentcraft is the term used to describe formal group education of issue relating to pregnancy, labour and delivery and care of the newborn. The aim of this is to lessen anxiety and increase the sense of maternal control surrounding delivery. Common issues requiring advice and education during pregnancy Food hygiene, dietary advice, vitamin supplementation. The risks of smoking during pregnancy, smoking cessation. Alcohol consumption. Use of medications. Recreational drug misuse. Exercise and sexual intercourse. Mental health issues. Foreign travel, DVT prophylaxis . Maternity rights and benefits. Female genital mutilation and domestic violence. Screening for fetal problems (Down’s syndrome, anomalies, haemoglobinopathies). Screening for maternal conditions (diabetes, hypertensive disorders, UTI, anaemia). Management of prolonged pregnancy. Place of birth and labour. Pain relief in labour. Breastfeeding and vitamin K prophylaxis. Care of the new baby and newborn screening. Accessing antenatal care: the ‘booking visit’ When a woman becomes pregnant one of the first interactions with the health services is known as the booking visit The first risk assessment is usually made at the booking visit which can be carried out in hospital or in the community . If risks are identified at this visit , the women is likely to be referred directly for hospital based care. Before risk assessment begins, the pregnancy should be confirmed and the expected date of delivery (EDD) should be calculated. Confirmation of the pregnancy Symptoms of pregnancy combined with a positive urinary or serum pregnancy test is sufficient confirmation of pregnancy. In many regions, all pregnant women are referred for US ‘dating scan’ which both confirm the pregnancy and accurately dates it. It may be possible to hear the fetal heart with the Doppler US from approximately 12 weeks onwards. Dating the pregnancy Setting a reliable ‘expected date of delivery’ (EDD) is an important function of antenatal care. A pregnancy can be dated either by using the date of the first day of the last menstrual period (LMP) or, more accurately, by ultrasound scan. Dating by ultrasound Dating by an ultrasound scan in the first or early second trimester is more accurate, especially if there is menstrual irregularity or uncertainity regarding the LMP. National recommendations state that all women should be offered a dating scan, ideally between 10 and 14 weeks, and that the EDD predicted by this scan should be used in preference to the menstrual EDD. The crown–rump length (CRL) is used up until 13weeks 6 days. Benefits of a dating scan: 1. 2. 3. 4. 5. Accurate dating in women with irregular menstrual cycles. Reduced incidence of induction of labour for prolonged pregnancy Maximizing the potential for serum screening to detect fetal abnormalities Early detection of multiple pregnancy Detection of asymptomatic failed intrauterine pregnancy The booking history 1. Past Medial History 2. Past Obstetric History 3. Previous Gynaecological History 4. Family History 5. Social History Past medical history Taking a detailed history about any previous medical illness is important as: The disease and its treatment may adversely affect the growth of the fetus There may be an associated increased risk of placental dysfunction Pregnancy may cause improvement or deterioration in the medical illness Major pre-existing diseases : Diabetes mellitus Hypertension Renal disease Epilepsy Venous thromboembolic disease Human immunodeficiency virus (HIV) infection Connective tissue disease Cardiac disease Past obstetrical history 1- Details of previous pregnancy complications. The features that are likely to have impact on future pregnancies include: Recurrent miscarriage (increased risk of miscarriage, intrauterine growth restriction (IUGR)), Preterm delivery (increased risk of preterm delivery), Early onset pre-eclampsia (increased risk of preeclampsia/ IUGR), Abruption (increased risk of recurrence), Congenital abnormality (recurrence risk depends on type of abnormality), Macrosomic baby (may be related to gestational diabetes), IUGR (increased recurrence), Unexplained stillbirth (increased risk of gestational diabetes) 2- Details of previous labours and deliveries Previous gynecological history: Previous history of infertility or recurrent abortion Previous history of cone biopsy as it may cause cervical incompetence. Previous history of myomectomy . Family history: Important areas are a maternal history of a first degree relative (sibling or parent) with: Diabetes (increased risk of gestational diabetes), Thromboembolic disease (increased risk of thrombophilia). Preeclampsia (increased risk of preeclampsia), Psychiatric disorder ( increased risk of puerperal psychosis). History of baby with congenital abnormality. Genetic problems, such as haemoglobinopathies. Social history: Smoking and drug abuse Social deprivation Domestic violence The booking examination Historically, a full physical examination (CVS, RS, abdominal, pelvic and breast examination) was carried out at the booking visit. The value of this has been questioned, as the detection of significant pathology in the absence of focal symptoms is uncommon. For most healthy women, without complicating medical problems, the booking examination will include the following: 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. Women with a low BMI are at greater risk of fetal growth restriction and obese women are at significantly greater risk of most obstetric complications, including gestational diabetes, preeclampsia, need for emergency Caesarean section and anaesthetic difficulties. Urine dip testing for protein, glucose,leukocytes,nitrates and blood. Booking investigations Full blood count: This Screens for anaemia and thrombocytopenia. Anaemia in pregnancy is most frequently caused by iron deficiency, however, other causes must be considered, especially if the Hb level is <9.0g/dl. Blood group and red cell antibodies Recording the blood group at this point will help with cross -matching blood at a later date if an emergency arises. Women found to be rhesus D negative will be offered prophylactic anti-D administration to prevent rhesus D iso-immunization and haemolytic disease of the fetus and newborn in future pregnancies. Urinalysis Hepatitis B: vertical transmission to the fetus may occur, mainly during labour and horizontal transmission to maternity staff or the newborn infant can follow contact with bodily fluids Human immunodeficiency virus Syphilis Haemoglobin studies: test for haemoglobinopathies for women with family history of it. Screening for fetal abnormalities This is a routine aspect of antenatal care, offered to all women in some form or another. Initial discussion of these screening tests usually occurs at the booking visit to establish the wishes of the couple. offered to all pregnant women at 11 and 22 weeks gestation and includes: screening for Down’s syndrome: Essentially they include a nuchal translucency scan at 11–14 weeks gestation, with or without biochemical tests, or biochemical blood tests in isolation at 15–20 weeks. Screening for neural tube defects (e.g. spina bifida, anencephaly) with maternal serum alphafetoprotein levels at 15–20 weeks gestation. Screening for structural congenital abnormalities by ultrasound examination at 18 to 20+ 6 weeks gestation. Screening for clinical conditions later in pregnancy Gestational diabetes: All women should be assessed at booking for risk factors for gestational diabetes. If risk factors are present, the woman should be offered a 2-hour 75 g oral glucose tolerance test (OGTT) at 24–28 weeks gestation. A previous history of gestational diabetes should prompt glucose monitoring, or an OGTT, at 16– 18 weeks. If these results are normal, the test should be repeated at 24–28 weeks. Pre-eclampsia and preterm birth All women should be screened at every antenatal visit for pr e-eclampsia by measurement of blood pressure and urinalysis for protein. Women without a history of preterm birth should not be routinely offered screening tests for preterm labour, such as bacterial swabs, or cervical length scans. Follow-up visits Customized antenatal care Through the process of booking and routine antenatal follow up, it may become apparent that a woman and her pregnancy have risk factors or special needs not met by standard care. Referrals to other hospital consultants, psychiatric services, social services and physiotherapists are common in pregnancy. ‘High-risk’ antenatal clinics staffed by specially skilled obstetricians and doctors from other disciplines can usually be found in tertiary centres. Antenatal complications dealt with in customized antenatal clinics Endocrine (diabetes, thyroid, prolactin and other endocrinopathies). Miscellaneous medical disorders (e.g. secondary hypertension and renal disease, autoimmune disease). Haematological (thrombophilias, bleeding disorders). Preterm labour. Multiple gestation. Teenage pregnancies.
