Prenatal Care ppt

8/13/2019 Prenatal Care ppt

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ntenatal Care

DR. Yasir Katib

MBBS, FRCSC

Perinatologest

Antenatal care (ANC) goals and

strategy

Explain the components and objectives of

prenatal goals Describe the frequency and aim of each

prenatal visit

Genetic counseling and its available tools

Risks and benefits of the genetic tests

ANC ObjectivesTo ensure the birth of a healthy baby with minimal

risk for the mother by

1. Early, accurate estimation of GA

2. Identification of the patient at risk forcomplications

3. Ongoing evaluation of the health status of bothmother and fetus

4. Anticipation of problems and intervention, ifpossible, to prevent or minimize morbidity

5. Patient education and communication

Prenatal care is not a single intervention “Quantity" Vs. “Quality" of ANC A systematic review of observational studies and

randomized trials concluded that there was noconclusive evidence that prenatal care improvedbirth outcomes

Randomized trials have also shown that enhancedprenatal care did not result in improved outcomes

compared to routine prenatal care

ANC Components1. HISTORY

2. PHYSICAL EXAMINATION

3. LABORATORY TESTS

4. DIAGNOSTIC IMIGING

5. PATIENT EDUCATION

6. MEDICATIONS

Physical examination

A complete physical examination

Specially…

Uterine size and shape Evaluation of the adenexea

Baseline blood pressure, weight, and height

LABORATORY TESTS

1st visit

A standard panel of laboratory tests(Routine)

1. CBC

2. Blood gp & antibodies screen3. HbS Ag4. Rubella5. VDRL6.

Urine C&S7. Cervical PAP smear

LABORATORY TESTS

1st visit

In high risk population

1. Chlamydia swab

2. HIV3. TFT

Follow-up visits

Major goals (PET, malpresentation)

Components

1. Wt, B/P, SPH, FH auscultation, FM, lie,presentation

2. Patient’s concerns

3. Education4. Risk identifications

Presentation & lie

Follow-up visits

Uncomplicated pregnancies

Every 4 weeks until 28 wks

Every 2 to 3 weeks from 28 to 36 wks Weekly until delivery

Follow-up visits

Laboratory follow-up

GDM screening at 24-28 wks

CBC & antibodies screen GBS screening (recto-vaginal swab)

at 35-37 wks

DIAGNOSTIC IMIGING

Ultrasound

Minimum requirement

Usefulness

Limitations

Others

1st Trimester U/S

1. Confirm pregnancy

2. Viability

3. Assess GA (Dating)4. Multiple gestations (chorionicity /

amnionicity)

5. Maternal pelvic anomalies

AIUM Standards and Guidelines

2nd Trimester U/S

Fetal normality: • Head shape and size and internal structures (cavum

pellucidum, cerebellum, ventricular size at atrium < 10 mm) • Spine: longitudinal and transverse • Abdominal shape and content at level of stomach • Abdominal shape and content at level of kidneys andumbilicus • Renal pelvis < 5 mm anterior–posterior measurement • Longitudinal axis abdominal–thoracic appearance (diaphragm

and bladder)

• Thorax at level of a four-chamber cardiac view • Arms: three bones and hand (not counting fingers) • Legs: three bones and foot (not counting toes)

VALUE OF PRENATAL GENETIC

DIAGNOSIS:

Why do we do it?

Reassurance

Increases options

Antenatal fetal treatment

Preparation for outcome

Avoidance of obstetric complications

Selective termination

15 20 25 30 35 40 45

Maternal age (yrs)

C h a n c e o f

Maternal age-based screening

1/200 risk of

miscarriage

Rationale

1/200 chance of

abnormality 30%

Assessment of Backg round Risk

Maternal Age

0.0001

20 25 30 35 40 44

Trisomy 21

Trisomy 18 Trisomy 13

47xxx/xxy/xyy

Triploidy

Risk %

Courtesy Dr J Johnson and the Fetal Medicine Foundation

10 14 18 25 30 35 40

Trisomy 21

Trisomy 18Trisomy 13

Triploidy

47xxx/xxy/xyy

Assessment of Backround Risk

Gestational Age

Snijders et al 1999Courtesy Dr J Johnson and the

Fetal Medicine Foundation

Prenatal ScreeningModalities

Screen ing at 11-20 wks

10 12 14 16 18 20 wks

• Allows adjustment of age-related risk

• Improved detection rate

A- Non-invasive prenatal

diagnostic tests1. Nuchal Screen

2. Nuchal plus biochemistry

3. Maternal Serum Screen

4. Ultrasound

“the skin is deficient in elasticity. . . . . . too large for the body” Langdon Down

Observations on an ethnic classification of idiots.

Clinical Lecture Reports, London Hospital 1866;3:259.

Nuchal Trans lucency

Courtesy Dr J Johnson and the Fetal Medicine Foundati

Nuchal Translucency

• Gestation 11-14 wks• CRL 45-84 mm

• Mid-sagittal view

• Image size >75%

• Neutral position

Away from amnion• Maximum lucency

• Calipers on-to-on

FETAL CENTREFETAL CENTRE

Fetal Fetal Nuchal Nuchal Translucency Translucency

Chromosome abnormalities

Birth defects (cardiac, d.hernia)

Genetic syndromes

Increased mortality (> 3.5 mm)

Significance of increased nuchal fluid

Courtesy Dr J Johnson and the Fetal Medicine Foundatio

Pathophysiology of increased

nuchal translucency•Abnormal or delayed lymphatic development

• Venous congestion

• Cardiac failure• Altered composition of extracellular matrix

• Failure of lymphatic drainage due to fetalhypokinesia

• Fetal anemia or hypoproteinemia

• Congenital infection Courtesy Dr J Johnson and the Fetal Medicine Foundation

First Trimester Biochemical Markers

PAPP-A: Pregnancy associated plasma protein A•Produced by placental trophoblast

•Increases in 10-14 week period

•Lower in DS pregnancies (0.43 MOM)

•Associated with 42 % DR at 5% FPR.

Free - hCg: Free subunit of human

chorionic gonadotrophin.•Placental protein

•Decreases in T1 like total hGC•Higher in DS pregnancies (1.79 MOM)

•Associated with 23% DR at 5% FPR

Fetal NT + Maternal age + ßhCG + PAPP-A at 11-14 wks

ßhCG PAPP-A

Detection Rate

ßhCGPAPP-A

Invasive

Testing

Screening at 11-14 wks

3- Maternal Serum Screen

Three biochemical markers BHCG

Estriol

Gives age adjusted risk

Screens for Down’s and NTD 15-20 wks

1/1 01/378

Risk = age X OR BHCG X OR uE3 X OR AFP

MSS Limitations

Sensitivity 70 %

Specificity 95% ( False positive 5%)

Two reasons for a false positive:

Wrong dates

4- Ultrasound

Ultrasound screening (detailed scan)

18-20 weeks

B- INVASIVE TECHNIQUES FOR

EARLY PRENATAL TESTING

Chorionic Villus Sampling

Amniocentesis

Amniocentisis

http://wchs.health.wa.gov.au/health/a/amnio.htm

Amniocentisis

Performed at or more 15 weeks

Takes 2-3 weeks for Karyotype

Pregnancy loss risk 1/200 Can get result of trisomies 13,18,21 and

Turners Syndrome X0 in 48 hours withFISH (Florescent Insitu Hybridization)

Chorionic Villus Sampling

Performed at 10-14 weeks

Takes 2-3 weeks for the result

Pregnancy loss rate 1/100

Operator experience important

Link to limb abnormalities (stillcontroversial)

Placental mosaicism up to 3%, but littleeffect on outcome

Post Test

A standard panel of laboratory tests(Routine) dose not include

1. Rubella

2. TFT

3. VDRL

4. Urine C&S

5. Cervical PAP smear

Post Test

First trimister scan does not include

1. Fetal morphology

2. Viability3. Assess GA (Dating)

4. Multiple gestations (chorionicity /amnionicity)

5. Maternal pelvic anomalies

Post Test

Which of the following is not a cause for an

abnormal MSS

a) Down’s syndrome

b) IUFD

c) Twins

d) Wrong dates

e) Congenital heart disease

Post Test

A false positive on the MSS occurs in 1/20 tests

True False

Post Test

List Two advantages of Amniocentesis over

Decreased miscarriage rate

Lower risk of mosaicism

No association with limb reductions

Post test

Which of the following tests is the best at

detecting Down’s Syndrome

1. MSS

2. Nuchal

3. Nuchal plus PAPP A and Free BHCG

Post Test

What is the miscarriage rate with

amniocentesis?

Post Test

List one advantage of CVS over amniocentesis

Early results

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