Antenatal care

Evidence-BasedRoutine Antenatal Care

MD. Amer khojah

The Main References Of My Lecture

Objectives of Antenatal Care

Early, accurate estimation of gestational age Identification of the patient at risk for complications Ongoing evaluation of the health status of both mother and fetus Anticipation of problems and intervention, if possible, to prevent or minimize morbidity Patient education and communication

Who provides care Midwife- and GP vs obstetricians?

Villar J, Khan-Neelofur D. Patterns of routine antenatal care for low – risk pregnancy. Cochrane Database of Systematic Review 2003

There was no significant difference in the levels of satisfaction with the types of care provided between the two groups

midwife-managed or midwife and GP-managed antenatal care programmes for women at ‘low risk’ did not increase the risk of adverse maternal or perinatal outcomes

RECOMMENDATION

Midwife- and GP-led models of care should be offered for women with an uncomplicated pregnancy. Routine involvement of obstetricians in the care of women with an uncomplicated pregnancy at scheduled times does not appear to improve perinatal outcomes compared with involving obstetricians when complications arise. [A]

What is the adequate no of visit?

• a schedule of ten appointments should be adequate

nulliparous with an uncomplicated

pregnancy

• a schedule of seven appointments should be adequate [B]

maltiparous with an uncomplicated

pregnancy

In the United States

every four to five weeks from 1st

visit until 28 weeks

every two to three weeks from

28 to 36 weeks

weekly until delivary

What to in the antenatal clinic ?

1st Appointm

ent

Other Visits

History Taking

Initial prenatal social and demographic assessment

• Names of patient, partner, emergency contact • Marital status • Age • Home address • Telephone numbers for day, night, emergency • Education • Occupation • Partner's name and occupation • Pediatrician • Primary care physician • Hospital for delivery • Religion (Jehovah's witness?)

Initial prenatal social and demographic assessment

• Date of delivery • Gestational age at delivery • Location of delivery • Sex of child • Birth weight • Mode of delivery • Type of anesthesia • Length of labor • Outcome (miscarriage, stillbirth, ectopic, etc) • Details (eg, type of cesarean section scar, forceps, etc) • Complications (maternal, fetal, child)

Basic medical history for the pregnant woman and her family

Infectious diseases

Gynecologic history

Surgical procedures

Hospitalizations

Allergies Medications

Substance use

Endocrine disorder

Cardiovascular disease

Kidney disease

Neurologic or muscular disorders

Gastrointestinal disease

Psychiatric problems

Cancer Autoimmune

disorder

History of blood transfusion

History of trauma

Pulmonary disease

Hematologic problems

Breast disordersdrug use

Initial prenatal menstrual history

• Last menstrual period (definite or uncertain?) • Last normal menstrual period • Previous menstrual period • Cycle length • Recent use of hormonal contraception? • Menarche • History of IUD use?_____ Date

removed:_____

Current pregnancy history

• Medications taken • Alcohol use • Cigarette use • Recreational drug use • Exposure to radiation • Vaginal bleeding • Nausea, vomiting, weight loss • Infections • Exposure to toxic substances • Restricted diet

Gestational age assessment: LMP and ultrasound

Pregnant women should be offered an early ultrasound scan to determine gestational age (in addition to last menstrual period [LMP] for all cases) – to detect multiple pregnancies.– This will ensure consistency of gestational age

assessments– improve the performance of mid-trimester serum

screening for Down’s syndrome – reduce the need for induction of labour after 41 weeks. [A]

Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008

Clinical examination ofpregnant women

Measurement of weight and body mass indexMaternal weight and height should be measured at the first

antenatal appointment, and the woman’s BMI calculated (weight [kg]/height[m]²). [B]

Repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to be influenced. [C]

Breast examinationRoutine breast examination during antenatal care is not

recommended for the promotion of postnatal breastfeeding. [A]


Clinical examination ofpregnant women

Pelvic examinationRoutine antenatal pelvic examination does not accurately assess

gestational age, nor does it accurately predict preterm birth or cephalopelvic disproportion. It is not recommended. [B](1)

Blood pressure measurementIt is not known how often blood pressure should be measured, but

most guidelines recommend measurement at each antenatal visit.[C](2)

Evaluation for edemaEdema occurs in 80 percent of pregnant women. It lacks specificity

and sensitivity for the diagnosis of preeclampsia[C](3).1 -Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008

2 -U.S. Preventive Services Task Force. Guide to clinical preventive services. 2d ed. Washington, D.C.: U.S. Department of Health and Human Services, Office of Public Health and Science, Office of Disease Prevention and Health Promotion, 1996.

3 -Smith MA. Preeclampsia. Prim Care 1993;20:655-64.

Screening for haematological conditions

AnaemiaScreening should take place at the first appointment and at 28 weeks

when other blood screening tests are being performed. This allows enough time for treatment if anaemia is detected.

Haemoglobin level less than 11 g/dl at first contact and 10.5 g/dl at 28 weeks should be investigated and iron supplementation considered if indicated.

Ramsey M, James D, Steer P, Weiner C, Gornik B. Normal values in pregnancy. 2nd ed. London: WB Saunders; 2000.

Screening for haematological conditions

Blood Typing• Rh and ABO blood typing should be performed at the first prenatal visit, as well as a

screening test for irregular red blood cell antibodies.(1)• Testing should be undertaken again at 28 weeks of gestation for all women with no

antibodies on initial testing to ensure that no additional antibodies have developed (4)• RhoD immune globulin (Rhogam) is recommended for all nonsensitized Rh-negative

women at 28 weeks' gestation (300 mcg) and within 72 hours after delivery of an Rh-positive infant (2,3)

• Nonsensitized, Rh-negative women also should be offered a dose of RhoD immune globulin after spontaneous or induced abortion, ectopic pregnancy termination, chorionic villus sampling (CVS), amniocentesis, cordocentesis, external cephalic version, abdominal trauma, and second- or third-trimester bleeding (2,3)

1-U.S. Preventive Services Task Force. Guide to clinical preventive services. 2d ed. 19962 -Clinical management guidelines for obstetrician-gynecologists. American College of Obstetrics and Gynecology. Int J Gynaecol Obstet 1999;66:63-70.

3 -Fung Kee, et al. Prevention of Rh alloimmunization. J Obstet Gynaecol Can 2003;25:765-73.4- British Committee for Standards in Haematology, Blood Transfusion Task Force. Guidelines for blood grouping and red cell antibody testingduring pregnancy. Transfusion Medicine 1996;6:71–4.

Screening for structural anomalies

ultrasound undertaken in

first and second trimesters

nuchal transluce

ncy

serum screening

Screening for fetal anomalies

Screening for structural anomaliesPregnant women should be offered an ultrasound scan to screen for

structural anomalies, ideally between 18 to 20 weeks of gestation, by an appropriately trained sonographer and with equipment of an appropriate standard as outlined by the National Screening Committee. [A]

Screening for Down’s syndrome• from 11 to 14 weeks

– nuchal translucency (NT)– the combined test (NT, hCG and PAPP-A)

• from 14 to 20 weeks– the triple test (hCG, AFP and uE3)– the quadruple test (hCG, AFP, uE3, inhibin A) [B]


Screening for infections

• Asymptomatic bacteriuriaPregnant women should be offered routine screening for

asymptomatic bacteriuria by midstream urine culture early in pregnancy. Identification and treatment of asymptomatic bacteriuria reduces the risk of preterm birth [A]

• Asymptomatic bacterial vaginosis Pregnant women should not be offered routine screening for

bacterial vaginosis because the evidence suggests that the identification and treatment of asymptomatic bacterial vaginosis does not lower the risk for preterm birth and other adverse reproductive outcomes.[A]



Cytomegalovirus The available evidence does not support routine cytomegalovirus

screening in pregnant women and it should not be offered. [B]Hepatitis B virusSerological screening for hepatitis B virus should be offered to pregnant

women so that effective postnatal intervention can be offered to infected women to decrease the risk of mother-to-child-transmission [A]

Hepatitis C virusPregnant women should not be offered routine screening for hepatitis C

virus because there is insufficient evidence to support its effectiveness and cost-effectiveness.[C]



HIVPregnant women should be offered screening for HIV infection early in

antenatal care because appropriate antenatal interventions can reduce mother-to-child transmission of HIV infection. [A]

RubellaRubella susceptibility screening should be offered early in antenatal care to

identify women at risk of contracting rubella infection and to enable vaccination in the postnatal period for the protection of future pregnancies. [B]

Streptococcus Group BPregnant women should not be offered routine antenatal screening for group

B streptococcu because evidence of its clinical and cost-effectiveness remains uncertain. [C]



Streptococcus Group BCDC ,ACOG,SOGC recommend that all women be offered GBS screening by

vaginorectal culture at 35 to 37 weeks' gestation and that colonized women be treated with intravenous antibiotics (e.g., high-dosage penicillin or clindamycin [Cleocin]) at the time of labor or rupture of membranes.

GBS bacteriuria indicates heavy maternal colonization (just ttt no need for further sceening)

Other organizations have made different recommendations, including recommending against GBS screening and recommending universal screening with selective treatment of colonized women who also have clinical risk factors (less than 37 weeks' gestation, prolonged rupture of membranes (more than 18 hours), and maternal fever)

Schrag S, atal Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR Recomm Rep 2002;(RR-11)51:1-22.Prevention of group B streptococcal infection in newborns: recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ 2002;166:928-30. American College of Obstetricians and Gynecologists. ACOG committee opinion: number 279, December 2002. Prevention of early-onset group B streptococcal disease in newborns. Obstet Gynecol 2002;100:1405-12.Money DM, Dobson S. The prevention of early-onset neonatal group B streptococcal disease. J Obstet Gynaecol Can 2004;26:826-40.


Syphilis• Screening for syphilis should be offered to all pregnant

women at an early stage in antenatal care because treatment of syphilis is beneficial to the mother and baby. [B]

Toxoplasmosis• Routine antenatal serological screening for toxoplasmosis

should not be offered because the risks of screening may outweigh the potential benefits. [B]

• Pregnant women should be informed of primary prevention measures to avoid toxoplasmosis infection [C]



Influenza• Influenza vaccination generally is recommended in

women who will be in the second or third trimester of pregnancy during flu season.(1,2)

• Pregnant women with medical conditions that increase their risk of complications from influenza should be immunized regardless of gestational age. There is no evidence that vaccination in the first trimester of pregnancy is unsafe.(3)

1 Ressel GW. ACIP releases 2003 guidelines on the prevention and control of influenza. Am Fam Physician 2003;68:1426, 1429-30, 1433.2 American College of Obstetricians and Gynecologists. ACOG committee opinion. Immunization during pregnancy. Obstet Gynecol 2003;101:207-12. 3 Goldman RD, Koren G. Influenza vaccination during pregnancy. Can Fam Physician 2002;48:1768-9.

Screening for gestational diabetes

The ACOG and the ADA recommend that all pregnant women be screened for gestational diabetes at 24 to 28 weeks' gestation, except women who are at low risk (e.g., younger than 25 years, belonging to a low-risk ethnic group, normal prepregnancy weight, no history of abnormal glucose metabolism, poor obstetric outcomes, or first-degree relatives with diabetes)

• RCOG The evidence does not support routine screening for gestational diabetes mellitus and therefore it should not be offered

1- American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 30, September 2001. Gestational diabetes. Obstet Gynecol 2001;98:525-38.2- American Diabetes Association. Gestational diabetes mellitus. Diabetes Care 2003;26(suppl 1):S103-5.

Screening for gestational diabetes

Screening protocols also differ: – a two-step protocol (i.e., one-hour, 50-g glucose-

challenge test followed by a diagnostic three-hour, 100-g glucose-tolerance test) is the main method used in North America

– a two-hour, 75-g glucose-tolerance test is offered in Europe.


Fetal growth and wellbeing

Determining fetal growth• Symphysis–fundal height should be measured and

recorded at each antenatal appointment from 24 weeks [A].

• Ultrasound estimation of fetal size for suspected large-for-gestational-age unborn babies should not be undertaken in a low-risk population.

• Routine Doppler ultrasound should not be used in low-risk pregnancies. [A]



Routine monitoring of fetal movementsRoutine formal fetal-movement counting should not be offered. [A]Auscultation of fetal heartAuscultation of the fetal heart may confirm that the fetus is alive but is unlikely to have anypredictive value and routine listening is therefore not recommended. However, when requestedby the mother, auscultation of the fetal heart may provide reassurance. [D]Ultrasound assessment in the third trimesterThe evidence does not support the routine use of ultrasound scanning after 24 weeks ofgestation and therefore it should not be offered. [A]Cardiotocography CTGThe evidence does not support the routine use of antenatal electronic fetal heart rate monitoring(cardiotocography) for fetal assessment in women with an uncomplicated pregnancy andtherefore it should not be offered. [A]



Determining fetal growth• Symphysis–fundal height should be measured and

recorded at each antenatal appointment from 24 weeks.

• Ultrasound estimation of fetal size for suspected large-for-gestational-age unborn babies should not be undertaken in a low-risk population.

• Routine Doppler ultrasound should not be used in low-risk pregnancies. [A]


Screening for clinical conditions

Preterm birth Routine vaginal examination to assess the cervix is not an

effective method of predicting preterm birth and should not be offered.[A]

Although cervical shortening identified by transvaginal ultrasound examination and increased levels of fetal fibronectin are associated with an increased risk for preterm birth, the evidence does not indicate that this information improves outcomes; therefore, they should not be used to predict preterm birth in healthy pregnant women. [B]



Placenta praeviaBecause most low-lying placentas detected at a

20-week anomaly scan will resolve by the time the baby is born, only a woman whose placenta extends over the internal cervical os should be offered another transabdominal scan at 36 weeks. If the transabdominal scan is unclear, a transvaginal scan should be offered. [C]










Outcomes Label Guidelines Supplement

Supplementation prevents neural tube defects.(1,2) A

Supplementation with 0.4 to 0.8 mg of folic acid (4 mg for secondary prevention) should begin at least one month before conception.

Folic acid

Folate deficiency is associated with low birth weight, congenital cardiac and orofacial cleft anomalies, abruptio placentae, and spontaneous abortion.(3)

Bdietary folate equivalents (e.g., legumes, green leafy vegetables, liver, citrus fruits, whole wheat bread) per day.(3)

Czeizel AE, Dudas I. Prevention of the first occurrence of neural-tube defects by periconceptional vitamin supplementation. N Engl J Med 1992;327:1832-5.Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. Lancet 1991;338:131-7McDonald SD, Ferguson S, Tam L, Lougheed J, Walker MC. The prevention of congenital anomalies with periconceptional folic acid supplementation. J Obstet Gynaecol Can 2003;25:115-21.

Nutritional supplements

Nutritional supplementsOutcomes Label Guidelines Supplement

Iron-deficiency anemia is associated with preterm delivery & low birth weight.

B Pregnant women should be screened for anemia (hemoglobin, hematocrit) and treated, if necessary.(1)

Iron

It does not benefit the mother’s or fetus’shealth and may have unpleasant maternal side effects

A Iron supplementation should not be offered routinely to allpregnant women. (2)

High dietary intake of vitamin A (i.e., more than 10,000 IU per day) is associated with cranial-neural crest defects. (4)

BPregnant women in industrialized

countries should limit vitamin A intake to less than 5,000 IU per day. (3)

Vitamin A

2 -Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 20081 -Routine iron supplementation during pregnancy. Review article. U.S. Preventive Services Task Force. JAMA 1993;270:2848-54

3 -American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 5th ed. Elk Grove Village, Ill.: American Academy of Pediatrics, and Washington, D.C.: American College of Obstetricians and Gynecologists, 2002.

4 -Rothman KJ, Moore LL, Singer MR, Nguyen US, Mannino S, Milunsky A. Teratogenicity of high vitamin A intake. N Engl J Med 1995;333:1369-73.

Outcomes Label Guidelines Supplement

Calcium supplementation has been shown to decrease blood pressure and pre-eclampsia, but not perinatal mortality.(2)

A

Recommended daily intake is 1,000 to 1,300 mg per day1,79

Routine supplementation with calcium to prevent pre-eclampsia is not recommended.(1)

Calcium

There is insufficient evidence to evaluate the effectiveness of vitamin D in pregnancy.(3)

AIn the absence of evidence ofbenefit, vitamin D supplementation should not be offered routinely to pregnant women.(3)

Vitamin D

Nutritional supplements

1 -American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 5th ed. Elk Grove Village, Ill.: American Academy of Pediatrics, and Washington, D.C.: American College of Obstetricians and Gynecologists, 2002.

2 -Bucher HC, Guyatt GH, Cook RJ, Hatala R, Cook DJ, Lang JD, et al. Effect of calcium supplementation on pregnancy-induced hypertension and preeclampsia: a meta-analysis of randomized controlled trials [published correction appears in JAMA 1996;276:1388]. JAMA 1996;275:1113-7.

3 -Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008Atallah AN, Hofmeyr GJ, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev 2002;(1):CD001059.

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Antenatal care