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ntenatal Care
DR. Yasir Katib
MBBS, FRCSC
Perinatologest
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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
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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
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ANC
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
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ANC Components1. HISTORY
2. PHYSICAL EXAMINATION
3. LABORATORY TESTS
4. DIAGNOSTIC IMIGING
5. PATIENT EDUCATION
6. MEDICATIONS
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Physical examination
A complete physical examination
Specially…
Uterine size and shape Evaluation of the adenexea
Baseline blood pressure, weight, and height
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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
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LABORATORY TESTS
1st visit
In high risk population
1. Chlamydia swab
2. HIV3. TFT
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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
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Presentation & lie
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Follow-up visits
Uncomplicated pregnancies
Every 4 weeks until 28 wks
Every 2 to 3 weeks from 28 to 36 wks Weekly until delivery
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Follow-up visits
Laboratory follow-up
GDM screening at 24-28 wks
CBC & antibodies screen GBS screening (recto-vaginal swab)
at 35-37 wks
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DIAGNOSTIC IMIGING
Ultrasound
Minimum requirement
Usefulness
Limitations
Others
MRI
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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
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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)
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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
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=
10
100
1000
15 20 25 30 35 40 45
Maternal age (yrs)
C h a n c e o f
D S
Maternal age-based screening
1/200 risk of
miscarriage
Rationale
=
1/200 chance of
abnormality 30%
70%
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Assessment of Backg round Risk
Maternal Age
0.0001
0.001
0.01
0.1
1
10
20 25 30 35 40 44
Years
Trisomy 21
Trisomy 18 Trisomy 13
47xxx/xxy/xyy
45x
Triploidy
Risk %
Courtesy Dr J Johnson and the Fetal Medicine Foundation
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%
0
20
40
60
80
100
10 14 18 25 30 35 40
Weeks
Trisomy 21
Trisomy 18Trisomy 13
Triploidy
47xxx/xxy/xyy
45x
Assessment of Backround Risk
Gestational Age
Snijders et al 1999Courtesy Dr J Johnson and the
Fetal Medicine Foundation
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Prenatal ScreeningModalities
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Screen ing at 11-20 wks
10 12 14 16 18 20 wks
• Allows adjustment of age-related risk
• Improved detection rate
Courtesy Dr J Johnson and the Fetal Medicine Foundation
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A- Non-invasive prenatal
diagnostic tests1. Nuchal Screen
2. Nuchal plus biochemistry
3. Maternal Serum Screen
4. Ultrasound
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“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
1-
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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
Courtesy Dr J Johnson and the Fetal Medicine Foundation
FETAL CENTREFETAL CENTRE
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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
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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
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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
Courtesy Dr J Johnson and the Fetal Medicine Foundation
2-
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Fetal NT + Maternal age + ßhCG + PAPP-A at 11-14 wks
All0
20
40
60
80
100
%
Ag
e
ßhCG PAPP-A
Detection Rate
30%
89%
72%
60%
Age
ßhCGPAPP-A
Age
NT
Invasive
Testing
5%
Screening at 11-14 wks
Courtesy Dr J Johnson and the Fetal Medicine Foundation
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3- Maternal Serum Screen
Three biochemical markers BHCG
AFP
Estriol
Gives age adjusted risk
Screens for Down’s and NTD 15-20 wks
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MSS
1/1 01/378
Risk = age X OR BHCG X OR uE3 X OR AFP
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MSS Limitations
Sensitivity 70 %
Specificity 95% ( False positive 5%)
Two reasons for a false positive:
Wrong dates
Twins
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4- Ultrasound
Ultrasound screening (detailed scan)
18-20 weeks
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B- INVASIVE TECHNIQUES FOR
EARLY PRENATAL TESTING
Chorionic Villus Sampling
Amniocentesis
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Amniocentisis
http://wchs.health.wa.gov.au/health/a/amnio.htm
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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)
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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
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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
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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
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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
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Post Test
A false positive on the MSS occurs in 1/20 tests
True False
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Post Test
List Two advantages of Amniocentesis over
CVS
Decreased miscarriage rate
Lower risk of mosaicism
No association with limb reductions
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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
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Post Test
What is the miscarriage rate with
amniocentesis?
0.5%
3%
5%
10%
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Post Test
List one advantage of CVS over amniocentesis
Early results