Antenatal care for the pregnant

woman
Dr. Abdelrahim Awadelkarim
 Preconception
Woman planning to become pregnant and her husband should
be seen before conception
Aiming to:
General measures
wt loss
Stop smoking
Immunizations ( Rubella immunity )
Cervical smear
Folic acid( if she had a history of neural tube defect, epilepsy .)
 Preconception
Genetic counseling For women with
• History of affected or handicapped child
• Family history of chromosomal
anomalies
 Preconception
Women with medical conditions
 Assessment of disease severity
 Plane pregnancy in disease free interval[SLE]
 Drug adjustments[epilepsy]
 Advice against pregnancy [sever heart
disease]and give contraception advice
 Control DM and hypertension
 Preconception
Proper obstetrical history
plan for procedure like cervical cerclage or
elective c\s
 Aims of antenatal care
1/ To prevent ,detect and manage those factors
that adversely affect the health of mother
and baby.
2/To provide advice, reassurance ,education
and support for the women and her family .
3/To deal with the
minor ailment of pregnancy .
4/To provide general health screening
 Who provides antenatal care?

• Hospital Maternity Team

• General Practitioner (GP) and Community

Midwives

• Share between GP and obestitrion

Frequency of antenatal appointments

According to NICE guideline

• For a woman who is nulliparous with an
uncomplicated pregnancy, a schedule of 10
appointments should be adequate.
• For a woman who is parous with an
uncomplicated pregnancy, a schedule of 7
appointments should be adequate.
• 4 visits + 2 extra visits
First visit --- at 12 weeks.
Second visit --- at 26 weeks.
Third visit --- at 32 weeks.
Fourth visit --- at 36 – 38 weeks.
If any complain or any emergency the
pregnant lady can go to her clinic or hospital
at any time.
 The booking visit [first visit]
• The booking appointment needs to be earlier in
pregnancy for:
• Confirmation and dating of pregnancy
• Detailed History taking and Physical examination
Body mass index and weight assessment
• and identified high risk pregnancy
• Investigation
• Give sufficient Information to enable informed
decision making about screening tests.
 The booking visit [first visit]

 Full blood count

 blood group [rhesus negative ]
 Rubella antibodies .
 Hepatitis B .
 HIV .
 The booking visit [first visit]
• Booking investigation
Women who have had previous GDM should be
offered a glucose tolerance test
or random blood glucose in the first trimester
Test for thalassaemia and sickle cell disease
[reserved for women who have ethnic
. background ]
• cervical smears and vaginal swabs are not
routinely taken .
 The booking visit [first visit]
• Booking ultrasound
1\To confirm fetal viability .
2\For dating pregnancy
• The dating scan and first trimester screening is best
performed between 11+3 and 13+6 weeks’ gestation
• Crown–rump length measurement should be used to
determine gestational age .
3\Is it single or multiple .
4\To detect early pregnancy complication
[ miscarriage, ectopic pregnancy ,molar pregnancy ]
.
 The content of fellow up visits

• General question regarding maternal well –being .

• Enquiry regarding fetal movement [ after 24
week] .
• Measurement of BP.
• Abdominal palpation for fundal height[assess
fetal growth] .
• Auscultation of fetal heart .
• Examination for oedema [in the face and hands is
more important ]
 The content of fellow up visits
• From 36 weeks the lie ,presentation and engagement of the
fetus should be assessed .
• The delivery and plan of delivery.

• breastfeeding

• At 41 week plan for induction of labour

• Rh-ve women should be offered and advice to have

prophylactic anti D administration at 28 and 34 weeks
• Screening for gestational DM GTT [28week]
 The content of fellow up visits
Ultrasound in the second and third trimester for:
• To look for Fetal anomaly[20-22week]
• To locate the placenta
• To estimate the amniotic fluid volume .
• To establish the presence of multiple pregnancy
• To perform doppler US
• To assess fetal growth and well-being .
Antenatal complications dealt with in customized
antenatal clinics
• Endocrine (diabetes, thyroid, prolactin and other
endocri nopathies).
• Miscellaneous medical disorders (e.g. secondary
hypertension and renal disease, autoimmune disease).
• Haematological (thrombophilias, bleeding disorders).
• Substance misuse.
• Preterm labour.
• Multiple gestation.
• Teenage pregnancies.
 Domestic violence
• One-third of women who experience
domestic violence are hit for the first time
while pregnant
Effect of domestic abuse:
• Leads to adverse pregnancy outcome,
• they may be prevented from attending
antenatal appointments.
• Leads to homicide when pregnant or
postpartum.
 Domestic violence
Key clinical features:
Associated with bruising; domestic violence commonly
results in abdominal trauma during pregnancy.
Specific investigations.
Assessment of fetal wellbeing, Keilhauer's test,
particularly if rhesus negative; check for other injuries
Management
Ensure safety, specialist midwifery service, social input.
 Domestic violence
• It is recommended that all women are seen
on their own at least once during pregnancy,
so that they can discuss this, if needed, away
from an abusive partner.
• you must ensure that information is passed
on to the relevant team{social worker------}
Education and advice during
pregnancy
 Weight gain
The Institute of Medicine have guidelines on
recommended weight increase in pregnancy.
• 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
• If the BMI is more than 35 kg/m2, it is
recommended that the woman is reviewed by an
obstetric consultant
 Healthy diet during pregnancy
The (RCOG) provides the following dietary advice
for optimal weight control in pregnancy
• Do not eat for two; maintain your normal
portion size and try and avoid snacks.
• Eat fibre-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.
 Healthy diet during pregnancy

• Restrict intake of fried food, drinks and

confectionary high in added sugars, and
• 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
 Supplementation
• Folic acid

• Taken before conception and up to 12 weeks

of gestation because it reduces the risk of
having a baby with neural tube defects
(anencephaly, spina bifida).
• The recommended dose is 400
micrograms/day.
 Supplemetation
• Iron supplementation
• Routine iron supplementation resulted in a
substantial reduction in women with a
haemoglobin level below 10 or 10.5 g/100 ml in
late pregnancy.
• it may have unpleasant maternal side
effects[gastritis ] .
 Supplemetation
• Vitamin A
• Safe vitamin A dosage during pregnancy
Preventive-10 000IU daily or 25 000IU weekly
might be teratogenic in high dose.
• Vitamin D and ca
NICE guidance states that
all pregnant and breastfeeding women
should be advised to take 10 μg of vitamin D
supplements daily.
Severe vitamin D deficiency in pregnancy results in
increased risk of neonatal rickets
 Exercises during pregnancy

• Aerobic and strength conditioning exercise in

pregnancy is considered safe and beneficial
• Contact sports should be avoided

• Pelvic floor exercises during pregnancy and

immediately after birth may reduce the risk of

urinary and faecal incontinence in the future
 Breast feeding education
• Breastfeeding protects against diarrhoea and common
childhood illnesses such as pneumonia reducing the risk of
obesity later in life.
• Also associated with a higher (IQ) in children.

The WHO recommends:

• Initiation of breastfeeding within an hour of birth.
• Exclusive breastfeeding for the first 6 months of life and
continued breastfeeding beyond 6months and at least up to 2
years of age.
 Pad habits
• Smoking in pregnancy
• risks of smoking during pregnancy include
• low birth weight ,still birth preterm birth
• Drugs abuse can cause:
• Preterm birth,Poor growth, Birth defects
• Behavioral and learning problem
• Addiction [withdrawal symptom in the new
born]
 Pad habits
• Alcohol consumption in pregnancy
• alcohol consumption can cause
• miscarriage
• IUGR
• still birth
congenital anomaly [fetal alcoholic
syndrome ]
 Immunization during pregnancy
• Is not a routine event as it is generally
preferred to administer vaccines either prior
to conception or in the postpartum period.
• As a rule of thumb:
• the vaccination with live virus or bacteria is
contraindicated in pregnancy, this includes
vaccines against measles, mumps,
poliomyelitis, rubella, yellow fever, BCG
vaccine and varicella vaccine
 Immunization during pregnancy

• Inactivated bacterial vaccine is used during

pregnancy for women who have a specific risk of
exposure and disease.
• Vaccination against pneumococcus or
meningococcus infections, or typhoid fever show
no confirmed side effects regarding the fetus,
however data are limited
• Tetanus toxoids appear safe during pregnancy and
are administered in many countries of the world to
prevent neonatal tetanus.
 Immunization during pregnancy

• Immune globulins are used for post exposure

prophylaxis and not associated with reports

that harm is done to the fetus. hepatitis B,

rabies, tetanus, varicella, and hepatitis A.

•
 Prenatal Diagnosis
• Definition: Prenatal diagnosis is the identification
of a disease prior to birth.
• Prenatal diagnosis is usually performed if there is
any suspicious of a disease after prenatal
screening by:
• FH – genetic disease with aknown recurrence risk.
• Past obstetrical history – RhD alloummunization
• Serum screening tsets - Trisomy 21.
• U/S screening - 20 weeks anomaly .
 Prenatal screening and diagnosis
The aim:
 Is to detect birth defects such as:
• Neural tube defect.
• Down syndrome
• Chromosome abnormalities, genetic diseases
• spina bifida,cleft palate ,sickle cell anemia----
 Purposes of prenatal diagnosis
(1) To enable timely medical or surgical treatment
of a condition before or after birth.
(2) To give the parents the chance to abort a fetus
with the diagnosed condition(not in Islam)
(3) To give parents the chance to "prepare"
psychologically, socially, financially, and
medically for a baby with a health problem or
disability, or for the likelihood of a stillbirth.
 Indications of prenatal screening and
diagnosis
Advanced maternal age .
Previous child with chromosomal abnormality
Family history of chromosomal abnormality with a single family
history gene disorder .
Family history of a neural tube defect .
Family history of other congenital structural abnormalities
Abnormalities identified during pregnancy e.g. ( Poor foetal
growth . )
 Methods of screening

• Check the blood of the mother

• Check the baby by sonography
• Do both .
[ Serum screening tsets - Trisomy 21.
U/S screening - 20 weeks anomaly ]
 Risk of prenatal diagnosis
•Failure to obtain a sample or culture failure .
•An ambiguous chromosome result .
•An unexpected chromosome result .

Risks of invasive tests:

 Infection .
 Miscarriage or Premature labour.
 Bleeding .
 leakage of amniotic fluid.
 Infertility
 Complications associated with anesthesia if used .
 Prenatal Diagnosis

• Detailed counseling prior to embarking on

any screening or diagnostic tests are
extremely important
• If fetal abnormality is diagnosed
antenatally,multidisciplinary management is
important
 Prenatal Diagnosis
Classification:
1) Non- invasive:
A\ Ultrasound - Neural tube defect, malformation of
lung, Cystic adenomatoid
Twin to twin transfusion syndrome.
B\ Maternal blood can be tested for exposure to viruses
(viral serology).
C\ Cell-free fetal DNA (cffDNA) can be extracted from
maternal blood to
• determine fetal blood group in cases of RhD
alloimmunization,
• to determine the sex of the fetus in X-linked disorders
• to diagnose skeletal dysplasias such as achondroplasia.
 Prenatal Diagnosis
2) Invasive:
I) Chorionic villus sampling (CVS) II) Amniocentesis for
Down’s syndrome
Cystic fibrosis
Thalassaemia
III) Cordocentesis:
Alloimmune thrombocytopnia.
IV) Preimplantation genetic diagnosis :
V ) Fetal visualization :
Embryoscopy
Fetoscopy •
3) Non – invasive followed by invasive:
U/S then invasive test:
congenital diaphragmatic hernia.
Exomphalos
Ventriculomegaly
Duodenal atresia.
 Chorionic villus sampling (CVS)
Chorionic villus sampling
Detect chromosomal abnormalites
• Sample is U\S guided either
transabdominally or transcervical
• After 10w gestation
• Risk of miscarriage 2%
 Amniocentesis

Under U\S guide 15ml of fluid taken

After 15w gestation
Risk of miscarriage1%
III) Cordocentesis:

Time after 20 weeks

Risk of miscarrage 3-5%

example Alloimmune thrombocytopnia.

3.Percutaneous umbilical sampling
Following any invasive procedure there should be:

• Documentation of the procedure and any

complications in the woman’s notes.
• The woman should be advised to avoid strenuous
exercise for the next 24 hours.
• She should be advised that if she has any fever,
bleeding, pain not relieved by paracetamol or
leakage of fluid vaginally she should seek medical
advice
• If the woman is RhD negative, an appropriate dose
of anti-D should be administered
• A plan of ongoing care should be discussed once
the results are available
screening for dawn syndrome
• NICE has recommended that all women
should be offered screening for Down’s
syndrome as part of their routine antenatal
care
 screening for dawn syndrome
Maternal age
First trimester test
(blood test between 10+0–14+1 weeks’ gestation)
Serum HCG
• Pregnancy associated plasma protein A[PAPP-
A]
• Nuchal translucency (from 11+2–14+1 weeks’
gestation) Fetuses with Down’s syndrome tend to have
a thicker NT
• Nasal bone
 U/S screening

• Nuchal translucency (from 11+2–14+1

weeks’ gestation) Fetuses with Down’s
syndrome tend to have a thicker NT
• Nasal bone
Second trimester tests
• Maternal serum alpha-fetoprotein MSAFP
(decrease)
• HCG( increase)
• Unconjugated estriol (decrease)
• inhibin A( increase)

recommends the quadruple test (hCG, AFP,

unconjugated oestriol and inhibin A as the screening
strategy of choice in the 2nd trimester.
• The test can be performed between 14+2 and
20+0 weeks gestation.
• prenatal diagnostic test must still be
performed to reach a definitive diagnosis.
• All pregnant women should be offered
screening for Down's syndrome.
Women should understand that it is their
choice to embark on screening for Down's
syndrome.
• Screening for Down's syndrome should be
performed by the end of the first trimester
(13 weeks 6 days), but provision should be
made to allow later screening (which could
be as late as 20 weeks 0 days) for women
booking later in pregnancy.
• The 'combined test' (nuchal translucency, beta-
human chorionic gonadotrophin, pregnancy-
associated plasma protein-A) should be offered
to screen for Down's syndrome between 11
weeks 0 days and 13 weeks 6 days.
• For women who book later in pregnancy the
most clinically and cost-effective serum screening
test (triple or quadruple test) should be offered
between 15 weeks 0 days and 20 weeks 0 days
• If a pregnant woman receives a screen-
positive result for Down's syndrome, she
should have rapid access to appropriate
counseling by trained staff and invasive
prenatal test should be offer
Thank you