Evidence-Based Routine Antenatal Care

MD. Amer khojah

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The Main References Of My Lecture

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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

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Who provides care Midwifeand GP vs obstetricians?

Villar J, Khan-Neelofur D. Patterns of routine antenatal care for low risk pregnancy. Cochrane Database of Systematic Review 2003 6/10/12

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]
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What is the adequate no of visit ?

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In the United States

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What to in the antenatal clinic ?

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History Taking

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Initial prenatal social and demographic assessment

Names of patient, partner, emergency contact Marital status Age Home address Telephone numbers for day, night, emergency Education
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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
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Basic medical history for the pregnant woman and her family

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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
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Current pregnancy history

Medications taken Alcohol use Cigarette use Recreational drug use Exposure to radiation Vaginal bleeding Nausea, vomiting, weight loss Infections
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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 midtrimester serum screening for Downs 6/10/12 syndrome

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Clinical examination of pregnant women

Measurement of weight and body mass index Maternal weight and height should be measured at the first antenatal appointment, and the womans BMI calculated (weight [kg]/height[m]). [B] Repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to 6/10/12 be influenced. [C]
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Clinical examination of pregnant women

Pelvic examination Routine 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 measurement It is not known how often blood
3- Smith MA. Preeclampsia. Prim Care 1993;20:655-64. 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.

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Screening for haematological conditions

Anaemia
Screening 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.

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Blood Typing

Screening for haematological conditions

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 1-U.S. Preventive Services Task after spontaneous or induced abortion, 1996 RhoD immune globulin Force. Guide to clinical preventive services. 2d ed. 2- Clinical management guidelines for obstetrician-gynecologists. American College of ectopic pregnancy termination, chorionic villus sampling (CVS), Obstetrics and Gynecology. Int J Gynaecol Obstet 1999;66:63-70. amniocentesis, cordocentesis, external cephalic version, abdominal 3- Fung Kee, et al. Prevention of Rh alloimmunization. J Obstet Gynaecol Can 6/10/12 trauma, and second- or third-trimester bleeding (2,3)
2003;25:765-73.

Screening for structural anomalies

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Screening for fetal anomalies

Screening for structural anomalies Pregnant 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]
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Screening for infections

Asymptomatic bacteriuria

Pregnant 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]

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Asymptomatic bacterial vaginosis

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Screening for infections

Cytomegalovirus The available evidence does not support routine cytomegalovirus screening in pregnant women and it should not be offered. [B] Hepatitis B virus Serological screening for hepatitis B virus should be offered to pregnant women so that effective postnatal 6/10/12
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Screening for infections

HIV Pregnant 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] Rubella Rubella susceptibility screening should 6/10/12
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Screening for infections

Streptococcus Group B CDC ,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
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.

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Screening for infections

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] Routine antenatal serological screening for toxoplasmosis should 6/10/12

Toxoplasmosis

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Screening for infections

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 6/10/12 gestational age. There is no evidence

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) 6/10/12
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 glucosetolerance test) is the main method used in North America a two-hour, 75-g glucose-tolerance test is offered in Europe.
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Fetal growth and wellbeing

Determining fetal growth

Symphysisfundal 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.
6/10/12 Routine Doppler ultrasound should not

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Fetal growth and wellbeing

Routine monitoring of fetal movements Routine formal fetal-movement counting should not be offered. [A] Auscultation of fetal heart Auscultation of the fetal heart may confirm that the fetus is alive but is unlikely to have any predictive value and routine listening is therefore not recommended. However, when requested by the mother, auscultation of the fetal heart may provide reassurance. [D] Ultrasound assessment in the third trimester The evidence does not support the routine use of ultrasound scanning after 24 weeks of gestation and therefore it should not be offered. [A] Cardiotocography CTG
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The evidence does not support the routine use of antenatal electronic fetal heart

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Fetal growth and wellbeing

Determining fetal growth

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

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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 6/10/12 increased risk for preterm birth, the
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Screening for clinical conditions

Placenta praevia Because 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 6/10/12 transvaginal scan should be offered.
Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008

Screening for clinical conditions

Placenta praevia Because 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 6/10/12 transvaginal scan should be offered.
Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008

Screening for clinical conditions

Placenta praevia Because 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 6/10/12 transvaginal scan should be offered.
Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008

Nutritional supplements
Outcomes
Lab el

Guidelines

Suppleme nt

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

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

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

dietary 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;338:131-7 McDonald 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.

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Nutritional supplements
Outcomes
Labe l

Guidelines Pregnant women should be screened for anemia (hemoglobin, hematocrit) and treated, if necessary.(1) Iron supplementation should not be offered routinely to all pregnant women. (2)

Supplemen t

Iron-deficiency anemia is associated with preterm B delivery & low birth weight. It does not benefit the mothers or fetuss A health and may have unpleasant maternal side effects

Iron

High dietary intake of Pregnant women in vitamin A (i.e., more industrialized countries B Vitamin A than 10,000 IU per should limit vitamin A intake day) is associated to less than 5,000 IU per day. with cranial-neural (3) 2- Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists 2008 crest defects. (4) pregnancy. Review article. U.S. Preventive Services Task Force. JAMA 1993;270:2848-54 1- Routine iron supplementation during
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

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Nutritional supplements
Outcomes
Lab el

Guidelines Recommended daily intake is 1,000 to 1,300 mg per day1,79 Routine supplementation with calcium to prevent preeclampsia is not recommended.(1)

Supplemen t

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

Calcium

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

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

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 2008

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Daily Activity

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Thank You

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