Antenatal Care

Antenatal Care:  How is GA determined?

- Careful, systematic assessment and follow up of a pregnant patient to assure • Accurate estimation is vital and mandatory.
the best health of the mother and her fetus. • First day of the last normal menstrual period:
 Regular and normal periods
 Objectives and Benefits:
 Oral contraceptive pills? (NOT USED IN THE PREVIOUS THREE MONTHS)
 To prevent and identify maternal or fetal problems that adversely affect
 Lactation? (lactational amenorrhea)
pregnancy outcomes.
 To educate the patient about pregnancy, labor-delivery, and parenting as well ➢ Ultrasonic estimation of EDD:
as about ways she can improve her health. a. 1st trimester: (week 0- week 12)
 To promote adequate psychological support from her partner, family, and  The best and most accurate, used up to?
caregivers.  Measure crown-rump (CRL ± 5 days).
 Midsagittal plane, neutral position,
 How often should patients be seen? head(neutral).
 First visit in early pregnancy (10 weeks).
 Then every 4 weeks until 28 weeks. b. 2nd trimester: (week 13-week 28)
 Then every 2 weeks until 36 weeks.  (BPD, Head Circumference, AC, FL ± 10 days).
 Then weekly until delivery.
 For high-risk patients, individualized and more visits.

1. First visit:
- History:
• Medical problems (DM, HT, others).
• Surgical, previous operations, complications and need for transfusion.
• Family history- inherited problems (medical diseases, congenital anomalies,
cystic fibrosis, haemophilia….) c. 3rd trimester: (week 29- week 40)
• Social History: psychosocial background and lifestyle, smoking, alcohol…  Much less accurate.
• Obstetric History: recurrent problems (fetal & neonatal death, preterm
deliveries, IUGR, macrocosmic babies, anomalies, abruption, PET, PPH, GDM,
thromboembolism, gender, birth weight, NICU, lactation….).  Physical examination:
• Gynecologic History: infertility treatment, PID, ectopic pregnancy, STDs). • General and full examination (height, weight and body mass index).
• Obstetric examination.
• Pelvic examination? Only If indicated (not routine).
 Routine laboratory tests:  Laboratory tests:
• CBC: Haemoglobin/ haematocrit.
 Haematocrit/ haemoglobin:
• Blood type & Rh (Rh-negative women).
→ Repeat at 28 and 36 weeks, or if indicated.
• Antibody screen (Kell, Duffy, E, S….).
 Urine dipstick on each revisit:
• Urinalysis: screen for bacteriuria: urine culture, if indicated.
→ Presence of significant proteinuria (PET)
• Hepatitis screen:
→ Presence of glucosuria (GDM).
→ Hepatitis B-sAg: transmit to the fetus mainly during birth.
→ Presence of leukocytes (UTI).
→ Many of those babies become carrier and can develop chronic hepatitis
 Antibody screen (Indirect Coombs Test), if Rh-negative women:
especially during delivery.
→ Repeat at 28 and 34 weeks,
→ So Hep.B Ig and vaccine given within 12 hours of life.
→ if negative, Give Anti-D immune globulin.
• Serologic tests for syphilis (VDRL): In our country not mandatory.
 Glucose screen, oral glucose tolerance test at 24-28 weeks in high-risk
• HIV antibody (with consent): not in our country.
patients.
• Blood sugar, random.
 Screening for group B streptococcus (GBS):
→ Low vaginal swab (LVS) at 35-37 weeks.
 Revisits:
→ Significant reduction of early-onset GBS neonatal infection.
 History:
 Brief history to uncover any new problems.
Ultrasound during ANC:
 Ask about pain, vaginal bleeding, vaginal discharge, fetal movements.
 Specific questions, those with medical problems or known complications. - 1st trimester:
 Counselling for those desiring sterilization.  Diagnose pregnancy.
 Assure accurate dating.
 Physical examination:
 Fetal number: confirm pregnancy size.
 Weight and blood pressure.
 Fetal viability.
 Examine the gravid uterus.  Adnexal mass.
 Measure the fundal height after 24 weeks to assess for IUGR.  Knowing the Chorionicity in multiple pregnancies.
 Determine fetal lie and presentation (3 rd trimester).
 Estimate fetal weight (small vs large baby).  Combined test: comprises detailed ultrasonography (USG) measuring
 Auscultate fetal heart tones. the nuchal translucency (NT) of the fetus at 11–13+6 weeks of gestation,
 Pelvic examination, if indicated. combined with serum screening of free beta-human chorionic gonadotrophin
(B-hCG) and pregnancy-associated plasma protein A (PAPP-A).
➢ Blood pressure and urine dipstick is done each antenatal visit.
- 2nd trimester:
 Detailed anomaly scan (18-21 weeks).
 Placental localization.
- 3rd trimester: Everyday Pregnancy Issues:
 Growth and Fetal welfare parameters.
1. Exercise:
✓ Reduces weight gain.
➢ Regular/ serial U/S:
✓ More rapid weight loss after pregnancy.
• High risk pregnancy.
✓ Improves mood.
• Poor obstetric history.
✓ Improves sleep patterns.
• New problem during ANC (IUGR, PET, GDM…).
• Then: pregnancy is classified to be low or high risk. → Some studies have shown:
• Scoring system for risk assessment. ✓ Faster labour.
✓ Less need for induction.
➢ Important signs: ✓ Less likely to need epidural.
 Vaginal bleeding. ✓ Fewer operative births.
 Abdominal or pelvic pain. ✓ Exercise does NOT increase risk of miscarriage.
 Uterine contractions from 20-36 weeks.
→ Exercise commonsense:
 Leaking of fluid from vagina.
✓ Take frequent breaks.
 Decrease in fetal movements.
✓ Avoid exercise in extremely hot weather.
 Severe headache or blurring of vision.
✓ Avoid unstable ground (joints more lax).
 Persistent vomiting. ✓ Avoid contact sports.
 Fever. ✓ Avoid lifting weights overhead.
 Swelling of hands or face. ✓ And weights that strain lower back muscles.

 Complications of pregnancy can be prevented or minimized by good ANC: 2. Nausea and vomiting:
 Anaemia due to iron or folic acid deficiency.
• Reassure women that mild to moderate nausea and vomiting are common
 Urinary tract infections and pyelonephritis.
in pregnancy and are likely to resolve before 16 to 20 weeks.
 Pregnancy-induced hypertension and PET.
 Preterm labour and delivery. • Women with mild-to-moderate nausea and vomiting who prefer a non-
 Intrauterine growth restriction. pharmacological option, suggest that they try ginger.
 Sexually transmitted diseases.
 Rh isoimmunization. • Women with nausea and vomiting who choose a pharmacological
treatment, offer antiemetics.
 Fetal macrosomia.
 Hypoxia or fetal death from post-term birth.
 Breech presentation at term.
3. Heartburn:  Fetal movements - what is normal?
• Lifestyle and dietary changes.
 There is no specific number of movements that is considered normal.
• A trial of an antacid.
 It’s related to the mother’s individual pattern of movements.
 A reduction or a change in the baby’s movements is what is important.
4. Air Travel:
• Travel must be completed by 36 th week.
 Vaginal Discharge:
• Medical clearance needed for twins and complicated pregnancy.
 Normally increases with gestation.
 Exclude rupture of membranes.
5. Preventing DVT:
• Support stockings.
 Sleep position:
• Hydration.
 Avoid going to sleep on their back after 28 weeks of pregnancy (left lateral
• Ankle rolls, walks around plane.
position) and to consider using pillows, for example, to maintain their
position while sleeping.

 Shoes won’t fit, rings too tight:

 85% of pregnancies have oedema.
 Rest and elevate.

 I am sick of being pregnant:

 Check CTG and AFI when 7 days post EDD.
 Post dates IOL= 10 days after EDD; (41+3 week)
 Cervical sweep