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Antenatal care & Counseling DR. KHALED ALDOSSARI SBFM, ABFM, MBBS ASSISTANT PROFESSOR.

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Presentation on theme: "Antenatal care & Counseling DR. KHALED ALDOSSARI SBFM, ABFM, MBBS ASSISTANT PROFESSOR."— Presentation transcript:

1 Antenatal care & Counseling DR. KHALED ALDOSSARI SBFM, ABFM, MBBS ASSISTANT PROFESSOR

2 objectives To know definition of antenatal care. To be familial with common symptoms during pregnancy. to know what should be done every visit. To know ten elements of antenatal counseling.

3 content I. Definition II. Antenatal visits III. counseling & common problem during pregnancy

4 Definition Continuous health care provided to pregnant women before labor.

5 diagnosis History: I. Menstrual period. II. Morning sickness. III. Abdominal pain.

6 antenatal visits Every month until 28 weeks gestation. Every 2weeks during till 36 week gestation. Every week during the last month & any time when medical care needed.

7 antenatal visits 1 st visit : History: A. Bio data. B. Compliant.

8 antenatal visits C. Menstrual history: LNMP, EDD. The Nãgele rule : EDD is calculated by adding 7 days to the first day of the LMP and adding 9 months.

9 antenatal visits D. Past obstetric hx: Hx of previous pregnancy. Hx of abortion. Mode of delivery. Birth weight. Mode of infant feeding.

10 antenatal visits E. Current obstetric hx : Symptoms of pregnancy (nausea,vomiting, sleep) Symptoms of pre eclampsia (edema,headache( Quickening.

11 antenatal visits F. Past medical hx (DM,HTN,HEART DISEASE) G. Past surgical hx. H. Drugs history, blood transfusion,x ray,RH incompatibility. I. immunization.

12 Antenatal visits Physical examination: A. General examination (wt, hight, v/s, general appearance,chest, abdomen,breast,thyroid). B. Local examination( inspection) Size of abdomen,scar, sign of pregnancy,fetal movement,varicose vein

13 Antenatal visits Palpation: (fundal level,fundal grip) Auscultation of fetal heart.

14 Antenatal visits 1 st visit investigations ; Hemoglobin & hematocrit Urine analysis Blood group

15 Antenatal visits Rh type Rubella anti body titer Syphilis screen Culture for gonorrhea

16 Antenatal visits Hepatitis B virus Cervical cytology HIV test ppd if there is risk of TB.

17 At weeks GA : Routine screen for DM. Repeat hemoglobin and hematocrit At this time prophylactic administration of anti- D immunoglobin.

18 At weeks GA: Testing for Sexually transmitted disease Repeat hemoglobin and hematocrit if needed

19 Vaccination During Pregnancy The following vaccines are considered safe to give to women who may be at risk of infection: Hepatitis B--Pregnant women who are at high risk for this disease and have tested negative for the virus can receive this vaccine. It is used to protect the mother and baby against infection both before and after delivery.

20 Vaccination During Pregnancy Influenza--This vaccine can prevent serious illness in the mother during pregnancy, but should be received after the mother has been pregnant for more than 14 weeks. If you have a serious medical condition that can lead to flu-related complications, you can receive the vaccine at any stage of pregnancy.

21 Vaccination During Pregnancy Tetanus/Diphtheria--This combination of vaccines are routinely recommended for pregnant women, both those who have never been immunized and those who have not received a booster in 10 years

22 Consultancy ten I-Nutritional supplements II- Gestational age assessment III-Prescribed medicines VI-Lifestyle considerations V-Management of common symptoms of pregnancy VI-Clinical examination of pregnant women VII-Screening for hematological conditions VIII-Screening for fetal anomalies IX-Screening for infections X-Screening for clinical conditions (e.g GDM,Preclampsia,GHTN) X-Screening for clinical conditions (e.g GDM,Preclampsia,GHTN)

23 The following guidance is evidence based. Developed by the National Collaborating Centre for Women’s and Children’s Health Developed at March 2008 The grading scheme used for the recommendations (A, B, C, D, good practice point [GPP] or NICE 2010)

24 Counseling I Nutritional supplements

25 Dietary supplementation with folic acid, before conception(about 3 month) and up to 12 weeks’ gestation, reduces the risk of having a baby with neural tube defects (anencephaly& spina bifida). Dietary supplementation with folic acid, before conception(about 3 month) and up to 12 weeks’ gestation, reduces the risk of having a baby with neural tube defects (anencephaly& spina bifida). The recommended dose is 400 micrograms per day.(Risky women 4mg) The recommended dose is 400 micrograms per day.(Risky women 4mg) Folic acid A

26 Iron supplementation should not be offered routinely to all pregnant women. Iron supplementation should not be offered routinely to all pregnant women. It does not benefit the mother’s or fetus’s health and may have unpleasant maternal side effects It does not benefit the mother’s or fetus’s health and may have unpleasant maternal side effects Iron A

27 Vitamin A supplementation (intake greater than 700 micrograms) might be teratogenic and therefore it should be avoided. Vitamin A supplementation (intake greater than 700 micrograms) might be teratogenic and therefore it should be avoided. Liver and liver products may also contain high levels of vitamin A, consumption of these products should also be avoided. Liver and liver products may also contain high levels of vitamin A, consumption of these products should also be avoided. Vitamin A C

28 Advise women of the importance of vitamin D intake during pregnancy and breastfeeding (10mcg/day) Ensure women at risk of deficiency are following this advice. – South Asian, African, Caribbean or Middle Eastern family origin – women who have limited exposure to sunlight, such as women who are predominantly housebound, or usually remain covered when outdoors – women who eat a diet particularly low in vitamin D, e.g. no oily fish, eggs, meat, vitamin D-fortified margarine or breakfast cereal – women with a pre-pregnancy body mass index above 30 kg/m2. Vitamin D

29 Counseling II Gestational age assessment

30 Gestational age assessment: LMP and ultrasound Pregnant women should be offered an early ultrasound scan to determine gestational age and to detect multiple pregnancies. Pregnant women should be offered an early ultrasound scan to determine gestational age and to detect multiple pregnancies. A

31 Early ultrasound scan 1. Ensure consistency of gestational age assessments, 2. Improve the performance of mid-trimester serum screening for Down’s syndrome and 3. Reduce the need for induction of labour after 41 weeks. A

32 Ideally, scans should be performed between 10 and 13 weeks and crown–rump length measurement used to determine gestational age. Ideally, scans should be performed between 10 and 13 weeks and crown–rump length measurement used to determine gestational age. Gestational age assessment: LMP and ultrasound GPP

33 Pregnant women who present at or beyond 14 weeks’ gestation should be offered an ultrasound scan to estimate gestational age using head circumference or bi-parietal diameter. Pregnant women who present at or beyond 14 weeks’ gestation should be offered an ultrasound scan to estimate gestational age using head circumference or bi-parietal diameter. Gestational age assessment: LMP and ultrasound GPP

34 Counseling III Prescribed medicines

35 Few medicines have been established as safe to use in pregnancy. D

36 Prescription medicines should be used as little as possible during pregnancy and should be limited to circumstances where the benefit outweighs the risk. Prescribed medicines D

37 ؟؟؟؟؟؟antiepileptic medication No live vaccine (3month befor conception) conception) No Expose to Radation

38 Counseling IV Lifestyle considerations

39 Exercise in pregnancy Beginning or continuing a moderate course of exercise during pregnancy is not associated with adverse outcomes. Pregnant women should be informed of the potential dangers of certain activities during pregnancy, e.g.: contact sports, scuba diving A

40 The majority of women can be reassured that it is safe to continue working during pregnancy. The majority of women can be reassured that it is safe to continue working during pregnancy. A woman’s occupation during pregnancy should be ascertained to identify those at increased risk through occupational exposure. A woman’s occupation during pregnancy should be ascertained to identify those at increased risk through occupational exposure. Working during pregnancy D GPP

41 Sexual intercourse in pregnancy Sexual intercourse in pregnancy is not know to be associated with any adverse outcomes. B

42 There are specific risks of smoking during pregnancy (such as the risk of having a baby with low birth weight and preterm). There are specific risks of smoking during pregnancy (such as the risk of having a baby with low birth weight and preterm). The benefits of quitting at any stage should be emphasized. The benefits of quitting at any stage should be emphasized. Women who are unable to quit smoking during pregnancy should be encouraged to reduce smoking. Women who are unable to quit smoking during pregnancy should be encouraged to reduce smoking. Smoking in pregnancy A B

43 Air travel during pregnancy Pregnant women should be informed that long air travel is associated with an increased risk of venous thrombosis. Pregnant women should be informed that long air travel is associated with an increased risk of venous thrombosis. Wearing correctly fitted compression stockings is effective at reducing the risk. Wearing correctly fitted compression stockings is effective at reducing the risk. B

44 Traveling abroad during pregnancy If pregnant women are planning to travel abroad, they should discuss considerations such as flying, vaccinations and travel insurance. GPP

45 Counseling V Management of common symptoms of pregnancy

46 Red flag Pain during urination Vomiting and nausea symptoms that are extra persistent Sudden body swelling Rapid heartbeat

47 Red flag Decreased fetal activity (i.e. far less than normal to no baby movement) for more than a daybaby Vaginal bleeding

48 Red flag Early uterus cramping (such as weeks or months before your due date) Leaking amniotic fluid early on - which will feel a little like a constant trickling peeing sensation

49 Most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks of gestation. Most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks of gestation. Nausea and vomiting are not usually associated with a poor pregnancy outcome. Nausea and vomiting are not usually associated with a poor pregnancy outcome. Nausea and vomiting in early pregnancy A

50 If a woman requests or would like to consider treatment, the following interventions appear to be effective in reducing symptoms: If a woman requests or would like to consider treatment, the following interventions appear to be effective in reducing symptoms: non-pharmacological non-pharmacological – ginger – ginger pharmacological pharmacological – Antiemetic – Antiemetic A

51 Hyperemesis Gravidarum intractable nausea and vomiting, severe enough to cause weight loss, dehydration, ketonuria, electrolyte imbalance, acid-base disturbances and if severe, hepatic and renal damage Pt. need referral

52 Heartburn Women who present with symptoms of heartburn in pregnancy should be offered information regarding lifestyle and diet modification. Women who present with symptoms of heartburn in pregnancy should be offered information regarding lifestyle and diet modification. Antacids may be offered to women whose heartburn remains troublesome Antacids may be offered to women whose heartburn remains troublesome GPP A

53 Constipation Women who present with constipation in pregnancy should be offered information regarding diet modification, such as bran or wheat fiber supplementation. A

54 Hemorrhoids Women should be offered information concerning diet modification. Women should be offered information concerning diet modification. If clinical symptoms remain troublesome, standard hemorrhoids creams should be considered. If clinical symptoms remain troublesome, standard hemorrhoids creams should be considered. GPP

55 Varicose veins Varicose veins are a common symptom of pregnancy that will not cause harm and Varicose veins are a common symptom of pregnancy that will not cause harm and Compression stockings can improve the symptoms but will not prevent varicose veins from emerging. Compression stockings can improve the symptoms but will not prevent varicose veins from emerging. A

56 Vaginal discharge Women should be informed that an increase in vaginal discharge is a common physiological change that occurs during pregnancy. GPP

57 If vaginal discharge is associated with itching, soreness, offensive smell or pain on passing urine there may be an infective cause and investigation should be considered. Vaginal discharge GPP

58 A 1-week course of a topical imidazole is an effective treatment and should be considered for vaginal candidiasis infections in pregnant women. Vaginal discharge A

59 The effectiveness and safety of oral treatments for vaginal candidiasis in pregnancy is uncertain and these should not be offered. Vaginal discharge GPP

60 Backache Women should be informed that exercising in water, massage therapy might help to ease backache during pregnancy. A

61 Counseling VI Clinical examination of pregnant women

62 Measurement of weight and body mass index (BMI) Maternal weight and height should be measured at the first antenatal appointment, and the woman’s BMI calculated (weight [kg]/height[m]2). A

63 Repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to be influenced. Measurement of weight and body mass index (BMI) C

64 Breast examination Routine breast examination during antenatal care is not recommended for the promotion of postnatal breastfeeding. A

65 Pelvic examination Routine antenatal pelvic examination does not accurately assess gestational age, nor does it accurately predict preterm birth or cephalopelvic disproportion. Routine antenatal pelvic examination does not accurately assess gestational age, nor does it accurately predict preterm birth or cephalopelvic disproportion. So, it is not recommended. So, it is not recommended. B

66 Counseling VII Screening for hematological conditions

67 Anemia Pregnant women should be offered screening for anaemia. Pregnant women should be offered screening for anaemia. Screening should take place early in pregnancy (at the first appointment) and at 28 weeks. Screening should take place early in pregnancy (at the first appointment) and at 28 weeks. This allows enough time for treatment if anaemia is detected. This allows enough time for treatment if anaemia is detected. B

68 Hemoglobin levels outside the normal range for pregnancy (that is, 11 g/dl at first contact and 10.5 g/dl at 28 weeks) should be investigated and iron supplementation considered if indicated. Anemia A

69 Blood grouping and red cell alloantibodies Women should be offered testing for blood group and RhD status in early pregnancy. B

70 It is recommended that routine antenatal anti- D prophylaxis is offered to all non-sensitized pregnant women who are RhD negative. Blood grouping and red cell alloantibodies NICE 2008

71 Women should be screened for atypical red cell alloantibodies in early pregnancy and again at 28 weeks regardless of their RhD status. Blood grouping and red cell alloantibodies D

72 screening for haemoglobinopathies Screening for sickle cell diseases and thalassaemias should be offered to all women as early as possible in pregnancy

73 Counseling VIII Screening for fetal anomalies

74 Screening for structural anomalies Pregnant women should be offered an ultrasound scan to screen for structural anomalies, ideally between 18 and 20 weeks’ gestation, by an appropriately trained sonographer and with equipment of an appropriate standard. A

75 Screening for Down ’ s syndrome Pregnant women should be offered screening for Down’s syndrome with a test which provides the current standard of a detection rate above 60% and a false-positive rate of less than 5%. N.B Age more than 35yr should be consider during preconception consuling as risk of down syndrome B

76 The following tests meet this standard: from 11 to 14 weeks from 11 to 14 weeks – nuchal translucency (NT) – the combined test (NT, hCG ) from 14 to 20 weeks from 14 to 20 weeks – the triple test (hCG, AFP and unconjugated oestradiol ) – the quadruple test (hCG, AFP, unconjugated oestradiol, inhibin A) B

77 Counselling IX Screening for infections

78 Asymptomatic bacteriuria Pregnant women should be offered routine screening for asymptomatic bacteriuria by midstream urine culture early in pregnancy. 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. Identification and treatment of asymptomatic bacteriuria reduces the risk of preterm birth. A

79 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

80 Chlamydia trachomatis Pregnant women should not be offered routine screening for asymptomatic chlamydia because there is insufficient evidence on its effectiveness and cost effectiveness. C

81 Cytomegalovirus The available evidence does not support routine cytomegalovirus screening in pregnant women and it should not be offered. B

82 Hepatitis B virus Serological screening for hepatitis B virus should be offered to pregnant women Serological 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. So that effective postnatal intervention can be offered to infected women to decrease the risk of mother-to-child-transmission. A

83 Hepatitis C virus Pregnant women should not be offered routine screening for hepatitis C virus because there is insufficient evidence on its effectiveness and cost effectiveness. C

84 HIV infection 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. D

85 Rubella Rubella-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

86 Streptococcus group B Pregnant women should not be offered routine antenatal screening for group B streptococcus (GBS) because evidence of its clinical effectiveness and cost effectiveness remains uncertain. C

87 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 fetus. B

88 Toxoplasmosis Routine antenatal serological screening for toxoplasmosis should not be offered because the harms of screening may outweigh the potential benefits. B

89 Counseling X Screening for clinical conditions

90 Gestational diabetes mellitus Screening for gestational diabetes at weeks GA using risk factors is …. body mass index above 30 kg/m² body mass index above 30 kg/m² previous macrosomic baby weighing 4.5 kg or above previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes (refer to Diabetes in pregnancy’) previous gestational diabetes (refer to Diabetes in pregnancy’) family history of diabetes family history of diabetes B

91 I-hour, 50 g Oral Glucose Challenge Test (OGCT) plasma glucose (PG) no GDM plasma glucose (PG) no GDM PG ~7.8 and do 2-hour 75 g oral glucose tolerance test (OGTT) PG ~7.8 and do 2-hour 75 g oral glucose tolerance test (OGTT) for diagnosis PG ~1O.3 mmol/L --> GDM established PG ~1O.3 mmol/L --> GDM established

92 Issues with diabetes In most women, gestational diabetes will In most women, gestational diabetes will respond to changes in diet and exercise Birth complications such as shoulder dystocia Birth complications such as shoulder dystocia Increased monitoring and interventions during Increased monitoring and interventions during both pregnancy and labour. Screening Screening

93 Gestational hypertension Risk Factors maternal factors maternal factors primigravida (80-90% of gestational HTN) primigravida (80-90% of gestational HTN) first conception with a new partner first conception with a new partner PMHx or FHx of gestational HTN PMHx or FHx of gestational HTN DM, chronic HTN, or renal insufficiency DM, chronic HTN, or renal insufficiency antiphospholipid antibody syndrome (APLA) antiphospholipid antibody syndrome (APLA) extremes of maternal age «18 or >35) extremes of maternal age «18 or >35) fetal factors fetal factors IUGR or oligohydramnios, GTN, multiple gestation, fetal hydrops IUGR or oligohydramnios, GTN, multiple gestation, fetal hydrops

94 Pre-eclampsia At first contact a woman’s level of risk for pre- eclampsia should be evaluated so that a plan for her subsequent schedule of antenatal appointments can be formulated. C

95 Developing pre-eclampsia during a pregnancy is increased in women who: 1. are nulliparous 2. are aged 40 or older 3. have a family history of pre-eclampsia 4. have a prior history of pre-eclampsia 5. have a body mass index (BMI) at or above 35 at first contact 6. have a multiple pregnancy or pre-existing vascular disease (for example, hypertension or diabetes). C

96 Whenever blood pressure is measured in pregnancy a urine sample should be tested at the same time for proteinuria. Pre-eclampsia C

97 Pregnant women should be informed of the symptoms of advanced pre-eclampsia because these may be associated with poorer pregnancy outcomes for the mother or baby. Pregnant women should be informed of the symptoms of advanced pre-eclampsia because these may be associated with poorer pregnancy outcomes for the mother or baby. Symptoms include Symptoms include headache; headache; problems with vision, such as blurring or flashing before the eyes; problems with vision, such as blurring or flashing before the eyes; bad pain just below the ribs; bad pain just below the ribs; vomiting and vomiting and sudden swelling of face, hands or feet. sudden swelling of face, hands or feet. Pre-eclampsia D

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100 references -Swanson -Family medicine practice -Emedicine - NICE clinical guideline 6 ( Routine care for the healthy - pregnant woman ) June SPECIAL THANKS FOR DR. ALI AL MOUSA

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