1. Antenatal Screen and Dating scan Dr Emeil Kamel

2. Pre-pregnancy Counselling and routine Antenatal Assessment in the absence of pregnancy complications

3. Pre-Pregnancy Counselling

4. Purpose  Assessment of any conditions of relevance and optimising any treatment with respect to the forthcoming pregnancy (Diabetic, Ht, etc..)  Obtaining general advice regarding personal health care in early pregnancy, in particular, stop smoking, medications, alcohol, X-rays … etc  The following investigations are recommended:  Rubella immunity status  Varicella immunity status (if unknown)  Cervical smear (if clinically appropriate)

5.  All women planning pregnancy should receive advice with respect to:  Where and when to attend in early pregnancy  Vitamin supplementation (particularly folic acid for 3 months preconception)  Models of care

6. First Antenatal Visit  All women should be advised to attend in early pregnancy with a view to:  Confirming pregnancy and establishing an EDC  A comprehensive clinical assessment in order to determine any clinical conditions that may be of relevance to the pregnancy  Obtaining general advice regarding common issues of concern in early pregnancy and management of the pregnancy

7. Clinical Assessment  A careful medical history and thorough clinical examination.  The following investigations are recommended (in the absence of specific complications):  Full blood examination  Particular note should be taken of the MCVas a potential indicator of an underlying Haemoglobinopathy  Blood group and antibody screen  Where the blood group has already been performed it does not need to be repeated. However, the antibody screen should be repeated at the beginning of each pregnancy.

8.  Rubella antibody status  All women should have their rubella antibody titre measured for each pregnancy.  There is evidence that levels may decline, particularly following immunization as compared to natural infection.  Syphilis serology  Syphilis testing should be performed by screening with a specific treponema pallidum assay for example Treponema pallidum haemaglutination assay (TPHA) or the Treponema pallidum particle assay (TPPT). The non-specific Treponema pallidum assays, such as rapid plasma reagin (RPR) test, although cheaper, are less likely to pick up latent infection.

9. All pregnant women need appropriate counselling as to the limitations of screening for viral infections in pregnancy and the implications of both positive and negative findings.  HIV  All pregnant women should be recommended to have HIV screening at the first antenatal visit  Hepatitis B serology  All pregnant women should be recommended to have Hepatitis B screening in pregnancy.  Hepatitis C serology  All pregnant women should be recommended to have Hepatitis C screening in pregnancy.

10.  Varicella  Consider when there is no history or uncertain history of previous illness.  Midstream urine  Examination by MCS  Cervical cytology  A cervical (Pap.) smear should be recommended at the first antenatal visit if this would fall due during the pregnancy ( The national cervical screening program )  There is no evidence to suggest that a Pap smear in pregnancy is harmful.  Pap smear can be taken ideally before 24 weeks gestation.

11.  Other tests Haemoglobinopathies Vitamin D CMV

12.  Screening for Haemoglobinopathies  As a minimum, all women should be screened with MCV and MCHC.  Haemoglobin electrophoresis and iron studies (ferritin) should be performed when MCV <80fL or MCHC <27pg  Testing of normal-MCV women for haemoglobinopathies may be considered if they are members of high-risk groups.  Southern European, Middle Eastern, African, Chinese, South East Asian, Indian subcontinent, Pacific Islander, New Zealand Maori, South American

13.  Vitamin D  There is a recognised re-surgence of rickets amongst our population  Vitamin D deficiency causes significant morbidity to both mother and baby  It is crucial that women at risk for vitamin D deficiency should be tested in early pregnancy and provided with vitamin D supplementation.

15. Actions of Vitamin D OrganAction Bone Bone formation (maintain Ca and PO4 concentration) Intestine Enhance Ca absorption Kidneys Decrease Ca and PO4 excretion Immune System Stimulates anti-tumour activity Decreases risk of auto-immune disorders Parathyroid Glands Inhibits PTH secretion Pancreas Stimulates insulin production

16. Aetiology of Vitamin D deficiency  Inadequate direct exposure to sunlight  5-15 minutes 3 times/week direct sunlight  Increased skin pigmentation  Dark skin requires 6 times the sun exposure to achieve same increase in vitamin D  Diet  Recommended daily adult intake is 600IU/day (Average adult intake 50-100IU)  Prolonged breastfeeding  Breast milk contains 25IU/litre vitamin D  Recommended daily infant intake is 200IU/day (8L breast milk/day!)  Reduce synthesis or increased degradation  Liver or Renal disease  Drugs: rifampicin, isoniazide and anti-convulsants

17. Features of Vitamin D deficiency  Osseous signs  Rickets and osteomalacia o Genu varum (bowed legs), genu valgum (knock-knees), knee deformities o frontal bossing o Limb pain and fractures o Hypocalcaemia: seizures, carpopedal spasm o Delayed fontanelle closure o Delayed tooth eruption  Non-Osseous signs  Dilated cardiomyopathy  Marrow fibrosis: pancytopenia

18. Relevance to Western Sydney  Greater Western Sydney (GWS) Area; the first point of arrival of largest refugee and migrant population in Australia  2 million people (10% total Australian population) live in the GWS area  Over 200 nationalities represented

19.  Retrospective descriptive study (1993 – 2003)  126 cases of vitamin D deficiency and rickets in children at  Sydney Children's Hospital at Westmead  Sydney Children’s Hospital  St. George Hospital.  Median age presentation 15 months (25% <6 months)  Most common presenting features  Hypocalcaemic seizures(33%)  Bowed legs (22%)

20.  Steady increase in number of cases per year, with a doubling in cases from 2002-2003  79% of cases were born in Australia or recently migrated children  Region of origin predominantly  Indian subcontinent(37%)  Africa(33%)  The Middle East (11%)

21. Vitamin D deficiency amongst pregnant women at Westmead  Prospective study of vitamin D levels amongst 313 pregnant women attending antenatal clinic at Westmead Hospital between June-August 2008  Serum concentrations of 25-OH-vitamin D were added to routine antenatal screen  Women were grouped according to country of birth  39% Australia  23% Indian Subcontinent  17% south East Asia  9% Middle East  5.1% Europe  4.5% New Zealand/Pacific Islands  2.5% Africa

22.  Vitamin D levels defined:  Severe deficiency: <37nmol/L  Moderate deficiency: 37-49 nmol/L  Mild deficiency: 50-79 nmol/L  Sufficient: 80-130 nmol/L

23. Australian Born (n=123)

24. Indian Subcontinent (n=71)Africa (n=8)

25. South East Asia (n=54)Middle East (n=27) Europe (n=16)NZ/Pacific Islands (n=14)

26. Vitamin D Levels <37 (S evere deficiency ) 37-49 (M oderate deficiency ) 50-79 ( mild deficiency ) 80-130 ( sufficient ) Australia7%15% 67% 11% Indian Subcontinent 44% 34%21%1% SE Asia9%20% 54% 17% Middle East21.5%30% 43% 5.5% Europe6.5%12.5% 53% 28% NZ/Pacific islands 5%13% 69% 13% Africa 69% 6%19%6%

27. Recommendations  Prevention and treatment of infant and childhood vitamin D deficiency in Australia and New Zealand: a consensus statement. MJA.vol 185;5: 268-272.2006

28. Recommendations  Dark-skinned or veiled pregnant women should be screened and treated for vitamin D deficiency, and their breastfed infants should be supplemented with vitamin D for the first 12 months of life.  At risk children should receive 400IU vitamin D daily, if compliance is poor, an annual dose of 150 000IU may be considered.  Treatment of vitamin D deficiency is with cholecalciferol for 3 months:  1000 IU/day if < 1 month of age  3000 IU/day if 1-12 months of age  5000 IU/day if> 12 months of age

29. CMV  Screening for CMV infection in pregnancy is currently not recommended as a routine.  Relatively low risk of infection  Low rate of possible damage to the fetus  95% of congenital CMV have no sequelae and half of these cases are restricted to hearing loss- termination is not recommended  No effective therapy is available to infected infants  Antiviral agents (acyclovir and ganciclovir) do not decrease risk of vertical transmission.  Seroprevalence in Australia is about 50%

30.  Risk of seroconversion during pregnancy in seronegative women  Generally approx 2%  Day care workers - 11% seroconversion / year  Parents with child in day care - 30% seroconversion / year  Prevent primary infection during pregnancy  Minimize exposure in high-risk areas (many kids).  Careful hand-washing

31. Dating Scan  All women should be offered a dating scan  NT scan  EDC (decrease IOL)  Ectopic, Twins  Live intrauterine pregnancy  B-HCG 1500, Sac seen with TV  B-HCG 5000, Sac seen with TA  High B-HCG with no intrauterine pregnancy  Suspect ectopic  But Twins and molar pregnancy

32. Normal Intrauterine gestation  By 5 weeks gestational, a double decidual sac sign  By 5.5 weeks, a yolk sac is usually visualized (5-6 mm). Involute by 11 weeks  By 6 weeks, an embryonic pole should be identifiable  By 6.0 to 6.5 weeks, cardiac activity should be visualized on real-time Imaging

34. Corpus Luteum  Forms from the ovarian follicle after ovulation.  Secretes progesterone to maintain the pregnancy until the placenta assumes this role.  Wide range of appearances:  Ill defined, hypoechoic, homogeneous structure  A thick-walled cystic structure  A complex cystic lesion with internal echoes

35.  Sonographic appearances of the corpus luteum  Cystic  Complex cystic lesion with thick wall

36. Abnormal intrauterine gestation  The literature reports that there should be  a yolk sac with MSD >8 mm  an embryo with MSD >16 mm  cardiac activity by the time the embryo is 5 mm in length or MSD >18 mm  Distorted non ovoid contour  Location in the lower uterine segment

37.  Gestational sac (MSD = 2.2 cm, 7 wk gestation) without evidence of yolk sac or fetal pole. The sac has a distorted non-ovoid contour with a thin decidual reaction  Distorted enlarged gestational sac with debris and membranes extending from the lower uterine segment into the cervix

38. Ectopic pregnancy  When a pregnancy test is positive and there is no evidence for an IUP, any adnexal finding should be considered suspicious for an ectopic pregnancy until proven otherwise  Findings  Live embryo in an extrauterine gestational sac  Adnexal mass with yolk sac or nonliving embryo  Complex or solid adnexal mass  Hemoperitoneum (nonspecific finding as other conditions can cause ruptured hemorrhagic corpus luteum cyst, spontaneous abortion)