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 Definition Antenatal visits
counseling & common problem during pregnancy

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

5. diagnosis
History:
Menstrual period.
Morning sickness.
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
1st visit :
History:
Bio data.
Compliant.

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

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

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

12. Antenatal visits Physical examination:
General examination (wt, hight, v/s, general appearance ,chest, abdomen ,breast ,thyroid) .
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 1st 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)

23. The following guidance is evidence based
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. Nutritional supplements
Counseling I
Nutritional supplements

25. Folic acid
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) A

26. Iron
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 A

27. Vitamin A
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. C

28. Vitamin D 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.

29. Gestational age assessment
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. A

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

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

33. Gestational age assessment: LMP and ultrasound
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.
GPP

34. Counseling III
Prescribed medicines

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

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

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

38. Lifestyle considerations
Counseling IV
Lifestyle considerations

39. Exercise in pregnancy A
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. 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. D
GPP

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

42. Smoking in pregnancy A B
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.
Women who are unable to quit smoking during pregnancy should be encouraged to reduce smoking. 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.
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 day
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. Nausea and vomiting in early pregnancy
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. A

50. Nausea and vomiting in early pregnancy
If a woman requests or would like to consider treatment, the following interventions appear to be effective in reducing symptoms:
non-pharmacological
– ginger
pharmacological
– 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.
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.
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
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. Vaginal discharge
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.
GPP

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

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

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

61. Clinical examination of pregnant women
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. Measurement of weight and body mass index (BMI)
Repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to be influenced. 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.
So, it is not recommended. B

66. Counseling VII
Screening for hematological conditions

67. Anemia B Pregnant women should be offered screening for anaemia.
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. B

68. Anemia
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. A

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

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

71. Blood grouping and red cell alloantibodies
Women should be screened for atypical red cell alloantibodies in early pregnancy and again at 28 weeks regardless of their RhD status. 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
– nuchal translucency (NT)
– the combined test (NT, hCG )
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.
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
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 C
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. Screening for clinical conditions
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
• previous macrosomic baby weighing 4.5 kg or above
• previous gestational diabetes (refer to Diabetes in pregnancy’)
• family history of diabetes B

91. I-hour, 50 g Oral Glucose Challenge Test (OGCT) • plasma glucose (PG) <7.8 mmol/L --> no GDM • PG ~7.8 and <10.3 mmol/L --> do 2-hour 75 g oral glucose tolerance test (OGTT) for diagnosis • PG ~1O.3 mmol/L --> GDM established

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

93. Gestational hypertension
Risk Factors • maternal factors • primigravida (80-90% of gestational HTN) • first conception with a new partner • PMHx or FHx of gestational HTN • DM, chronic HTN, or renal insufficiency • antiphospholipid antibody syndrome (APLA) • extremes of maternal age «18 or >35) • fetal factors • 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:
are nulliparous
are aged 40 or older
have a family history of pre-eclampsia
have a prior history of pre-eclampsia
have a body mass index (BMI) at or above 35 at first contact
have a multiple pregnancy or pre-existing vascular disease (for example, hypertension or diabetes). C

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

97. Pre-eclampsia
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
headache;
problems with vision, such as blurring or flashing before the eyes;
bad pain just below the ribs;
vomiting and
sudden swelling of face, hands or feet. D

100. references -Swanson -Family medicine practice -Emedicine
NICE clinical guideline 6 (Routine care for the healthy
pregnant woman )June 2010
SPECIAL THANKS FOR DR. ALI AL MOUSA

101. Thank you
Thank you