1. IMPORTANT ASPECTS OF
ANTENATAL CARE
CME Conducted by
ATLAS HOSPITAL, RUWI
MUSCAT

2. NICE/RCOG GUIDELINES – JUNE
2010
Pregnancy is a normal physiological
process & any interventions offered should
have known benefits & be acceptable to the
pregnant women
 Current models of ante-natal care originated in
the early 20th century.
 The pattern of visits recommended at that time
(monthly until 30 wks, then fortnightly to 36 wks
and then weekly until delivery) is still
recognisable today

3. AIMS OF ANTENATAL CARE
 Monitoring the progress of pregnancy
with minimum interference
 Guidance to the expectant mother
 Early detection of any deviation from
normal
 Institution of corrective measures
wherever possible
 Preparation of the mother for labour &
delivery

4. PRENATAL CARE
 The ideal initial prenatal care visit occurs before
conception with a pre-conceptive visit.
 A pre-conceptive visit allows modification of
behavioral choices, medication, and optimizing
medical concerns before conception.

5. FIRST VISIT – 10 WEEKS
ANC BEGINS AS SOON AS PREGNANCY IS
CONFIRMED
 CONFIRMATION OF PREGNANCY – UPT
 HISTORY TAKING
 GENERAL & SYSTEMIC EXAMINATION
 INVESTIGATIONS – Hb, RBS, Ur, Blood Group, HIV,
VDRL, HbsAg , Sickling Test
 USG –Confirming viability & number
Estimation of GA & EDD (10–13wks)

6. Advice - Do’s And Dont’s
 DIET
 WORK & EXERCISE – Continue working till the end & moderate
exercise
 COMMON SYMPTOMS – Morning
sickness, Heartburn, LBA, Frequency, Vg Discharge, Constipation
 SEXUAL INTERCOURSE – safe
 MEDICATIONS – Folic acid & calcium
 ALCOHOL INTAKE - <1-2 UK units/wk (1 u= half a pint of ordinary
strength lager/beer, or one shot [25 ml] of spirits. One small [125
ml] glass of wine =1.5 UK units)
 SMOKING – Quit-LBW, IUGR
 DRIVING & TRAVEL – Car (seat belts) & Air travel (36wks), travel
abroad & related vaccinations

7. Seat Belt in pregnant lady – the right
way!

8. SCREENING FOR MATERNAL
DISEASES
 ANEMIA – Booking – 11 gm%
28wks – 10.5 gm%
 No need for routine Iron supplements
 SICKLE CELL DISEASE - Sickling test
 ALLO-ANTIBODIES - ICT - Routine anti-D
prophylaxis at 28 & 36 wks to all non-sensitised
pregnant women
 Women should be screened for atypical red cell
allo antibodies (Kidd, Duffy, Anti-C) in early
pregnancy & at 28 weeks, regardless of their
rhesus D status

9. SCREENING FOR FETAL ANOMALIES
 DOWN’S SYNDROME- Nuchal Thickness -
performed end of first trimester (13w0d-13w6d) –
increased >6 mm
 COMBINED TEST – NT + HCG + PAPP-A (11w-
13w6d)
 TRIPLE/QUADRUPLE TEST 15-20wks.
 CONTINGENT SCREENING measuring free β-
hCG & PAPP-A in all pts at 10 wks -those with low
risk are screened negative- remainder NT - 13 wks -
low risk are screened negative-others offered marker
assays & diagnostic tests.
 ANOMALY SCAN - 18w 0d-20w 6d – Optional

10. TRIPLE MARKER TEST
 Performed between the 15th & 18th wk.
 AFP (fetus), HCG (placenta), and Estriol
(both)
 High AFP levels - neural tube defects,
anencephaly, mistaken dates.
 Low AFP & Estriol & High HCG -Trisomy 21
(Down) Trisomy 18 (Edwards) or any other type
of chromosome abnormality.

11. QUADRUPLE TEST
 Pts registering in late 2nd trimester-22wks
 AFP (fetal liver), Estriol (placenta+fetal
liver),HCG (placenta),Inhibin-A (placenta)
 High AFP levels - open neural tube defect,
mistaken dates or twins.
 Low AFP levels - high risk for Down syndrome.
 High HCG and Inhibin-A levels - increased
risk Down syndrome.
 Low Estriol - high risk for Down syndrome

12. SCREENING FOR INFECTIONS
 Asymptomatic bacteriuria - persistent bacterial
colonisation of the urinary tract without symptoms.
 After the initial screening, patients only need to be
screened for UTI infections if they are symptomatic
 HIV – MTCT- more than 35% reduced to 5% with
ART with ZT(300mg)+NVP(200mg)+3TC(150mg)
twice daily-14 wks till BF & 6wks for infant after BF
 The combination of ART, LSCS and avoiding breast
feeding can further reduce the transmission to 1%.
 Latest guidelines – Continue ART + Breast feeding

13. SCREENING FOR INFECTIONS
 HEPATITIS–B - Screening for HBsAg, new
sample-confirmatory testing & testing for e-markers
to know if baby will need Ig along with vaccine
postnatally
 RUBELLA - susceptibility screening offered early to
identify women at risk of contracting rubella
infection and vaccinate in the postnatal period.
 SYPHILLIS- TPHA if VDRL is positive
Mother-to-child transmission is associated with
neonatal death, congenital syphilis, stillbirth and
preterm birth

14. SCREENING FOR CLINICAL
CONDITIONS
GESTATIONAL DIABETES
 RBS at booking - less than 130 mg/dl or 7.2 mmol/l
 OGCT - 1 hr after 50 gm of glucose - 24wks – h/o
GDM–16wks-< 140mg/dl or 7.8 mmol/l
 GTT– 75 gm of glucose and 03 days of diet rich in
carbohydrates.
 Fasting – 104 mg/dl or 5.8 mmol/l
 2 hr after glucose – 140 mg/dl or 7.8 mmol/l
 A 2 hr 75 g OGTT is used as the gold standard
diagnostic test and is assumed to be 100%
sensitive and specific

15. PRE-ECLAMPSIA
 Pre-eclampsia is a complex disorder with
widespread endothelial damage in all organs, thus
presenting signs and symptoms may be more varied
than just high BP & proteinuria
 Blood pressure measurement and urinalysis
for protein–each visit.
 Hypertension single diastolic BP of 110 mmHg or
any consecutive readings of 90 mmHg on more than
one occasion at least 4 hours apart.
 Proteinuria 02 clean catch samples-4 hours apart
with 2+ proteinuria by dipstick are significant.
 300 mg protein in a 24 hour sample

16. PLACENTA PREVIA
 Low-lying placentae - not an uncommon finding
on early trimester scans
 Most low-lying placentae detected at the routine
scan generally resolve by the time the baby is
born.
 Only a woman whose placenta extends over the
internal cervical os should be offered another
trans-abdominal scan at 32 weeks.
 If the trans-abdominal scan is unclear, a trans-
vaginal scan should be performed.

17. MONITORING FETAL WELL BEING
 Clinical Examination – Symphysis-Fundal height
– after 24wks (difference of more than 2 cms is
significant)
 Daily Fetal Movement Count – DFMC–10/12 hrs
or 3 in one hr – one hr post meals.
 Ultrasound – not accurate in assessing fetal growth
in later trimesters
 Doppler Studies - in suspected IUGR
 CTG/NST– valid only after 32 weeks
 Biophysical Profile – Movement, tone, HR (NST),
Breathing, AFI – Normal score 8 or more
 Modified Biophysical Profile – NST + AFI

18. VACCINATIONS
 Tetanus Toxoid - 02 doses
 Killed/Inactivated/Toxoids can be given .
 Live vaccines are contraindicated
 Not Given - BCG, Cholera, Japanese Encephalitis,
Measles , Mumps, Rubella, Typhoid, Varicella
 Give only if essential as safety in pregnancy has
not been documented - Hepatitis A & E
Influenza
Meningococcal
OPV
Rabies
Diphtheria
Yellow fever

19. MANAGEMENT OF COMMON
SYMPTOMS IN PREGNANCY
NAUSEA & VOMITTING
 More in primigravidas & multiple pregnancies
 Cause - First/Increased exposure to HCG
 No harm to fetus - Generally settles by 16-20wks
 Diet - Avoid oily & spicy food
Small frequent meals
 Home remedies – Ginger & lemon
 Medications - T. Pyridoxine - twice daily
Severe cases – Inj. Metoclopramide

20. HEARTBURN
 Effect of progesterone - reduced tone of
lower esophageal sphincter
 Diet modifications – reduce spicy food & eat
small and frequent meals at short intervals
 Postural modifications – avoid bending &
lying down immediately after meals
 Medications–H2 receptor blockers - Ranitidine
Proton Pump Inhibitors - Omez ®
Antacids - Gelusil®

21. CONSTIPATION
 Effect of Progesterone – Relaxes musculature
reduces tone & motility of smooth muscles
 Diet modification – High fibre diet
Plenty of water
More fruits & vegetables
 Medications – Mild Laxatives–Lactulose
Herbolax ®
Liquid Paraffin

22. VAGINAL DISCHARGE
 Due to vascular congestion & increased activity
of cervical mucus secreting glands
 No treatment required
 Watch for – Change of colour
Foul Smell
Associated Pruritis
Painful or burning micturition
Above signs indicate infection in which case the
same will have to be treated accordingly

23. BACKACHE
 Initially due to pelvic organ congestion & later
due to strained pelvic supports & exaggerated
lumbar lordosis
 Lifestyle – as active as possible
 Support- Lower back when sitting
Abdominal bump when lying down
 Non-pharmacological - Back massage
- Hot fomentation
 Drugs - Unrelenting cases - Analgesics
- Balms/gels for LA

24. HAEMORRHOIDS & VARICOSE
VEINS
 Due to vascular congestion
 Effect of Progesterone
 No effective treatment in pregnancy
 Avoid constipation
 Diet advice – high fibre, plenty of water
 Leg elevation & avoid prolonged periods of
standing
 Compression stockings
 Medications – Laxatives, creams & Flavinoids
Hirudoid cream

25. POST-DATISM
 At 40 wks of gestation, only 58% of women had
delivered, 74% by 41 wks and 82% by 42 wks
 Perinatal mortality & morbidity is increased if
duration of pregnancy is more than 42 wks.
 Sweeping/Stripping of membranes – 41 wks –
likelihood of spontaneous onset of labour in 48
hrs
 41-42 weeks – Twice weekly NST, USG for AFI
 42 weeks – Induction of labour & delivery

26. INTERVENTIONS NOT ROUTINELY
RECOMMENDED
 Repeated maternal weighing.
 Breast or pelvic examination.
 Iron or vitamin A supplements.
 Routine Doppler ultrasound in low-risk pregnancies.
 Ultrasound estimation of fetal size for suspected LGA
 Routine screening for preterm labour.
 Routine screening for cardiac anomalies using NT.
 Routine fetal-movement counting.
 Routine auscultation of the fetal heart.
 Routine antenatal electronic cardio-tocography.
 Routine ultrasound scanning after 24 weeks

28. THANKS