Antenatal care

Antenatal care
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics and gynecology
Ain Shams University
3/21/20 ELBOHOTY 1

Pregnancy can be
•Low risk pregnancy
•High risk pregnancy
•Mother
•Fetus
3/21/20 ELBOHOTY 2

Pathway of care
•Preconception
•Antenatal
•Intrapartum
•Postpartum
3/21/20 ELBOHOTY 3

The aims of antenatal care are to:
1.Provide high-quality information
2.Provide an informed choice about the
pathways of antenatal care
3.screen for maternal complications
4.screen for fetal complications
5.Assess maternal and fetal wellbeing
throughout pregnancy
6.Provide advice and education on the normal
symptoms of pregnancy
3/21/20 ELBOHOTY 4

Who?
1.general practitioners
2.community midwives
3.hospital midwives
4.obstetricians.
5.Often health professionals such as
physiotherapists, social workers HIV
physcians, Diabetogists, ……..are involved.
3/21/20 ELBOHOTY 5

•Antenatal care should be woman-
centred.
•Care offered to women should be
planned carefully, ensuring the early
detection of problems without
becoming over-intrusive.
•Women and their husbands/partners
have the right to be involved in all
decisions regarding their antenatal care.
3/21/20 ELBOHOTY 6

Assigning a care pathway
•Midwife and GP-led models of care
should be offered to women with
uncomplicated pregnancies, but there
should be clear referral pathways to
specialists when either fetal or
maternal problems are detected.
3/21/20 ELBOHOTY 7

Documentation of care
•Structured maternity records should be used
for antenatal care.
•Maternity services should have a system in
place whereby women carry their own case
notes.
•A standardised, national maternity record with
an agreed minimum data set should be
developed and used.
3/21/20 ELBOHOTY 8

The booking appointment
•This usually takes place at the local surgery, hospital or home
depending on accessibility.
•The booking appointment is usually done by the community
midwife
•All information collected from the woman and all
information given to her should be clearly documented in
her maternity notes.
3/21/20 ELBOHOTY 9

Lifestyle considerations
3/21/20 ELBOHOTY 12

Food-acquired infections
• Pregnant women should be oﬀered informa5on on how to reduce the
risk of listeriosis by:
• drinking only pasteurised or UHT milk
• not ea5ng ripened so> cheese such as Camembert, Brie and blue-
veined cheese (there is no risk with hard cheeses, such as Cheddar,
or coEage cheese and processed cheese)
• not ea5ng pâté (of any sort, including vegetable)
• not ea5ng uncooked or undercooked ready-prepared meals.
• Pregnant women should be oﬀered informa5on on how to reduce the
risk of salmonella infec5on by:
• avoiding raw or par5ally cooked eggs or food that may contain
them (such as mayonnaise)
• avoiding raw or par5ally cooked meat, especially poultry.
3/21/20 ELBOHOTY 16

• the safest 5me to fly is:
• Before 37 weeks, for uncomplicated singlton pregnancy.
• Before 32 weeks, for uncomplicated mul5ple pregnancy.
• With regard to minimising the risk of DVT during long–haul flights
las5ng more than 4 hours , appropriate general advice would be to:
• have an aisle seat to facilitate ease of movement
• take regular walks around the cabin and/or
• carry out in–seat exercises approximately every 30 minutes on a
medium or long–haul flight
• maintain a good fluid intake and minimise caffeine and alcohol
intake to avoid dehydra5on
• make a specific individualised risk assessment for thrombosis in
pregnant women who are flying.
• LMWH for those with significant risk factors such as previous
thrombosis or morbid obesity.
3/21/20 ELBOHOTY 18

Alcohol consumption
•Advise women to avoid alcohol especially in first 3
months of pregnancy if possible
•If women choose to drink alcohol they should be
advised to drink no more than 1 to 2 UK units once
or twice a week
•there is uncertainty regarding a safe level of
alcohol consumption in pregnancy, at this low level
there is no evidence of harm to the unborn baby
•Women should be informed that getting drunk or
binge drinking during pregnancy may be harmful
3/21/20 ELBOHOTY 19

Risks
• Fertility
• Alcohol may be exerting toxic effects throughout the reproductive process from infertility
through miscarriage, aneuploidy, structural congenital anomaly, disordered fetal growth,
perinatal death, developmental delay and indeed susceptibility to disease in adult life.
• Miscarriage and structural congenital malformations
• Preterm labour
• alcohol consumption both in early pregnancy and in late pregnancy and preterm birth but
only at levels of consumption in excess of 10 drinks a week
• Fetal growth and development
• There is a clear dose response relationship between alcohol consumption in the second
half of pregnancy and fetal growth.
3/21/20 ELBOHOTY 20

Equivalents
•1 unit equals half a pint of ordinary strength
lager or beer, or one shot [25 ml] of spirits.
•One small [125 ml] glass of wine is equal to 1.5
UK units
3/21/20 ELBOHOTY 26

Smoking consumption
•Use any appointment or meeting as an opportunity
to ask women if they smoke. If they do, explain how
NHS Stop Smoking Services can help people to quit
and advise them to stop.
•Offer those who want to stop a referral to NHS Stop
Smoking Services.
•Pregnant women should be informed about the
specific risks of smoking during pregnancy (such as
the risk of having a baby with low birthweight and
preterm birth). The benefits of quitting at any stage
should be emphasised.3/21/20 ELBOHOTY 27

Identifying pregnant women who smoke
action for midwives
• A carbon monoxide (CO) test is an immediate and non-invasive biochemical
method for helping to assess whether or not someone smokes. However, it is
unclear as to what consAtutes the best cut-off point for determining smoking
status.
• Some suggest a CO level as low as 3 parts per million (ppm), others use a cut-off
point of 6–10 ppm.
• It is important to note that CO quickly disappears from expired breath (the level
can fall by 50% in less than 4 hours). As a result, low levels of smoking may go
undetected and may be indisAnguishable from passive smoking.
• Conversely, environmental factors such as traffic emissions or leaky gas
appliances may cause a high CO reading – as may lactose intolerance.
• When trying to idenAfy pregnant women who smoke, it is best to use a low cut-
off point to avoid missing someone who may need help to quit.
3/21/20 ELBOHOTY 28

Nico@ne replacement therapy
• Use only if smoking cessation without NRT fails. If they express a clear
wish to receive NRT, use professional judgement when deciding
whether to offer a prescription.
• Only prescribe NRT for use once they have stopped smoking (they may
set a particular date for this).
• Only prescribe 2 weeks of NRT for use from the day they agreed to
stop. Only give subsequent prescriptions to women who have
demonstrated, on re-assessment, that they are still not smoking.
• Advise pregnant women who are using nicotine patches to remove
them before going to bed.
• Neither varenicline or bupropion should be offered to pregnant or
breastfeeding women
3/21/20 ELBOHOTY 30

vitamin D
•All women should be informed at the booking
appointment about the importance for their
own and their baby’s health of maintaining
adequate vitamin D stores during pregnancy
and whilst breastfeeding.
•In order to achieve this, women may choose to
take 10 micrograms of vitamin D per day, as
found in the Healthy Start multivitamin
supplement.
3/21/20 ELBOHOTY 31

Risks of deficiency
• Pre-eclampsia and neonatal hypocalcaemia are the most prevalent complications
of maternal hypocalcaemia and are clearly associated with substantial morbidity.
• A statistical association of glucose intolerance and hypovitaminosis D has been
demonstrated.
• Maternal vitamin D is important to fetal bone development.
• Fetal lung development and neonatal immune conditions such as asthma may
relate in part to maternal vitamin D levels.
• Vitamin D deficiency (< 37.5 nmol/l) has been associated with a four-fold
increased risk of primary caesarean section (caesarean section performed for the
first time),34 although this has not been demonstrated in all studies.16 Vitamin
D deficiency is also associated with bacterial vaginosis in pregnant women.
• Although it is not clear whether maternal vitamin D supplementation will
prevent these conditions, a strategy for supplementation and treatment of
maternal vitamin D deficiency is proposed.
3/21/20 ELBOHOTY 32

Neonatal
• Fetal lung development and childhood immune disorders Low
maternal vitamin D intake in pregnancy is associated with wheeze and
asthma in the offspring.49 Low cord blood 25(OH)D concentra5ons
have been associated with respiratory syncy5al virus bronchioli5s50
and respiratory infec5ons.
• Maternal vitamin D levels have been shown to posi5vely correlate with
birthweight cen5le.
• Neonatal hypocalcaemic seizures Neonatal vitamin D levels are
correlated with those of their mother, with maternal vitamin D
deficiency increasing the risk of neonatal vitamin D deficiency.
3/21/20 ELBOHOTY 33

vitamin D
•Healthcare professionals’ should take particular care to check that
women at greatest risk of vitamin D deficiency are following advice to
take this daily supplement. These include:
• women of 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, such as
women who consume nooily fish, eggs, meat, vitamin D-fortified
margarine or breakfast cereal
• women with a pre-pregnancy body mass index above 30 kg/m2.
3/21/20 ELBOHOTY 34

Health professionals should not routinely
test people's vitamin D status unless:
•they have symptoms of deficiency
•they are considered to be at particularly high risk of
deficiency (for example, they have very low exposure to
sunlight)
•there is a clinical reason to do so (for example, they have
osteomalacia or have had a fall).
3/21/20 ELBOHOTY 35

Three categories of vitamin D supplementation are
recommended.
• In general,
• vitamin D 10 micrograms (400 units) a day is recommended for all pregnant women
(Healthy Start programme).
• High-risk women
• are advised to take at least 1000 units a day (women with increased skin pigmentation,
reduced exposure to sunlight, or those who are socially excluded or obese)
• Women at high risk of pre-eclampsia are advised to take at least 800 units a day combined
with calcium. There may be particular benefits of vitamin D/calcium supplementation in
women at risk of pre-eclampsia if it was associated with hypocalcemia.
• Treatment.
• For the majority of women who are deficient in vitamin D, treatment for 4–6 weeks, either
with cholecalciferol 20 000 iu a week or ergocalciferol 10 000 iu twice a week, followed by
standard supplementation, is appropriate.
• For women who require short-term repletion, 20 000 iu weekly appears to be an effective
and safe treatment of vitamin D deficiency.
• A daily dose is likely to be appropriate to maintain subsequent repletion (1000 iu daily). In
adults, very high doses of vitamin D (300 000–500 000 iu intramuscular [IM] bolus) may be
associated with an increased risk of fractures and such high doses are not recommended
in pregnancy
3/21/20 ELBOHOTY 36

• All patients receiving pharmacological doses of vitamin D should have
their plasma-calcium
3/21/20 ELBOHOTY 38

Risks of treatment
• Vitamin D may be inappropriate in sarcoidosis (where there may be
vitamin D sensitivity) or ineffective in renal disease.
• Deficient renal 1-α hydroxylation necessitates the use of active vitamin
D metabolites, such as 1α-hydroxycholecalciferol or 1,25-
dihydroxycholecalciferol.
• Specialist medical advice should be sought in such cases.
• The limitation to therapy compliance mostly relates to the calcium
which has a side effect of tasting of chalk, rather than the vitamin D
element of oral therapy.
• It is often more appropriate to give vitamin D alone for patient
acceptability. However, this is limited by the availability of suitable
agents
• In pregnancy there is enhanced intestinal calcium absorption. Vitamin
D toxicity is manifested through hypercalcaemia and hypercalciuria.
Therefore, there is a hypothetical concern that when secondary
hyperparathyroidism follows vitamin D deficiency, calcium given with
vitamin D may be associated with temporary hypercalcaemia3/21/20 ELBOHOTY 39

Folic acid
•Pregnant women (and those intending to
become pregnant) should be informed that
dietary supplementation with folic acid, before
conception and throughout the rest 12 weeks,
reduces the risk of having a baby with a neural
tube defect (for example, anencephaly or spina
bi da).
•The recommended dose is 400 micrograms
per day.
3/21/20 ELBOHOTY 40

5 mg per day is recommended for:
•women who have previously had an infant
with a neural tube defect
•who are receiving anti-epileptic medication
•who have diabetes
•BMI >30
•Malabsorption syndrome (e.g. inflammatory
bowel disease)
•Women with known MTHFR mutation
•Haemoglobinopathy - due to rapid turnover
of cells (e.g. beta thalassaemia)3/21/20 ELBOHOTY 41

Avoid high dose of vitamin A
•Pregnant women should be informed that vitamin A
supplementation (intake above 700 micrograms)
might be teratogenic and should therefore be
avoided. Pregnant women should be informed that
liver and liver products may also contain high levels
of vitamin A, and therefore consumption of these
products should also be avoided.
3/21/20 ELBOHOTY 42

Adverse effects of isotretinoin
• Mood disturbance
• Dryness of skin and mucous membranes
• Facial erythema, eczema, hair loss, photosensi5vity, skin fragility,
• paronychia and pyogenic granuloma
• Myalgia and arthralgia
• Photophobia, impaired night vision and kera55s
• Nausea, coli5s and pancrea55s
• Abnormali5es of liver func5on including hepa55s
• Eleva5on of triglyceride and cholesterol levels
• Bacterial overgrowth, e.g. Staphylococcus aureus
• Cutaneous vasculi5s
• Acne ﬂare
3/21/20 ELBOHOTY 43

Malformations associated with isotretinoin use
• Craniofacial defects:
• ear defects
• eye defects
• cleft palate
• micrognathia (small jaw) depressed nasal bridge dysmorphism
• ocular hypertelorism (widely spaced eyes)
• Central nervous system defects:
• Microencephaly
• facial nerve palsy
• Hydrocephalus
• cortical and cerebellar defects
• Cardiovascular defects:
• Fallot’s tetralogy
• septal defects
• transposition of the great vessels and aortic arch hypoplasia
• Thymic abnormalities:
• hypoplasia
aplasia and ectopia3/21/20 ELBOHOTY 44

Management of common symptoms
of pregnancy
3/21/20 ELBOHOTY 45

Nausea and vomiting in early pregnancy
• most cases of nausea and vomiting in pregnancy will resolve spontaneously
within 16 to 20 weeks and that nausea and vomiting are not usually associated
with a poor pregnancy outcome.
• If a woman requests or would like to consider treatment, the following
interventions appear to be effective in reducing symptoms:
• non-pharmacological:
• ginger
• acupressure
• pharmacological:
• antihistamines.
3/21/20 ELBOHOTY 46

• 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 despite lifestyle and diet modi cation.
• Constipation
• Women who present with constipation in pregnancy should be
offered information regarding diet modi cation, such as bran or
wheat bre supplementation.
• Haemorrhoids
• In the absence of evidence of the effectiveness of treatments for
haemorrhoids in pregnancy, women should be offered information
concerning diet modification.
• If clinical symptoms remain troublesome, standard haemorrhoid
creams should be considered.
3/21/20 ELBOHOTY 47

Constipation
• The prevalence of cons5pa5on is es5mated to affect 11–38% of
pregnancies.
• Func5onal (primary) cons5pa5on is defined as infrequent bowel
mo5on and/or difficulty in passing stool, which is not aEributable to an
underlying pathology.
• Secondary cons5pa5on results from either pharmacotherapy or a
medical condi5on.
• Medical condi5ons include
• primary disease of the gastrointes5nal tract (such as, anal fissure,
colorectal strictures and neoplasia),
• metabolic disturbances (such as, hypothyroidism,
hypercalcaemia)
• neurological disorders.
• Some individuals may suffer from irritable bowel syndrome
associated with cons5pa5on (IBS-C).3/21/20 ELBOHOTY 48

The following circumstances warrant a prompt referral to
a gastroenterologist:
• A change in bowel habit for longer than 6 weeks.
• Rectal bleeding.
• Known history of gastrointestinal disorders such as
• inflammatory bowel disease.
• A family history of colorectal cancer.
3/21/20 ELBOHOTY 50

stop laxatives
• When regular bowel movements occur without difficulty, laxatives can be
withdrawn gradually.
• The reduction in the dose of laxatives should be guided by the frequency and
consistency of the stools.
• Gradual withdrawal will reduce the risk of requiring re-initiation of therapy for
recurrent faecal loading.
• If a combination of laxatives is used, one laxative should be stopped at a time,
reducing stimulant laxatives first.
• Patients should be aware that the process of weaning off laxatives may take
several months.
3/21/20 ELBOHOTY 52

• Varicose veins
• Women should be informed that varicose veins are a common symptom of
pregnancy that will not cause harm and that compression stockings can improve
the symptoms but will not prevent varicose veins from emerging.
• Vaginal discharge
• Women should be informed that an increase in vaginal discharge is a common
physiological change that occurs during pregnancy. If it is associated with itch,
soreness, offensive smell or pain on passing urine there may be an infective cause
and investigation should be considered.
• A 1-week course of a topical imidazole is an effective treatment and should be
considered for vaginal candidiasis infections in pregnant women.
• The effectiveness and safety of oral treatments for vaginal candidiasis in
pregnancy are uncertain and these treatments should not be offered.
• Backache
• Women should be informed that exercising in water, massage therapy and group
or individual back care classes might help to ease backache during pregnancy.
3/21/20 ELBOHOTY 53

Screening at the booking visit
•Screening is not a diagnostic test and the
woman may need to be offered further
tests to confirm a diagnosis
•A woman may choose to opt out of some
screening tests for personal reasons
•Her decision must be respected
•However, she must understand the
implications of not being tested and this
should be documented in her notes
3/21/20 ELBOHOTY 54

Obstetric history
•Planned or not
•Age
•gesta.on
•presen.ng complaint
•history of presen.ng complaint
•history of index pregnancy
•past obstetric history
•past medical history/past medical history
•drug history
•family history
•social history
3/21/20ELBOHOTY
55

•Domestic violence:
• at any visit you should be alert to signs and symptoms of
domestic violence
• women should also feel safe to discuss issues of domestic
violence, which may not have been disclosed on the first
visit
3/21/20 ELBOHOTY 56

Red spot system
•An easy and cost-effective way to help women to reveal that
they may be victims of domestic abuse is the red spot
system.
•Put the following notice or something with similar wording
on the inside of the toilets where the women provide urine
samples. Attach a small supply of red dots.
•They can discreetly put one on the urine sample and her
partner is unlikely to notice that the spot was not on before
she went to the toilet even if they do notice it afterwards.
•You now know you must find a way of seeing the woman on
her own
3/21/20 ELBOHOTY 57

•Mental disorders:
• any relevant history of mental health disorders,
along with communica8on between healthcare
professionals, should be documented in the notes
3/21/20 ELBOHOTY 59

Screening for depression and anxiety
3/21/20 ELBOHOTY
At a woman's first contact with primary care
or her booking visit, and during the early
postnatal period,
60

•Consider asking the following depression
identification questions :
•During the past month, have you often been
bothered by feeling down, depressed or hopeless?
•During the past month, have you often been
bothered by having little interest or pleasure in
doing things?
•Also consider asking about anxiety using the 2-item
Generalized Anxiety Disorder scale (GAD-2):
•During the past month, have you been feeling
nervous, anxious or on edge?
•During the past month have you not been able to
stop or control worrying?
3/21/20 ELBOHOTY 61

History taking
• past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in
the postnatal period and severe depression
• previous treatment by a psychiatrist/specialist mental health team, including inpatient care
• a family history of perinatal mental illness.
• Other specific predictors, such as poor relationships with her partner, should not be used
for the routine prediction of the development of a mental disorder.
3/21/20 ELBOHOTY 62

Calculation of GA
3/21/20 ELBOHOTY 63

calcula6on of fetal gesta6onal age:
• LMP
• US
• CRL
• Based on day of embryo transfer in IVF
• According to day 3 or 5
3/21/20 ELBOHOTY 64

By LMP (Naegele’s rule):
• Prerequisites:
• Sure of her date of 1st day of last menstrual period.
• Regular cycle (at least the last 3 cycles of average duration and length).
• No use of hormonal contraception in the last 3 cycles.
• No lactation.
• How to calculate:
• The 1st day of LMP = day / month / year
• The EDD = +7days of LMP / +9 months of LMP / year
• To make calculations easier try to use these equations:
• 1 month = 4wks + 2days (or 3 days).
• 2 months = 8 wks + 5 days.
• 3 months = 13 wks.
• It overestimate GA
• You can modify if the cycle if frequency is not 28 days
• For 21 day cycle: The EDD = +9 months of LMP / year so Add one week to the
GA
• For 35 day cycle: The EDD = +14 days of LMP / +9 months of LMP / year so
Remove one week from the GA
3/21/20 ELBOHOTY 65

Late bookers
• NICE recommends that the booking appointment should occur by 10 weeks of
gestation.
• Late bookers are at an increased risk of perinatal mortality and around 20% of
women who died from direct or indirect causes booked for maternity care after
20 weeks of gestation.
3/21/20 ELBOHOTY 66

Women are more likely to book late if they are:
1.black and ethnic minority teenagers (whether born inside or outside the UK)
2.from deprived areas
3.single parents
4.are mulAparous
5.have a history of alcohol or substance abuse
6.are of low intelligence
7.are in an abusive relaAonship
8.have diﬃculty with access to health care
3/21/20 ELBOHOTY 67

Clinical examination
The following must be examined or asked for during the
antenatal period.
Measurement of weight and body mass index:
the maternal weight and height should be measured at the
first contact visit and BMI calculated
routine repeated weighing is not recommended
• Female genital mutilation
• Pregnant women who have had female genital mutilation should be identified early in
antenatal care through sensitive enquiry. Antenatal examination will then allow planning
of intrapartum care.
3/21/20 ELBOHOTY 68

• Breast examination
• Routine breast examination during antenatal care is not recommended for the promotion
of postnatal breastfeeding.
• Pelvic examination
• Routine antenatal pelvic examination does not accurately assess gestational age, nor does
it accurately predict preterm birth or cephalopelvic disproportion. It is not recommended.
3/21/20 ELBOHOTY 69

Migrant women
They should have a medical assessment of their overall health and a
cardiovascular examination at booking
women from countries where genital mutilation is prevalent should be
sensitively questioned and examined
3/21/20 ELBOHOTY 70

Pregnant asylum seekers
• They are a highly vulnerable and socially excluded group of women.
• They have complex medical and psychosocial healthcare needs, often booking
late, possibly secondary to dispersal.
• Healthcare professionals may have limited knowledge of the asylum process in
the UK and therefore at times risk providing suboptimal care for these women.
• Studies and government reports have suggested that small yet practical changes
can lead to empowerment of these women and improve their health, mental
wellbeing and quality of life and that of their babies.
3/21/20 ELBOHOTY 71

Screening for clinical conditions
• All pregnant women within the UK should be screened for the following
conditions:
• VTE: Risk factors
• Anaemia (Hb)
• gestational diabetes (risk factors)
• hypertensive disease and pre-eclampsia (Blood pressure measurment and urine
analysis)
• blood groups and red cell auto-antibodies
• haemoglobinopathies – sickle cell and thallasaemias
• infection – asymptomatic bacturia, hepatitis B, HIV, rubella and syphilis
• placenta praevia (scan)
3/21/20 ELBOHOTY 75

Identifies Example
Existing conditions that may worsen
during pregnancy
•Medical conditions such as diabetes,
hypertension, cardiac conditions,
infections
•Mental conditions such as depression,
bipolar disorders
•Social issues such as substance abuse
and domestic violence
Women at risk of developing conditions
that may adversely affect the pregnancy
•Gestational diabetes
•Pre-eclampsia
Identifying conditions with postnatal
implications
•Social issues
•Infection (HIV, hepatitis B)
3/21/20 ELBOHOTY 76

Women needing additional care
3/21/20 ELBOHOTY 78

• Screening for pre-eclampsia
• Pre-eclampsia is hypertension associated with proteinuria that occurrs after 20
weeks of gestation and resolves after birth, and chronic hypertension occurs
before this.
• Blood pressure measurement and urinalysis for protein must be measured at
each antenatal visit.
• Mothers should be warned of the symptoms of pre-eclampsia (frontal headache,
epigastric pain, vomiting and visual disturbances)
• Key figures
• Pre-eclampsia affects 5–10% of pregnancies
• Severe pre-eclampsia affects 1–2% of pregnancies
• Eclampsia affects about 1:2000 of pregnant women
3/21/20 ELBOHOTY 79

Blood pressure should be measured as outlined
below:
• remove tight clothing, ensure arm is relaxed and supported at heart level
• use cuff of appropriate size
• inflate cuff to 20–30 mmHg above palpated systolic blood pressure
• lower column slowly, by 2 mmHg per second or per beat
• read blood pressure to the nearest 2 mmHg
measure diastolic blood pressure as disappearance of sounds (phase V).
• Hypertension in which there is a single diastolic blood pressure of 110 mmHg or
two consecutive readings of 90 mmHg at least 4 hours apart and/or significant
proteinuria (1+) should prompt increased surveillance.
• If the systolic blood pressure is above 160 mmHg on two consecutive readings at
least 4 hours apart, treatment should be considered.
•
3/21/20 ELBOHOTY 81

• All pregnant women should be made aware of the need to seek immediate
advice from a healthcare professional if they experience symptoms of pre-
eclampsia.
• Symptoms include:
• severe headache
• problems with vision, such as blurring or ashing before the eyes severe pain just below
the ribs
• Vomiting
• sudden swelling of the face, hands or feet.
3/21/20 ELBOHOTY 82

Screening for infections
• asymptomatic bacteriuria
• HIV, rubella, syphilis and hepatitis B
3/21/20 ELBOHOTY 83

Asymptomatic bacteriuria
This is defined as the presence of bacterial colonisation of the urinary tract in the
absence of symptoms
It occurs in 2–5% of pregnant women
It is associated with pyelonephritis (30%), preterm labour and structural
abnormalities of the renal tract (3–5%)
Midstream culture should be performed early in pregnancy
Treatment reduces the risk of pyelonephritis and preterm labour
3/21/20 ELBOHOTY 84

HIV, syphilis and hepatitis B
• Currently four infections are screened for in the UK:
• human immunodeficiency virus (HIV)
• syphilis
• hepatitis B
• Maternal blood should be screened at booking and with the woman's consent
3/21/20 ELBOHOTY 85

Screening for haematological disorders
• anaemia
• blood groups and red cell antibodies
• haemoglobinopathies
3/21/20 ELBOHOTY 86

Diagnosis of anaemia
•Anaemia in pregnancy is defined as
• first trimester haemoglobin (Hb) less than
110 g/l
•second/third trimester Hb less than 105 g/l
•postpartum Hb less than 100 g/l
3/21/20 ELBOHOTY 87

haemoglobinopathies
•Sickle cell and thallassaemia are the two most
common haemoglobinopathies in the UK.
•Screening for should be offered to women as early as
possible in pregnancy (ideally by 10 weeks)
3/21/20 ELBOHOTY 88

•MCV is done as a part of CBC
•Screening tests offered for sickle cell depends on it's
prevalence within that area
•high prevalence is more than 1.5 per 10,000
pregnancies
•low prevalence is less than or equal to 1.5 per 10,000
pregnancies).
• The designation of high and low prevalence is kept under review based on
newborn screening carrier results.
• The list of high and low prevalence Trusts can be found at sct.screening.nhs.uk/
evaluationsreviewssurveys.
• In Trusts defined as covering high prevalence populations, laboratory sickle cell
and thalassaemia screening should be offered to all women.
3/21/20 ELBOHOTY 89

Diagnosis
•Where prevalence of sickle cell disease is high (fetal prevalence above
1.5 cases per 10,000 pregnancies)
• laboratory screening (preferably high-performance liquid chromatography) should be
offered to all pregnant women to identify carriers of sickle cell disease and/or
thalassaemia.
•Where prevalence of sickle cell disease is low fetal prevalence 1.5
cases per 10,000 pregnancies or below)
• all pregnant women should be offered screening for haemoglobinopathies using the
Family Origin Questionnaire.
• If the Family Origin Questionnaire indicates a high risk of sickle cell
disorders, laboratory screening (preferably high-performance liquid
chromatography) should be offered.
•If the mean corpuscular haemoglobin is below 27 picograms,
laboratory screening (preferably high-performance liquid
chromatography) should be offered.
3/21/20 ELBOHOTY 90

Further ac@ons
• if the pregnant woman is identified as, or known to be a carrier – offer screening
to the baby’s father as soon as possible
• if the pregnant woman and baby’s father are identified as carriers or affected
refer for counselling and offer prenatal diagnosis by 12+ 6 weeks of pregnancy
• all babies are offered screening for sickle cell disease as part of newborn blood
spot screening
• testing can be carried out pre conceptually on request
3/21/20 ELBOHOTY 91

• In low prevalence areas
• the Family Origin Questionnaire (FOQ) is principally used as a tool to identify
women who are at highest risk of being a carrier or having a baby with a
haemoglobin variant or disorder.
• In high and low prevalence areas
• the FOQ is used as a tool by laboratory staff to help with the interpretation of
results, particularly in the interpretation of results indicating possible alpha or
beta thalassaemia.
• The family origin is also relevant in the interpretation of red blood cell indices and
essential for accurate prenatal diagnosis. More information about its use can found in the
laboratory handbook: http://sct.screening.nhs.uk/publications
• Therefore you need to ask for the family origins of both the woman
AND the baby's father going back at least 2 generations (or more if
possible).
• Women with Sickle Cell Disease
• Screening will also identify women with sickle cell disease, who should be considered
”high risk“ requiring specialist care during pregnancy from an Obstetrician and
Haematologist, and who should be booked for a hospital delivery.
3/21/20 ELBOHOTY 93

”Low risk“ Family Origins
• United Kingdom (White)
• England, Scotland, Northern Ireland, Wales.
• Northern European (White)
• Austria, Belgium, Denmark, Greenland, Iceland, Ireland (Eire), Finland, France,
Germany, Luxembourg, Netherlands, Norway, Sweden, Switzerland.
• Some populations of the following countries have Northern European origin
(countries listed above) and are also at low risk for haemoglobin variants:
• Northern European Origin (White)
• Australia, North America (USA, Canada), South Africa, New Zealand.
3/21/20 ELBOHOTY 94

Family origin questionnaire is not useful
• Adoption
• If either parent has been adopted, the FOQ information may not
accurately reflect the true family origins. Such cases should be
treated as high risk and have full laboratory screening.
• Fertility treatment – donor gametes
• If the pregnancy has been achieved by the use of a donor egg then
the screening results on the woman will not be informative so the
baby’s father should always be tested to ensure that this is not a
high risk pregnancy.
• If donor sperm has been used then it may be appropriate to refer
back to the fertility clinic if the screening results on the woman
show that she is a carrier for a haemoglobinopathy.
3/21/20 ELBOHOTY 95

Bone marrow transplants
•In women who have received a bone marrow transplant,
the haemoglobin results on her blood specimen will not
necessarily indicate the gene.c make up of the fetus.
•The baby’s father should always be tested to ensure that
this is not a high risk pregnancy.
•Cau.on should be exercised in the interpreta.on of any
haematology results in this instance.
•If DNA conﬁrma.on of mother’s status is required then
pre- transplant DNA or DNA obtained from hair follicles
should be used.
3/21/20 ELBOHOTY 96

•The need for testing of the baby’s father in
possible cases of α0 thalassaemia in both low
and high prevalence areas will also be
determined from the family origin
questionnaire in conjunction with the red cell
indices.
•All women should be screened for
thalassaemia using the red cell MCH
measurement.
3/21/20 ELBOHOTY 97

Tes?ng algorithm for laboratory screening in LOW
PREVALENCE area
3/21/20 ELBOHOTY 98

Testing algorithm for laboratory screening in HIGH
PREVALENCE areas
3/21/20 ELBOHOTY 99

Iron deficiency
• The Hb A2 level may be lowered by up to 0.5% in cases of severe iron deficiency
anaemia, however screening for haemoglobin variants and thalassaemia should
proceed without regard to iron deficiency, suspected or proven.
• Any decrease in MCH should be regarded as potentially due to a
haemoglobinopathy and the Hb A2 should be measured. If the Hb A2 is equal to
or greater than 3.5% or if the woman’s haemoglobin is less than 80 g/L and the
Hb A2 is between 3.0% and 3.5%, testing of the baby’s father is recommended. It
may be appropriate to simultaneously investigate pregnant women for iron
deficiency, using ferritin or zinc protoporphyrin (ZPP) but this is not specifically
part of the screening protocols.
• In pregnant women there is no justification for delaying the investigation
• of haemoglobinopathies whilst treating iron deficiency, as this will delay the
process of identifying at-risk carrier couples who should be offered prenatal
diagnosis.
• Justification for above approach
• Iron deficiency makes the red cell indices difficult to interpret and so an underlying
haemoglobinopathy may be present. Severe iron deficiency anaemia (Hb < 80 g/L) can also
reduce the Hb A2 level slightly (up to 0.5%), but in practice this should not interfere with
the screening protocol and testing of the baby’s father should still be requested. If the
father is found to be iron deficient, this could be a significant clinical finding and he should
be referred to his General Practitioner.3/21/20 ELBOHOTY 100

Indications of anti D for all non-sensitised RhD-negative
women
:• Aner birth (500 IU within 72 hours with calculaAon of FMH)
• rouAne antenatal anA-D prophylaxis
• At 28 and 34 (500IU)
• At 28 (1500 IU)
• threatened miscarriage, spontaneous complete or incomplete miscarriage at or
aner 12 weeks of gestaAon.
• surgical evacuaAon of the uterus or surgical management of ectopic pregnancy
• therapeuAc terminaAon of pregnancy, whether by surgical or medical methods
• invasive tesAng
• APHge
• ECV
3/21/20 ELBOHOTY 101

3/21/20 ELBOHOTY
Screening for gestational
diabetes using risk factors
1. body mass index above 30 kg/m2
2. previous macrosomic baby weighing 4.5 kg or above
3. previous gestational diabetes
4. family history of diabetes (first-degree relative with diabetes)
5. family origin with a high prevalence of diabetes
South Asian (speci cally women whose country of family origin is India, Pakistan or
Bangladesh)
black Caribbean
Middle Eastern (specifically women whose country of family origin is Saudi Arabia,
United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or
Egypt).
6. Glucosuria +2 or 2 times +1
Confirmatory test: OGT usually at 24 weeks
except if previous GDM do at booking or self monitoring
102

3/21/20 ELBOHOTY
Diagnosis of GDM based on
OGTT
1. Fasting plasma venous glucose
concentration greater than or equal
to 5.6 mmol/litre or
2. 2-hour plasma venous glucose
concentration greater than or equal
to 7.8 mmol/litre.
103

Screening the fetus
The aims of screening the fetus are to:
•conﬁrm fetal viability, gesta.onal age and diagnose mul.ple
gesta.on
•Screen for structural and chromosomal anomalies
•screen for fetal growth and fetal wellbeing

Confirmation of fetal viability and estimation of gestational
age
This is best done by the 'dating scan' and should be offered
between 10 weeks 0 days and 13 weeks + 6 days:
the crown–rump length is measured with the fetus in the
neutral position
if the crown–rump length is above 84 mm, then the head
circumference should be used
the dating scan will confirm viability, detect up to 80% of
lethal abnormalities, detect multiple pregnancies and allow
accurate assessment of chorionicity
it ensures consistency of gestational age measurements and
reduces the need for induction of labour at 41 weeks of
gestation
it can be incorporated into the combined screening test for
Down syndrome between 11 weeks and 13 weeks 6 days.3/21/20 ELBOHOTY 105

Screening for chromosomal abnormali6es-
All women should be offered screening for Down’s, Edwards`
and Patau`s syndromes
Currently, the recommendations are to provide the 'combined
test' (nuchal translucency, beta-human chorionic
gonadotrophin, pregnancy-associated plasma protein-A)
between 11 weeks 0 days and 13 weeks 6 days.
For women who book later in pregnancy, the most clinically
and cost-effective serum screening test (quadruple test)
should be offered between 15 weeks 0 days and 20 weeks 0
days
If the probability of the woman to have a baby with Down
syndrome > 1/150 offer her a diagnostic test3/21/20 ELBOHOTY 106

Down’s, Edwards` and Patau`s syndromes
• All pregnant women in England should be offered a screening test for
Down`s (1 :1000), Edwards` (3 :10000) and Patau`s (2:10000)
syndromes that meets agreed national standards
• The recommended screening strategy in the first trimester for Down`s,
Edwards` and Patau`s syndromes is the `Combined test`
• Optimum time for screening is when fetal crown rump length (CRL) is
between 45.0mm and 84.0mm, which equates to 11+2 and 14+1
weeks
• The recommended screening strategy for Down`s syndrome only for
women booking later in pregnancy or when it is not possible to
measure the nuchal translucency is the `Quadruple test` between 14+2
and 20+0 weeks
• The recommended screening strategy for Edwards` and Patau`s
syndromes for women booking later in pregnancy or when it is not
possible to measure the nuchal translucency is the fetal anomaly
ultrasound scan undertaken between 18+0 and 23+0 weeks

Results
• one for Down’s syndrome and another for Edwards’ and Patau’s
syndromes.
• If the screening test shows that the chance of the baby having Down’s,
Edwards’ or Patau’s syndrome is lower than 1 in 150 this is called a “lower-
chance” result. Over 95 out of 100 (95%) screening test results will be
lower chance. A lower-chance result does not mean that there is no chance
at all of the baby having Down’s, Edwards’ or Patau’s syndrome.
• If the screening test shows that the chance of the baby having Down’s,
Edwards’ or Patau’s syndrome is higher than 1 in 150 – that is from 1 in 2 to
1 in 150 – this is called a “higher-chance” result. Fewer than 1 in 20 (5%) of
screening test results will be higher chance. A higher-chance result does
not mean the baby definitely has Down’s, Edwards’ or Patau’s syndrome.

Screening for structural anomalies
•This should be oﬀered between 18 weeks 0 days and 20
weeks 6 days

Screening of fetal wellbeing during pregnancy
Each antenatal visit allows the opportunity to screen for fetal
growth and wellbeing.
The following should be performed during each antenatal visit:
•from 24 weeks – measurement of the symphysis–fundal height
•from 36 weeks – abdominal palpation for presentation
There is no evidence that the following practices have any
benefit in routine antenatal care:
•routine auscultation of the fetal heart
•routine monitoring of fetal movements (however, a woman
should contact her midwife or hospital if she notices a
reduction in fetal movements)
• The evidence does not support the routine use of antenatal
electronic fetal heart rate monitoring (cardiotocography) for fetal
assessment in women with an uncomplicated pregnancy and
therefore it should not be offered.
• The evidence does not support the routine use of ultrasound
scanning after 24 weeks of gestation and therefore it should not
be offered.3/21/20 ELBOHOTY 112

Screening
3/21/20 ELBOHOTY September 2014/March 2015

ANC
• Aims to triage the pregnancy from the booking visit and during subsequent
visists:
• High risk
• Low risk
• All women should be assessed at booking for risk factors for SGA fetus/neonate
to identify those who require increased surveillance.

3/21/20 ELBOHOTY
Serial measurement of SFH is
recommended at each antenatal
appointment from 24 weeks of
pregnancy as this improves prediction of
SGA.
SFH should be plotted on a customised
rather than a population-based chart as
this may improve prediction of SGA
neonate.
Abdominal palpation has limited accuracy for the prediction of
SGA neonate & thus should not be routinely performed for this
purpose.
For low risk pregnancies
122

Abnormal growth
• Women with single SFH which plots below the 10th centile or serial measurement
of fetal size which demonstrates slow or static growth by crossing centiles should
be referred for ultrasound measurement of fetal size.
3/21/20 ELBOHOTY
Routine fetal biometry is thus not
justified.
September 2014/March 2015

Sta@c growth

Slow growth

High risk pregnancy
• The likelihood of an adverse outcome (mortality or morbidity) in the mother
and/or the baby is greater than that in the general population

Risk factors for SGA

Vaccination
• Clinical classifications of vaccines.

A prepara@on containing an@genic material:
• Dead microorganism (salk vaccine)
• Attenuated (harmless) microorganism (sabine, MMR, ..
• Toxoid (harmless form of toxin) (DPT)
• Recombinant DNA techniques (HPV)
• Subunits

puriﬁed macromolecule vaccines
• inactivated toxins
• Bacterial toxins can be detoxified by formaldehyde treatment and used to stimulate
immunity. Examples include diphtheria toxoid and tetanus toxoid.
• conjugate vaccines
• Conjugate vaccines or carbohydrate vaccines are polysaccharides. As the glycans tend to
be poorly immunogenic, they are conjugated to a carrier protein to increase their
immunogenicity. Examples include Haemophilus influenzae vaccine, Neisseria meningitidis
vaccine and Streptococcus pneumoniae vaccine.
• subunit vaccines.
• Sub-unit vaccines – make use of the most antigenic subunit of the organism. These can be
produced by genetic engineering
• for example Dane particle from the surface antigen of hepatitis B virus (hepatitis B
vaccine).

Rational during the pregnancy
• Toxoids, inactivated virus vaccines and immune globulin preparations
are generally considered safe for administration to pregnant women
because there is neither evidence nor biological plausibility of
harmful effects on the fetus or pregnancy.
• Nevertheless, if prompt administration is not medically indicated, it
is preferable to delay administration of these agents until the second
trimester to allow for completion of the critical period of fetal
organogenesis

Vaccines specially indicated in
pregnancy
•Inactivated influenza vaccine
•Pertussis (whooping cough) vaccine
•Inactivated polio vaccine
•Diphtheria toxoid
•Tetanus toxoid

Influenza Vaccination
• Influenza vaccination in pregnancy
• Reduces maternal morbidity and mortality
• improves fetal outcomes including reduced
likelihood of perinatal death, prematurity and
low birth weight,
• prevents influenza in the infant up to 6
months of age through transfer of maternal
antibodies and potentially improves long-term
adult outcomes for the infant
• The nasal spray vaccine is live attenuated virus
and contraindicated during pregnancy, while
intramuscular vaccine is killed virus and can
be given in the first trimester.3/21/20 ELBOHOTY 138

•Pregnant women should be offered the
diphtheria, tetanus, pertussis (whooping
cough) and polio (dTaP/IPV) vaccine in weeks
28–38 of their pregnancy (ideally in weeks 28–
32), for each pregnancy.
•The pertussis vaccine can be given at the same
time as the influenza vaccine but pertussis
vaccination should not be given early in order
to offer the vaccines at the same time as this
will compromise the passive protection to the
infant.3/21/20 ELBOHOTY 139

whooping cough
•Women will now be offered the whooping cough
vaccine by their GP or maternity services from their
20th week of pregnancy (almost at 28 weeks).
•Pregnant women who receive the whooping cough
vaccination produce antibodies to whooping cough
which are passed through the placenta to their
baby.
•The baby then has good protection against
whooping cough when it is born.
•This protection will wear off and babies should
receive their routine whooping cough vaccine from
8 weeks of age3/21/20 ELBOHOTY 140

Pertussis, Diphteria, Tetanus, Poliomyelitis
• In the UK, Repevax (diphtheria, tetanus, acellular pertussis/
inactivated polio vaccine [DTap]) was the recommended
vaccine for this programme.
• Although the optimal timing for the DTaP vaccine
administration is between 28 weeks and 32 weeks of
gestation, this can be given at any time during the pregnancy.
• In July 2014 Repevax was replaced by Boostrix IPV – the 4 in 1
vaccine containing diphtheria toxoid, tetanus toxoid, acellular
pertussis and inactivated polio vaccine

Vaccines recommended in pregnancy in certain
situa?ons
• _ Hepatitis A vaccine
• _ Hepatitis B vaccine
• _ Meningococcus vaccine
• _ Pneumococcal vaccine
• _ Rabies vaccine
• _ Typhoid vaccine
• _ Yellow fever vaccine

Hepatitis A
•Formalin inactivated Hepatitis A is recommended if another
high risk condition or indication is present.
•High-risk factors for Hepatitis A23 include:
• long-term liver disease
• haemophilia
• intravenous illegal drugs
• working with or near sewage
• working in institutions where levels of personal hygiene
may be poor
• working with primates (monkeys, apes, chimps and
gorillas)

Hepatitis B
• Hepatitis B infection in pregnancy may result in severe hepatic disease
for the mother and chronic infection for the baby. Hence, if a pregnant
woman is in a high-risk category, Hepatitis B vaccination should not be
withheld.25 As this is an inactivated subunit vaccine, the risks to the
unborn baby are negligible.26
• Women considered to be at risk of Hepatitis B27 and would therefore
benefit from vaccination28 are:
• women who inject drugs or have a partner who injects drugs
• women with multiple sexual partners
• women who are close family and sexual partners of a
• patient with Hepatitis B
• women who receive regular blood transfusions or blood products
• women with liver disease or chronic kidney disease
• women travelling to high risk countries
• female sex workers
• women who work in settings that place them at risk of contact with
body fluids, such as nurses, doctors, dentists and lab staff.

Meningococcal vaccine
• There is no evidence that either vaccine, the conjugated or the quadrivalent
vaccine, is unsafe.
• The usual advice is to avoid vaccinaAon unless the mother is at high risk of
disease.
• Women considered to be at high risk of meningococcal disease are those:
• with funcional and anatomical asplenia
• with immunosuppression
• with complement deﬁciency
• who travel to high-risk endemic areas
• who have contact with infected individuals
• who are university students under the age of 25 years.
• The vaccines are safe to give to women who are breasseeding. The two available
vaccines are Meningococcal Group C conjugated vaccine (MenC) and
quadrivalent (ACW135Y) polysaccharide vaccine.
• The UK Department of Health recommends that the conjugated vaccine be used
in preference to the polysaccharide vaccine because it provides beter and longer
lasAng protecAon.

Pneumococcal conjugated vaccine
•The use of the pneumococcal conjugated
vaccine is limited among women of child
bearing age.
•Ideally the vaccine should be given prior
to conception but the indication for
administration (patients with functional or
anatomical asplenia, sickle cell disease,
splenectomy or patients with HIV) are not
altered by pregnancy.

Typhoid
•Pregnant women should be advised to
avoid travel to typhoid endemic areas but
may be immunised with the inactive
parenteral vaccine if such exposure is
unavoidable

Rabies
•Rabies is virtually always fatal.
•Given the potentially disastrous consequences of
inadequately managed rabies exposure to both mother and
baby and the fact that it is an inactivated viral vaccine,
pregnancy is not considered a contraindication to
postexposure prophylaxis.
•Pre-exposure prophylaxis against rabies may be justified
during pregnancy, where the risk of exposure to rabies is
substantial.

Yellow fever
•Yellow fever is associated with a high case fatality
rate.
•If travel is unavoidable and the risk of yellow fever is
high, immunization with live attenuated viral vaccine
may be considered after discussion with an
infectious disease specialist.
•Pregnancy is a precaution for yellow fever vaccine
administration, compared with other live vaccines
which are contraindicated in pregnancy.

Vaccines contraindicated in pregnancy
• BCG vaccine
• Measles vaccine
• Mumps vaccine
• Rubella vaccine
• Varicella vaccine
• Vaccinia vaccine
• Human papillomavirus vaccine
The risk–benefit ratio of administering live vaccines to
pregnant women should be weighed individually for each
patient in consultation with an infectious disease expert.

Before the pregnanacy
•MMR vaccine – women should be counselled to avoid
becoming pregnant for 28 days after vaccination.
•Varicella vaccine – Varicella vaccination prepregnancy or
postpartum is an option that should be considered for
women who are found to be seronegative for VZV IgG. It is a
live attenuated vaccine administered in two separate doses
4–8 weeks apart.
•If a woman of reproductive age is vaccinated, she should be
advised to avoid pregnancy for 1 month after each dose and
to avoid contact with other susceptible pregnant women
should a postvaccination rash occur.

Folic
acid
Booking inv.
Hb & Ab
Combined test
+ Early scan Physical exam.
&
Screening
Anomaly scan
3/21/20ELBOHOTY
15
6

Considerations for delivery
• Age > 40 years
• the small-for-gestaAonal-age fetus
• placenta praevia
• breech presentaAon
• pregnancy aner 41 weeks of gestaAon and women who decline inducAon of
labour
• birth aner caesarean
•

Pregnancy after 41 weeks
• Prior to formal induction of labour, women should be offered a vaginal
examination for membrane sweeping.
• Women with uncomplicated pregnancies should be offered induction of labour
beyond 41 weeks.
• From 42 weeks, women who decline induction of labour should be offered
increased antenatal monitoring consisting of at least twice-weekly
cardiotocography and ultrasound estimation of maximum amniotic pool depth.

Age > 40 years
•Maternal age 40 years of older
constitutes a moderate risk factor for the
development of pre-eclampsia.

The risk of antepartum stillbirth at term
• The overall cumulative risk of antepartum stillbirth throughout gestation (from
20 to 41 completed weeks) for women of all ages is 6.5 per 1000 pregnancies.
• The cumulative risks of stillbirth for women younger than 35 years, 35 to 39
years and older than 40 years old, were 6.2, 7.9, and 12.8, respectively.

• In presence of another moderate risk factor for PE give low dose aspirin from 12
weeks gestation
• Maternal age 40 years or older should be offered serial ultra- sounds for growth
and umbilical artery Doppler from 26 to 28 weeks.
• Consideration should be given to offering women of advanced maternal age
induction of labour from 39 weeks’ gestation (it decreses SB with no increase in
CS rate).

Placenta praevia
In approximately 1.5% of women the placenta will cover the cervical os at the 20
week scan. At delivery, 0.14% will have a placenta praevia.
Current recommendations
If the placenta extends over the internal os at the routine 20 week anomaly scan,
you should offer a transabdominal scan at 32 weeks of gestation. (Transvaginal
scanning may give clearer images, especially for the posterior placenta).
Women who have had a previous caesarean section must have placental
localisation in their current pregnancy in order to exclude placenta praevia. If
placenta praevia is present, investigations for praevia accreta may be
appropriate.

Breech presentation
Approximately 3% of singleton pregnancies are breech at term. This percentage
increases with decreasing gestational age.
Where it is not possible to schedule an appointment for external cephalic version
at 37 weeks, it should be scheduled at 36 weeks.
• Women undergoing ECV who are D negative should undergo testing for
fetomaternal haemorrhage and be offered anti-D

3/21/20 elbohoty
Time of elec*ve deliveryIndication
> 41uncomplicated pregnancies
Around 40 weeksMaternal age > 40 years
< 40 weeks + 6 daysGestational DM
37-38 weeks + 6 daysDM
> 37Twins dichorionic
> 36Twins monochorionic
> 35 csTriplets
32-34 csTwins (monoamniontic)
34+0 and 36+6monochorionic twin pregnancies complicated by TTTS
> 34 except……Severe PET
37Mild PET
> 37PPROM
> 37Cholestasis with BA >40
36-37 CSPlacenta previa (Asymptomatic)
34-36weeks +6 CSPlacenta previa with vaginal bleeding
35- 36 weeks + 6 CSPlacenta previa accreta(Asymptomatic)
37Fetal anaemia reciving IUT
between 34 & 36 weeks CSConfirmed vasa praevia

Newborn Blood Spot Screening
• The blood spot is taken on day 5 and in exceptional circumstances between day 5
and 8. The day of birth is counted as day 0
• The Programme screens for: sickle cell disease (SCD), cystic fibrosis (CF),
congenital hypothyroidism (CHT) and six inherited metabolic diseases (IMDs):
phenylketonuria (PKU), medium-chain acyl-CoA dehydrogenase deficiency
(MCADD), maple syrup urine disease (MSUD), isovaleric acidaemia (IVA), glutaric
aciduria type 1 (GA1) and homocystinuria (pyridoxine unresponsive) (HCU)
• Good quality spots and all the fields on the card filled in are essential to avoid
repeats
• Screening is recommended but parents can decline screening for SCD, CF and
CHT individually but the six IMDs can only be declined as a group
• Babies found to be affected are referred for appropriate timely care
• Parents receive all results by six weeks

Newborn Hearing
• 1 to 2 in 1000 babies in the UK are born with a permanent hearing loss or
deafness in one or both ears
• Around 1 in 100 babies who have spent at least 48 hours in a special care baby
unit, or a neonatal intensive care unit, have a hearing loss in one or both ears
• 90% of babies with a hearing loss are born to families with no history of deafness
• Early identification is very important for speech, language and social
development
• All babies born in England should be offered a hearing screen at 0-5 weeks of age
• Babies referred from the programme should be seen for a full audiological
assessment within 4 weeks of screen completion
• GPs should be notified of screen referrals by letter

Newborn and Infant Physical Examination
• Screening is offered in the newborn and infant periods : the first by 72 hours of
age, the second at 6-8 weeks
• Screening of eyes, heart, hips, and testes
• Examinations are performed by appropriately trained healthcare professionals

Antenatal care

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