Antenatal care presentation by HMC FM residents

1. Antenatal Care: Clinical Practice
Guideline

2. Walk-In Clinic – Client Pathway

4. ANC Clinic – Client Pathway

6. Initial Risk Assessment
 History:
Personal condition:
 current pregnancy information, previous obstetric risk,
medical & surgical history, current medication, family history
of risk factors.
any complains in the current pregnancy.
Examination:
Vital signs and the BMI results, Perform systematic
examination.
“Clients with more than ten (>10) weeks of gestational age
calculates BMI by using pre-pregnancy weight”.

7. Initial Risk Assessment
Review screening test results.
CBC: Hb, WBC, Platelets level.
Urine analysis (Routine & Microscpic) & urine culture.
Blood grouping/ Rh identification.
FBS or RBS
Screening for syphilis (RPR test).
Hepatitis B & C serology.
Rubella IgG.
HIV test.
Ultrasonography (U/S)

8. Management
• according to the findings from clinical assessment
and lab investigation results.
• Prescribe Routine Supplement. (folic acid)
• Issue Pregnancy Care notebook and document
information

9. Follow-UP
 No risk factor
Primigravida:
- 1st & 2nd trimester every 4 weeks
- 3rd trimester  every 2 weeks
Multigravida: follow at specific gestational ages up to 34
wk according to the following schedule:
 Booking (6-10 weeks),
 11-14 weeks gestation,
 22-24 weeks gestation,
 28 weeks gestation,
 30-32 weeks gestation
 34weeks gestation.
 High risk factor:
 Close follow up may needed based to client risk and according to
available management guideline.

10. Referral
 No risk: referred at 34 wks gestation to WH.
 High risk: early referral to WH

11. Regular Follow up
 Review risk & previous management.
 Review screening test result.
 Assess Gestational age (by week).
 Do general obstetric examination as per gestational age.
 Check Fetal heart sounds and movement (present or not).
 Assess position of the fetus (Longitudinal, oblique, transverse) and
presenting part; cephalic or breach (mainly in 3rd trimester).
 Risk grading and manage accordingly.
 Request for standard screening tests according to gestation age.
 Health counseling & education. In addition to give relevant educational
material.
 Prescribe routine Supplement: folic acid, iron & vitamin D tablet (after 12
weeks gestation).
 Maintain complete record (clinical form & notebook).

12. Late Enrolment
If pregnant women attend initial visit and she is ≥ 34 weeks:
-Determine the reason of late antenatal care.
- Assess the pregnancy risk factors, Ask about any complain.
- Request for ANC standard screening tests.
- Request for U/S & glucose 75 gm.
- Check vital signs & BMI results.
 Refer to ANC clinic by giving nearest appointment within 1 week to be
seen by a physician.
 At first ANC clinic: the physician should check the result, do obstetric
examination, check fetal heart, and document all information at antenatal
care clinical form & notebook then refer to nearest obstetric Hospital
either secondary or tertiary Hospital based on client risks .

13. Screening tests during antenatal care visit

14. screening tests during antenatal care visit

15. Case 1
24 year-old Aisha , G2 P1, at 15 weeks gestation
is found on routine prenatal CBC to have:
hemoglobin9.0, hematocrit 26.3, MCV 75, RDW
18..
What is your Management?

16. Anemia
HGB screening is requested at:
Booking visit & at 28 weeks.
If patient is on 2nd or 3rd trimester and she
cannot tolerate oral iron supplement and Hb
level is ≤ 8  refer urgently to obstetric
Hospital for IV ferosac and continue antenatal
care follow up at PHC Center.

17. Anemia

20. If Hb <11 g/dL, MCV, MCH are normal (normochromic,
normocytic anemia)
 Check Ferritin level:
 Ferritin level is <20 mcg/L treat as iron
deficiency anemia + manage according to above
guideline.
 Ferritin level is >20 mcg/L  refer to
hematologist & continue ANC at PHCC.

21. If Hb <11 g/dL, MCV, MCH are high (macrocytic,
hyperchromic anemia)
 Check B12 & folate.
Refers to hematology department and
continue ANC at primary health care center.
High Risk to B12 Deficiency anemia:
Patient With chronic illness.
Family history of B12 deficiency.
Previous history of blood transfusion.
K/C of anemia.
Vegetarians.

22. Counseling
 iron rich food and factors inhibiting and promoting Iron absorption.
 should be taken on an empty stomach, 1 hr before meals, with a
source of vitamin C (ascorbic acid) such as orange juice to maximize
absorption.
 Avoid taking it with some medication as it reduces iron absorption
for example: Antacids, PPI , bile acid sequestrates (cholestyramine
& colestipol).
 Most iron preparations inhibit the absorption of some medications
such as; tetracycline, sulphonamides
.

23.  S.E: Epigastric discomfort, nausea, diarrhea, or
constipation may appear with a daily dose of 60 mg or
more supplement should be taken with meals.
 Stools may turn black, which is not harmful
Treatment should continue.
 Maintenance dose:
If hemoglobin level becomes normal  maintenance
dose of iron which is 65 mg /day.

24. Refer to WH
Emergency

25. No Resolution

27. Obesity in pregnancy
(BMI) > = 30 kg/m2 at the first antenatal visit
using current weight if < 10 weeks gestation and
pre-pregnancy weight if > 10 weeks gestation

28. Recommended Weight Gain:

29. Management
Preconception Care:
 Counseling:
-Inform about risk of obesity during pregnancy and child
birth.
-Advice on weight loss and lifestyle modification before
getting pregnant.
- Consider healthy diet.
Supplement:
-o If BMI ≥30 kg/m² Give folate supplement 5 mg daily,
starting one month before conception and continue
during 1st trimester.

30. Management
Antenatal Care:
 Measure weight, height and BMI (using current weight if <
10 weeks gestation and pre-pregnancy weight If > 10 weeks
gestation) at booking visit.
 Counseling:
- Counsel about the recommended weight gain during pregnancy
based on her calculated BMI.
- Advice in healthy eating, appropriate exercise
- risk of obesity during pregnancy and child birth and
counsel about signs of thromboembolism.
- dietitian referrale
-risks of long term obesity, possible of developing HTN&
DM.

31. Prescription:
 BMI ≥30 kg/m²  Prescribe folic acid 5 mg once daily.
 If BMI ≥40 kg/m²; Prescribe oral aspirin (enteric
coated) 75-100 mg once daily.
 Maintenance dose of Vitamin D supplement 1,000 IU
orally on daily basis after 12 weeks of gestational age.
Referral:
 If BMI ≥40 kg/m²; regularly refer to obstetric Hospital
for antenatal follow-up, if client > 34 weeks of
gestational age refer urgently

32. Thyroid disease
 Hypothyroidism:
Subclinical Hypothyroidism
 Hyperthyroidism:
Gestational Hyperthyroidism & Hyperemesis
Gravidarum
Graves’ Disease

33. Screening
ONLY for high risk for thyroid dysfunction:
-Personal history of thyroid dysfunction and/or thyroid surgery.
-Family history
-Age > 30 years.
-BMI ≥ 40 kg/m2.
-Positive Thyroid Peroxidase Antibodies (TPO Ab).
- Clinical signs and symptoms or the presence of goiter.
- her autoimmune disease such as: DM1, vitiligo, adrenal
insufficiency, hypoparathyroidism, .
- History of miscarriage or preterm delivery.
- Case of infertility.
- Received radiation to the head or neck area as a cancer treatment.
- Use of amiodarone or lithium, or recent administration of iodinated
radiologic contrast.
- Residing in an area of known moderate to severe iodine insufficiency.

34. Hypothyroidism
K/C of Hypothyroidism (Overt Hypothyroidism)
Management:
 Preconception: adjust the dose to reach a TSH level not higher than
2.5 μU/L prior to pregnancy.
 Newly pregnant: increase the dose by 25% -30%.
 Postpartum: Preconception dose.
Follow-up:
 Antenatal: Check TFT every 4-6 weeks.
 Postnatal: Check TFT at 6-8 weeks postpartum.

35. Hypothyroidism
Newly diagnosed hypothyroidism during pregnancy:
Diagnosis:
 TSH1 (>2.5 μU/L) + low FT4 concentration.
 TSH >10.0 μU/L irrespective to FT4level.
Management:
 start with low dose & observe the response to treatment, if the patient
responding very well, continue with the same dose. If not, you can
gradually increase the medication dose.
 Start treatment to adjust TSH level not higher than the normal value
which is based on pregnancy trimester.
Follow up :
 Postnatal: Check TFT at 6-8 weeks postpartum.
Dose:
- TSH < 10 μU/L a 1 mcg/kg/day.
- TSH > 10 μU/L  1.6
mcg/kg/day.
Max f 200 mcg/day.

36. Subclinical Hypothyroidism:
Diagnosis:
 TSH (2.5- 10 mIU/L) with a normal FT4 level.
Management:
 Check thyroid peroxidase (TPO) antibodies:
 If Positive, start treatment to adjust TSH level not higher the normal
value based on trimester.
 If Negative: treatment based on physician/patient decision. If the
decision was for no treatment then continue monitor TFT level.
Follow up:
 Check TFTS in 4-6 wks.

37. Euthyroid with Thyroid Antibodies(Tab) Positive
Euthyroid woman with thyroid autoimmunity (not receiving L-thyroxin) who is
Tab positive is at risk for developing for hypothyroidism. Close monitoring of
TSH level is necessary.
Follow up: Check TFT every 4-6 weeks.
Treatment:
o Therapy should be started once TSH level rise above trimester specific
status.
Counseling:
Medication should be taken in empty stomach. Ideally 30 minute to one
hour before breakfast.
Note: “Empty stomach means 3-4hrs after meal”.
Certain drugs e.g.: cholestyramine, ferrous sulfate, calcium carbonate &
antacid, may interfere with L-thyroxine absorption from the gut. L-thyroxine

38. Hyperthyroidism
Gestational Hyperthyroidism & Hyperemesis
Gravidarum:
Diagnosis:
 No prior history of thyroid disease or signs of Graves’s
disease.
 TFT: Low serum TSH and an elevated FT4.
 Limited to the first half of pregnancy
 Serum T4 return to normal by 14-18 wks gestation.
Treatment:
 Antithyroid Drugs (ATD) are not indicated.

39. Hyperthyroidism
Graves’ Disease:
Preconception:
 Counseling: reach euthyroid state before attempting pregnancy.
Antenatal care: medications are Not available at PHCC
If graves’ disease diagnosed during pregnancy:
 Diagnosed during 1st Trimester begin prophlthiouracil.
 Diagnosed during 2nd trimester  begin methimazol.
If graves’ disease diagnosed and treated prior to pregnancy:
 Currently on methimazole: switch to prophlthiouracil as soon as
pregnancy confirmed.

40. Medication dose:
 Mild hyperthyroidism start PTU 50 mg,
3times/day, or methamazole 5-10 mg/day.
 severe hyperthyrodisium  start PTU 100
mg, 3times/day, or methamazole 10-30
mg/day.
Referral:
Refer urgently to endocrine clinic at women’s
Hospital and continue ANC at women’s
Hospital.

41. Management and Referral
Considerations for Common Risk
Conditions during PregnancyActionRisk Condition
- Assess social, mental & health risk &
wellbeing.
- Provide standard antenatal care & follow-up
unless the client has Risk.
- Diet advice.
- Ensure family support.
Age < 15 years
- Do U/S at 11-14 wks. For nuchal translucency
& nasal bone.
- Counsel about amniocentesis to rule out
anomalies. If the client agreed refer to FMU
(Feto Maternal Unit) at women’ Hospital to do
the procedure.
- Do U/S at 20 wks. of gestational age for
checking detail anomalies.
Age ≥ 35 years
“advance maternal age”

42. ActionRisk Condition
Refere to WH.
- Need U/S at 10-12 wks. For nuchal translucency & nasal bone by
well trained staff.
- Detail anomaly scan in FMU (Feto Maternal Unit), if abnormality
discovered the client should be followed in tertiary care facility.
age ≥ 40 years
- Prescribe Aspirin 75-100 mg once daily.
- Prescribe folic acid 5 mg once daily.
- Regular Referral to the nearest obstetric Hospital (Secondary
Care).
Note:” If client > 34 wks of gestational age, urgently refer to the
nearest obstetric hospital
(BMI) ≥ 40 kg/m2
-Diet advice.
- Give iron + multivitamins supplement.
- Refer to dietitian at PHCC.
- Monitor fetal well-being by U/S routinely unless if abnormality
discovered its need more often or refer to hospital based on
abnormality result.
BMI < 18.5 kg/m2 or
weight (less than) < 45kg

43. ActionRisk Condition
Emergency referral to WHUnexpected Problem in Current
Pregnancy:
- Massive Polyhydramnious.
- Oligohydramnious.
- Vaginal Bleeding.
- Absent fetal heart or fetal
movement.
- Decrease fetal movement (from
24wks gestation).
- Signs of preterm labor.
Urgent Referral to FMU) depending on Trimester and type of
Hazard for detailed anomalies scans between 20 -22 weeks.
Exposed to hazardous medication or
radiation in current pregnancy
- Counsel the client about risk of abortion if keeping or
removing IUCD.
- Should not be removed in PHCC.
Note:” Would refer to emergency of the nearest obstetric
hospital (secondary care)”
Pregnancy with IUCD in situ

44. - Refer to WH
- Urgent Referral to WH if ≥ 20 wks gestation otherwise regular referral
is acceptable.
Note: “Multiple pregnancy ≥ 3 should be referred & followed in WH.”
Multiple Pregnancy
Emergency referral to WHPlatelet < 30,000
irrespective to gestational
age
- Request for U/S if available in your HC;
If normal, continue antenatal care at PHCC.
If abnormality is suspected, refer to emergency (WH)
- If U/S is not available; emergency refer to the WH.
-Suspected hydatidiform
mole.
- Previous Molar Pregnancy
-< 14wks Urgent referral to FMU at WH.
- > 14 weeks refer to emergency.
Rh –ve with Positive Rh
antibodies in current
pregnancy
- Request for U/S
- Checks Beta-hCG level, Get at least 2-3 reading within 48hrs.
- If ectopic confirmed refer to emergency to nearest obstetric
Hospital.
Suspect Ectopic Pregnancy

45. ActionRisk
If chronic problem is stable:
- Regular Referral WH and continue antenatal care at the same
hospital.
K/C of Chronic Disease:
- Autoimmune/lupus.
- Congenital heart disease,
cardiomyopathy, Hx of MI.
-IBD.
-ITP.
- Kidney disease.
- Pulmonary hypertension.
- Thromboembolic
Urgent Referral to WH and continues antenatal care at the same
hospital.
- Cancer.
- Mental Disorder.
Urgent Referral to women’s Hospital (Tertiary care) and
continues antenatal care at the same hospital.
- Bleeding disorder (ex. Hemophilia)
Urgent referral to endocrine clinic and continue antenatal care at
the same Hospital.
Graves’s disease,Thyroid nodule &
previous Hx of thyroid cancer.
Urgent referral WH- Epileptic disease.
- Stop all antihypertensive medication.
- Prescribe aldoment drug; starting dose between 250 mg – 500
mg (depending on patient condition).
- Prescribe 75 -100 mg of aspirin daily and stop at 32 weeks of
gestational age.
- Give calcium supplement 1000 mg/ day.
- Refer urgently to WH.
K/C of Chronic Hypertension:
Women who have high BP ≥140/90
before or early pregnancy (before 20
weeks).

46. Action to be takenRisk Factors
- Confirmed: if two (2) reading of blood pressure ≥140/90
per week in a setting position.
- Prescribe aldoment drug; starting dose between 250 mg
– 500 mg
- Give Ca supplement 1000 mg/ day.
- Refer urgently to WH if pregnant ≥ 20wks of gestational
age
Pregnancy induced hypertension:
High BP≥140/90 that develops after 20
wks in without proteinuria and goes
away after delivery
Emergency Referral to WH by ambulanceBP ≥ 140 / 90 and with symptoms of pre-
eclampsia:
- Severe headache.
- Problems with vision, such as blurring
vision or flashing.
- Severe pain just below the ribs.
- Vomiting.
- Sudden swelling of the face, hands or
feet and sudden weight gain in short
period
Urgent referral WH
Previous Obstetric Problem:
- IUFD/still birth or neonatal death.
- Fetal anomaly, congenital or genetic
disease.
- Down syndrome.

47. .
Urgent referral to FMU. abnormal 
WH.normal HC
Previous History of RH isoimmunization
(+ ve combs test) or hydrops fetalies.
Urgent referra to WHPrevious Hx of mid trimester miscarriage
( >16 wks gestation)
Regular referral to WH≥ 2 previous subsequent abortions.
Prescribe aspirin 100 mg daily from 12 wks.
- Close monitoring the fetal wellbeing by U/S at
26 & 28 wks.
- Urgent referral to WH at 28wks.
Previous Hx of IUGR:
” Term baby with weight less than 2.5 kg”
Emergency WHIUGR in Current Pregnancy:
- IUGR with Reduce Fetal Movement
URGENT referral to WH
- Only IUGR

48. - If C/S done at governmental obstetric Hospital:
Regular Referral at 32 wks
- If C/S done outside governmental Hospital such as
in private or abroad Hospital:
Regular Referral at 28 wks.
- If C/S done at early gestational age “<37wks” refer
as early as possible
Previous Cesarean Section “C/S”
Contact:
Close contact with no previous Hx of infection, refer
to emergency and continue Antenatal care at PHC.
Active Lesion:
Assess the general condition of patient to rule out
pneumonia:
- Give antipyretic.
- Give calamine lotion.
- Avoid contact with others.
- Emergency referrale to WH.
Positive Infectious Disease:
- Chicken Pox
- 1ST attack start (Acyclovir) and Urgent referral WH
- 2nd and more attack with active lesion need
urgent referral to WH
- Genitalia Herpes

49. - Check all serology of hepatitis B.
- Check result of Hepatitis C.
- Urgent Referral to a specialist in
Gastroenterology within nearest secondary
care.
- Continue antenatal care at PHC.
- Hepatitis B
Give Treatment for client & partner with urgent
referral to nearest obstetric hospital (secondary
care) for further investigation.
- Syphilis
Emergency Referral to Women’s Hospital
Patients on Teratogenic Drugs