ANTENATAL CARE Definition: o Is the systemic medical supervision of women during pregnancy to preserve the physiological aspect of pregnancy and labour and to prevent or detect, as early as possible, all that is pathological in order to have a healthy mother and healthy baby by the end of the pregnency. Aims: o Providing education, reassurance and support to the pregnant woman and her partner. o Giving advices to the pregnant woman regarding diet and life style modification during the pregnancy. o Assessment of maternal and fetal risk factors for development of abnormalities. o Management of detected abnormalities. o Determination the time and the mode of delivery, where complications arise. How is antenatal care provided? o It is provided by mean of visits to: community midwife, general physician, or family physician, hospital specialist. Pregnancy Test - Measuring the urine β-hcgh: o β-hcgh is a peptide hormone produced by placental trophoblastic cells. o It is important to maintain corpus luteum during pregnancy. o It becomes posive in serum 9 days post-conceponal and in the urine 4 weeks (28 days) aer the LMP.
Preconceptional Councilling: 3 rd to 8 th week of gestation is a critical period of organogenesis, so early preparation is important. Past medical history is important to optimize these conditions as well as their medications before the onset of pregnancy e.g., DM, CV disease, epilepsy, renal diseases and endocrine diseases. Supplementation: o Folic Acid Supplement: Encourage diet rich in folic acid 8-12 weeks preconceponand continues for the first trimester to prevent neural tube defects e.g., spina pifida. o Iron supplementation: especially anemic. o Vitamines. Antenatal Care Visits First Visit: Within the 12 weeks of the LMP. (8 th to the 12 th weeks). History taking: o LMP. o Gestation age: from the first day of the LMP. o Estimate the date of delivery. o History of current pregnancy (any problems). o History of all previous pregnancies: (G? + P?+????) Year. Sex. Weight. Twins. Gestational age. Mode of delivery. Length of labour. Complications. o Gynaecological history. o Past medical history.
o Drug history. o Family history: Genetic diseases, congenital malformation, birth defects, multiple gestatin, o Social history: Smoking, alcohol, drug abuse, domestic violence,.. Physical Examinations: Complete physical examination from head to toe. BP. Weight and height. Pelvic examinations. Investigations: Blood work: o CBC. o Blood group. o Rh antibodies. o Screening for infection e.g., TORCH: (Toxoplasmosis, Rubella, CMV, Herpes simplex), Syphilis, HBV, HIV, o TFTs (Thyroid Function Tests). Urinalysis: o Bacteriurea and proteinurea. Pelvic exam: o Vaginal examinations for STD (e.g., culture for gonorrhea and Chlamydia). o Pap smear for cervical cancer. Subsequent Visits Number of visits: at least 10 visits for primgravida, and at least 7 visits for mugravida. Timing: - From the first visit to the 28 th week of gestaon: 1 visit every 4 weeks. - From the 28 th week to 36 th week: 1 visit every 2 weeks. - From the 36 th week to delivery: 1 visit every week.
In each visit assess: History: - Estimate GA; - History of present pregnancy: o fetal movements, Vaginal bleeding, o o Vaginal discharge, o Cramping. Physical examination: - BP. - Weight. - Symphysio-fundal height. - Leopold's maneuvers for: o Lie of the fetus. o Position of the fetus. o Presentation of the fetus.
Advices for Pregnant Mother Exercises: - Exercises in pregnancy should be encouraged since they improve cardiovascular functions. - It is essential to avoid weight bearing exercises. - Absolute Contraindications to Exercises: o Ruptured membranes. o Preterm labor. o Cervical incompetence. o Multiple gestation. o Placenta previa. o Vaginal bleeding. o Cardiovascular diseases. o Uncontrolled type I DM. o Thyroid diseases. o Past history of abortion. o Past history of preterm labor. o Anaemia. o Malnutrition. Diet: Nutrients important during pregnancy: - Folic Acid: o decreases incidence of neural tube defects. 0.4 5.0 mg/ day. - Calcium: o maintains integrity of maternal bones, skeletal development of fetus, breast milk production. 1200 1500 mg / day. - Vitamin D: o is important for calcium absorption. 200 IU/ day (5µg/ day). - Iron: o Prevents anaemia development and support increase in maternal plasma volume and support the fetal and placental tissue. o iron is the only known nutrient for which requirements during pregnancy cannot be met by diet alone. o So, it should be given as supplements. o Mild anaemia: iron tablets are enough. o Severe anaemia: both tablets and injections are given. In 1 st trimester: 0.8 mg/ day. In 2 nd trimester: 4-5 mg/day. In 3 rd trimester: > 5 mg/ day.
Travell: - is usually, not harmful per se, but stress related travel may be associated with preterm labor. Work: - mild works is not harmful. - but, strenuous work, extended hours and shift work during pregnancy may be associated with greater risk of low birth weight, prematurity, and spontaneous abortion. Smoking: - encourage to reduce or quite smoking because it causes hypoxia, IUGR (Intra-Uterine Growth Retardation), vasoconstriction. Cocaine: - IUGR, ruptured membranes, and abruption placenta due to severe vasoconstriction. Sexual Intercourse: - No problem and may continue except if there are contraindications: Risk for abortion. Risk for preterm labour. Placenta previa. - Breast stimulation may increase uterine contraction so that it is discouraged near the term to prevent preterm labour. Screening for Gestational DM - At 24 th 28 th weeks of gestaon ( the 28 th week is the best tima). - Screening tests: o 1 hour, 50g Oral Glucose Challenge Test (OGCT): The pregnant woman is given a soluon contains 50g glucose orally and the plasma glucose is measured aer 1 hour. If plasma glucose is 7.8mmol/L ( 135 mg/dl) No GestaonalDM. If plasma glucose is >7.8mmol/L (>135 mg/dl) do the diagnosc tests. - Diagnostic Tests: o Fasng Plasma Glucose FPG and 2 hours, 75 Oral Glucose Tolerance Test (OGTT): FPG 125 mg/dl (Normal). OGTT 200 mg/dl (Normal). If both tests are abnormal Gestational Diabetes is established. Starts with diet modification. If diet modification is not effective, treat her with insulin. Oral hypoglycemic agents should be avoided in pregnancy since majority of them are teratogenic. If one is normal and the other is abnormal impaired glucose tolerance in pregnancy. (only controlled by diet modification).
US in Pregnancy - An US is done in the first time she comes to see: Number of fetuses. Gestational age. If the fetus is alive or not. - 2 nd trimester: US is done to detect any fetal anomalies e.g., cardiac anomalies. - 3 rd trimester: US is optional. to see the growth of the fetus. Maternal Serum Screen - is used to detect anomalies. - 15 th to 19 th week is the best time for doing this test. - The following are measured: α-fetoprotein AFP. β-hcgh. Estriol. - AFP: Increases with neural tube defect. But, later, it was discovered that it increases with any skin disease. It decreases in Down syndrome. - β-hcgh: increases in Down syndrome. - Estriol: decreases in Down syndrome....good LUCK...