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For house officers

Presented By:

Lecturer of obstetrics and gynecology
Faculty of Medicine-Cairo University

Introduction
 Pregnancy is considered a normal physiologic event, yet it can be
complicated by dangerous pathologic processes in 5-20% of cases.

 Many of these conditions & complications are:
• Preventable, or
• Predictable

 Screening, early diagnosis, and management of such conditions will help to
minimize both maternal morbidity and mortality during pregnancy, labour,
and puerperium

Antenatal Care(ANC)

 Definition:
 Antenatal care: Routine care for the healthy pregnant woman

 NICE clinical guideline 6, 2003

ANC is a program of preventive obstetrics with a main objective to
ensure a
 Safe motherhood, culminating in a
 Safe delivery, of a
 Healthy foetus.

Objectives of ANC
• Antenatal information

• Lifestyle considerations (Folic Acid)

• Screening for haematological conditions (sickle cell disease and
thalassaemias)

• Screening for fetal anomalies (congenital anomaly registers and
testing for Down’s syndrome)

• Screening for clinical conditions (gestational diabetes)

Who provides care ??!!!

GP-led models of care should be offered for women with an
uncomplicated pregnancy. Routine involvement of obstetricians in
the care of women with an uncomplicated pregnancy at scheduled
times does not appear to improve perinatal outcomes compared
with involving obstetricians when complications arise.

ANC Visits
 The Preconception visit

 The 1st ANC visit

 Return ANC visits

 The PNC visit

The Pre-Conception Visit (PCV)

Pregnancy Planning visit:

The aim to allow for pregnancy to start in optimum conditions

 Personal & family history including Consanguinity
 Presence of chronic disease in couple or family
 Health education for appropriate timing of pregnancy
 Advice regarding avoidance of harmful and teratogenic factors (drugs,
cigarette smoking and alcohol intake…)
 Absence or control of chronic medical disorders (as diabetes,
hypertension…).

Diagnosis Of Pregnancy

Signs

Pregnancy Test


Quantitative BHCG

Sensitive enough to detect very low concentrations of human chorionic gonadotrophin.

Positive results may be therefore detectable as early as 10 days after fertilisation—that

is, four days before the first missed period.


Ultrasonography
 Vaginal ultrasound can detect a sac from five weeks and
a fetal cardiac echo a week or so later

The First ANC Visit
Aim: identify important risk factors:
History:
 Menstrual: for LMP, calculate GA , and the EDD (Naegle’s formula).
 Obstetric : Previous pregnancies problems if any
 Medical : Medical disorders (HTN, DM, Cardiac, Liver, & Renal disorders
 Surgical : GYN (C.S., myomectomy), & Non GYN surgery
 Family : e.g. DM, HTN, twins, familial disorders.
General examination: Pulse, temperature and B.P., pallor…etc.

Abdominal Examination: enlarged liver or spleen, hernias,…etc

Vaginal examination: if necessary, e.g.: for suspected pelvic masses, ectopic
pregnancy …etc.

The First ANC Visit

Pregnant
Cases

High Risk
ANC
Patients

High Risk Pregnancy
 High Risk Pregnancy is a pregnancy complicated by a disease or a disorder
that may either;
 Endanger the life, or
 Affect the health, of the mother, the fetus, or the newborn.

 Identification of HRP cases;
 Thorough history
 Careful physical examination
 Performing special investigations other than routine pregnancy

 Management of HRP;
 Referred to a specialized center in maternal and fetal medicine.

Identification of HRP during ANC

A-Conditions detected during history taking:
 Age; whether young ( 18) or elderly ( 35) Primigravidas.

 Parity; whether nulliparous or grand multipara ( 4)

 Previous obstetric difficulties, fetal loss or abnormalities

 Medical disorders as; Diabetes mellitus, cardiac or renal disease


B-Conditions observed during general examination

 Extreme obesity (BMI > 35 Kg/M²)

 Short stature (less than 150 cm)

 Hypertension (>140/90)

 Cardiac or renal disease (HV disease, RHD, AV Replacement)

 Poor weight gain during pregnancy


C-Conditions observed during obstetric examination

 Pre- eclampsia (PE)

 Antepartum hemorrhage (APH)

 Multiple pregnancy

 Malpresentations, and malpositions

 Feto-pelvic disproportion


D-Conditions detected during routine investigations

 Severe anemia: Hb < 8.0 gm/dl

 Thrombocytopenia: low platelets < 150.000

 Hyperglycemia: FBS > 100 mg%, PPBS > 160 mg%.

 Glycosuria and albuminuria (>+)

 Rh negative blood typing (when husband is RH +ve)

Screening for fetal anomalies:

 Congenital anomalies:
 US for fetal anatomy survey (FAS)for detection of
 Anencephaly, hydrocephalus and NTDs
 Limb and skeletal deformities
 Cardiac and renal anomalies…etc.

 Chromosomal abnormalities: as Down's syndrome:
 1st trimester US: 11-13 wks (for NT & NB)
 Double & Triple marker screening tests (11 & 15 wks)
 Chorionic villous sampling (CVS 1st trimester)
 Amniocentesis (2nd trimester).

Screening for infections

 TORCH:
 Toxoplasmosis (TG)
 Rubella (RV)
 Cytomegalovirus (CMV)
 Herpes simplex (HSV)

 Hepatitis B (HBS)
 Hepatitis C (HCV)
 Human Immunity Virus (HIV).

The First ANC Visit

Routine laboratory tests:

 BLD GRP & Rh typing, to identify RH negative patients.
 CBC : for Hb%, WBCs, and platelets.
 RBS: fasting and 2 hrs PPBS when necessary.
 CUA: for pus cells, RBCs, albumin and sugar…etc,

 Other tests as:
• TORCH antibodies IgG and IgM,
• VDRL: for syphilis
• HBS & HCV: for hepatitis
• HIV, if necessary, especially in the first pregnancy.

Return ANC Visits

 Monthly visits : in the first 6 months
 Biweekly visits: in the 7th & 8th months
 weekly visits : in the 9th month until delivery.

For a woman who is nulliparous with an uncomplicated pregnancy, a

schedule of 10 appointments should be adequate. For a woman who

is parous with an uncomplicated pregnancy, a schedule of 7

appointments should be adequate.

Return ANC Visits

 BP measurement: To detect early GH or PE .

 Weight gain:

• Average weight gain during pregnancy is 11-16 Kg.

• Excessive weight gain many denote occult oedema, PE,

• Inadequate weight gain may reflect nutritional deficit or fetal IUGR

 L.L. Oedema: Ankle oedema is acceptable in late 2nd and 3rd trimesters.

 Fundal level: measured and recorded at each visit after 20 weeks.

 FHS: in 2nd trimester by Sonicaid Duplex instrument.

Fundal Level

12 wks: S. Pubis

20 wks: Umbilicus

28 wks: Mid umb. / sternum

36 wks: X. sternum

Return ANC Visits

 Warning symptoms:

• Vaginal Bleeding

• Regular menstrual like colicky pains

• Persistent vomiting

• Sudden escape of liquor amnii

• Severe persistent headache, blurring of vision, marked swelling of the LLs

Return ANC Visits

 Ultrasonography:

Ultrasonography in pregnancy
1st Trimester Ultrasound

Number

Dating

Site

Viablity

Nuchal translucency –
congenetal anomalies

2nd Trimester Ultrasound

Dating

Fetal anomaly scan
± 3D US

3rd Trimester Ultrasound

Fetal Weight

Fetal well being

What to write in prescription ??

Drug intake during pregnancy

Drug categories during pregnancy according to FDA
classification:

 Group A : Safe
 Group B : Risky in animal, no enough data on humans.
 Group C : Risk in human cannot be ruled out.
 Group D : Risky in human pregnancy, but benefits outweigh risks.
 Group X : Contraindicated in pregnancy, may cause adverse fetal effects.

 1st Trimester:

Folic acid 500 microgram

Folic acid 500 tab

Folicap 0.5 mg cap

Cobal F tab

 Rest of pregnancy:

Multivitamins
Calcium
Treat Accordingly
Materna - Mamyvit

Calcitron – Cal-Mag –Caldin-C -Calcimax

Ferrotron –Ferrosanol D-

Hemacaps

Instructions to the Patient

 Exercise: Mild to moderate exercise, as walking, and regular daily house
work are allowed.

 Sleep and rest: Proper night sleep (8 hrs), and adequate periods of
afternoon rest are advisable.

 Care of teeth: To avoid dental caries caused by increased acidity, and
septic foci.

 Bowel habit: Avoiding constipation; fresh vegetables and mild laxatives
if necessary.

 Clothes: Avoid tight and too heavy uncomfortable clothing

Instructions to the Patient
 Breasts:
• Daily washes as a part of body hygiene.
• Nipple massage using lubricant creams to reduce cracking.
• Retracted nipple is withdrawn by the thumb and finger using a lubricant.

 Sexual intercourse:
• Is better minimized in the 1st trimester
• It is completely restricted if there is recurrent bleeding, tendency to abortion,
preterm labour, or suspected rupture of the membranes.
 Smoking:
• Should be strictly avoided
• Excessive smoking may result in placental insufficiency, SGA babies, or PTL

 Travelling: Only comfortable travelling may be allowed. However, travelling should
be avoided in the last month and it is completely prevented in patients with a
history of bleeding, threatened abortion, habitual abortion, or premature labour.

Nutritional Requirements :

 Caloric requirements average 2300 Kcal/day.

 Protein: 80-100 gm/day, Calcium: 1-1.5 gm/day, Iron: 30-60 mg/day.

 Vitamins and minerals: Especially B, C, D, K.

 Folic acid is important for cell division and replication. In the first few
weeks, a dose of 400 ug/day has been shown to effectively reduce the risk
of neural tube defects.

 Salt restriction, is advisable in cases with marked oedema or tendency to
hypertension.

 A suitable daily diet in pregnancy should thus include: 400 ml. of milk or
its derivatives, one egg, fresh fruits and vegetables, about 120 gm of red
meat, fish or liver.

Effect of Malnutrition on Pregnancy

Effect on the mother:
 Loss of weight and anaemia.
 Decalcification of bones, caries of teeth.
 Affection of lactation.
 Lowered resistance against infection.

Effect on the foetus:
 Low birth weight infants.
 Higher incidence of rickets and anaemia, in severe cases.

Vaccination (immunization) in pregnancy

 Live attenuated vaccines are contraindicated.

 The vaccines for the following diseases may be given if needed, preferably
after the 1st trimester:

• Tetanus, poliomyelitis, rabies,
• influenza, cholera and typhoid.

 Passive immunization against hepatitis A and B may be given.

COMMON COMPLAINTS DURING PREGNANCY

 Morning sickness  Urinary symptoms
 Heart Burn  LL oedema
 Constipation  Leg cramps
 Haemorrhoids  Varicose Veins
 Headache  Backache
 Breast tenderness  Fatigue
 Breathlessness  Vaginal discharge
 Abdominal pain  Sweating and hot flushes
 Abdominal cramps

Mobile : 01001951615

Email : aymanobgyn@gmail.com

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