ANTENATAL CARE

DR LATIFA HABIB LASSOUED

COLLEGE OF MEDICINE, ALHASA Obstetric and Gynecology Department

OBJECTIVES
Students should recognize the relationship between good health prior to and during pregnancy and reduction in maternal and fetal morbidity/ mortality.

Dr Latifa Habib Lassoued

INTRODUCTION
Pregnancy: normal physiologic state Normal pregnancy: delivery of a single baby in good condition at term with no maternal complication ANC: systematic supervision( examination and advice) of a women during pregnancy High risk pregnancy: when the probability of an adverse outcome is greater than in the general pregnant population
Dr Latifa Habib Lassoued

INTRODUCTION(2)

ANC AIMS: Providing advice, reassurance, education, and support for the women and her family Managing the minor ailments of pregnancy

Providing a screening program to confirm that a women continues to be at low risk Preventing, detecting, and managing factors that adversely affect mother & infant health Dr Latifa Habib Lassoued

INTRODUCTION(3)

ANC OBJECTIVE To ensure a normal pregnancy with delivery of a healthy baby from a healthy mother

Dr Latifa Habib Lassoued

DEFINITIONS
Nulligravida: women who is not now & never has been pregnant Primigravida women who is pregnant for the first time Multigravida is one who has previously been pregnant
Dr Latifa Habib Lassoued

DEFINITIONS (2)

Nullipara: women who has never completed a pregnancy to the stage of viability (may or may not have aborted previously) Primipara: women who has delivered one viable child Multipara: women who has delivered two or more children
Dr Latifa Habib Lassoued

DEFINITIONS (3)

Parturient: women in labor Puerpera: women who has just given birth

Dr Latifa Habib Lassoued

PRECONCEPTION CARE
Optimal ANC: before pregnancy P.CARE: identifying conditions that could affect a future pregnancy but may be ameliorated by early intervention (HT,DM, metabolic & inherited disorders)

Couple evaluation: histories review

(reproductive, family, genetic, and medical)
Dr Latifa Habib Lassoued

PRECONCEPTION CARE(2)

Addressed elements :
Identification of preconceptional risks & history assessment Nutritional status Environmental-occupational exposure & social concerns Current medications Substances use: alcohol, tobacco, illicit drugs
Dr Latifa Habib Lassoued

PRECONCEPTION CARE(3)

Rubella status: immunize susceptible patients

Hepatitis B status: offer to immunize patients

Toxoplasmosis status Varicella status

HIV status: offer HIV testing

Dr Latifa Habib Lassoued

PRECONCEPTION CARE(4)

Genetic disorders: screening based on

1. Racial and ethnic background (ex: hemoglobinopathies) 2. Family history (ex: cystic fibrosis, fragile x)

Use of vitamins & folic acid

Dr Latifa Habib Lassoued

PRENATAL VISITS
ANC:
From the beginning of pregnancy to delivery Include

1. History taking and examination

(general & obstetrical)

2. Advices
Dr Latifa Habib Lassoued

INITIAL PRENATAL VISIT

INITIAL PRENATAL VISIT

OBJECTIVES Pregnancy diagnosis

Maternal & fetal health status assessment

High risk pregnancy screening out Subsequent management preparation
Dr Latifa Habib Lassoued

INITIAL PRENATAL VISIT

A. HISTORY TAKING General history Medical and surgical history Obstetric history Actual pregnancy B. PHYSICAL EXAMINATION
Dr Latifa Habib Lassoued

INITIAL PRENATAL VISIT

A. HISTORY TAKING
GENERAL HISTORY Maternal Age
Age <20: increased risk of 1. Premature births 2. Late prenatal care 3. Low birth weight 4. Uterine dysfunction 5. Fetal and neonatal deaths

Maternal age >35 : increased risk of 1. First trimester miscarriage 2. Genetically abnormal conceptuses 3. Medical complications: HT,DM, preeclampsia 4. Multiple gestation 5. Higher rate of cesarean section 6. Fetal morbidity and mortality Lassoued Dr Latifa Habib

INITIAL PRENATAL VISIT

A. HISTORY TAKING
GENERAL HISTORY Maternal Age Socioeconomic status Substance abuse: tobacco, drugs, alcohol, caffeine Environmental risks:
1. Noxious chemicals 2. Radiation and radioactive compounds
Dr Latifa Habib Lassoued

INITIAL PRENATAL VISIT

SURGICAL HISTORY
Pelvis surgery Pelvis traumatism

FAMILIAL HISTORY DM, HT Multiple pregnancy

Genetic disorders

Dr Latifa Habib Lassoued

INITIAL PRENATAL VISIT

MEDICAL HISTORY
1. Chronic Hypertension 2. Cardiac disease 3. Pulmonary disease 4. Renal disease 5. Diabetes 6. Thyroid disease 7. Thromboembolic disease 12. Medications 10. Infectious diseases: CMV, HSV, Toxo, Varicella, Hepa BV.. 11. Autoimmune disorders (APS) 8. Systemic lupus erythematosus

9. Genetic disorders

Dr Latifa Habib Lassoued

INITIAL PRENATAL VISIT

OBSTETRIC AND REPRODUCTIVE HISTORY

1. Review previous pregnancy 2. Complications of previous pregnancy

3. Actual pregnancy

Dr Latifa Habib Lassoued

INITIAL PRENATAL VISIT

1.

REVIEW PREVIOUS PREGNANCIES+++

1. Pregnancy number Abortion

Parity

Nulliparous

Grand Multiparous
Increased risk

preg. induced hypertension (PIH)

Placenta previa PPH -uterine atony Twins

INITIAL PRENATAL VISIT

1. REVIEW PREVIOUS PREGNANCIES (2)

Obtain history of each preg.:

Gestational age (weeks) at delivery Infant weight (macrosomia, IUGR) Used Anesthesia Mode of delivery: spontaneous/ instrumental, vaginal/ cesarean section (indication-technique)

Dr Latifa Habib Lassoued

INITIAL PRENATAL VISIT

2. COMPLICATIONS OF PREVIOUS PREGNANCIES

Ectopic preg. Recurrent preg. Loss 2nd-trimester preg. loss Preterm delivery
(preterm labor, premature rupture of membrane)

Large infant (>4000g)

Perinatal death (stillborn or neonatal)

PIH (preeclampsia and eclampsia)

Gestational DM... Habib Lassoued Dr Latifa

INITIAL PRENATAL VISIT

3. ACTUAL PREGNANCY

Diagnosis of pregnancy
1. 2. 3. 4. LMP (1st day of last menstruation period ) EDD (estimated delivery date) =LMP-3months+7 days Biologic tests USG : IUGS, sacs number, estimation of gestational age and EDD
Dr Latifa Habib Lassoued

INITIAL PRENATAL VISIT

B. PHYSICAL EXAMINATION
1. GENERAL EXAMINATION
Signs of anemia: pale complexion, fingernails, conjunctiva, oral mucosa, tongue tip, breath shortness Weight (kg) /height (cm): mother's nutritional status

Blood pressure
Chest/ heart auscultation Extremities: edema?

2. ABDOMINAL EXAMINATION

Fetal part palpation

Measure uterine height (cm)

Fetal heart tones auscultation

3. PELVIC EXAMINATION
Vaginal and cervix examination
1. Chadwick sign 2. Discharges? 3. Pap smear and cultures
(speculum)

PV: configuration and capacity of the bony pelvis= Clinical Pelvimetry

Dr Latifa Habib Lassoued

LABORATORY TESTS

ULTRASONOGRAPHY

LABORATORY TESTS
1. INITIAL SCREENING
HB, HT levels Urine analysis, culture BG, Rh type, antibody screening Rubella titers Serologic tests: Syphilis, Hepatitis B, C Cervical cytological analysis Sickle cell test( risk) Skin test (exposed) 1 h glucose tolerance test (OGTT)
Dr Latifa Habib Lassoued

2. MATERNAL SERUM FETOPROTEIN: NTD, Trisomy 21-18

3. TRIPLE SCREEN EXAMINATION

(MSAFP-hCG-Estriol)

4. 3rd trimester routine screening

HB,Ht 50 gr OGTT Antibody screening Vaginal- perineal swab (GP B streptococcus)
Dr Latifa Habib Lassoued

ULTRASOUND
1st TRIMESTER Diagnosis of pregnancy
(age, site, number, viability)

2nd TRIMESTER Fetal morphology and growth 3rd TRIMESTER Fetal morphology, growth and wellbeing
Dr Latifa Habib Lassoued

OFFICE VISITS
FREQUENCY : A "standard" schedule of antenatal visits was frequently referred to as:
every four weeks until 28 WG
then every two weeks until 36 weeks then every week until 40 weeks or delivery
Dr Latifa Habib Lassoued

Dr Latifa Habib Lassoued

MONITORING
Each visit: maternal and fetal well-being check up

MATERNAL
1. Weight gain (12-15 kg in total) 2. BP 3. Urinalysis (protein, glucose, UTIs) 4. Uterine size in accordance with dates/ ultrasound

Dr Latifa Habib Lassoued

FETAL
1. Fetal activity: movements, heart rate 2. Fetal size 3. Fetal lie, presentation, engagement

Dr Latifa Habib Lassoued

Special instructions: Danger signals

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Vaginal bleeding Swelling (face or hands) Severe headaches Blurring of vision Abdominal pain Persistent vomiting Fever Dysuria Loss of fluid from vagina Decrease of fetalLatifa Habib Lassoued (nl:10 fm/2h) movements Dr

NUTRITION
Recommended weight gain: 11.5-16 kg Energy requirement:+300 kcal/day Well-balanced and varied diet

Dr Latifa Habib Lassoued

 Adequate daily folate (0.5mg, or 5mg if high NTD risk), iron (30-60 mg), calcium (1200mg) and fluids (2-3L). Avoid foods likely to be contaminated with listeria (raw meat, raw seafood, soft cheeses) Minimizing nausea by frequent small meals rich in B group vitamins and low in spice and fat Severe caloric restriction can result in reduced fetal growth
Dr Latifa Habib Lassoued

EXERCISE
Restricted to non-contact sports after 16 WG Intensity reduction by 25%, followed by a cooldown period Core temperature < 38C and HR< 140/min
(exercise limited to 15-20 minutes)

Walking > 5 h/day increases preterm labour risk

Dr Latifa Habib Lassoued

CONCLUSION
Effective ANC
Care from a skilled attendant/ continuity care
Preparation for birth & potential complications

Promoting health & preventing disease

Detection of existing diseases and treatment Early detection & management of complications
Dr Latifa Habib Lassoued

REFERENCES
Essential Obstetrics and Gynecology. Symonds, CHURCHIL LIVINGSTONE,4th EDITION Obstetrics by ten teachers. Baker, HODDER ARNOLD,18th EDITION Obstetrics and Gynecology. LIPPINCOTT WILLIAMS & WILKINS,5th EDITION Obstetrics and Gynecology. NMS Pfeifer, LIPPINCOTT WILLIAMS & WILKINS,6th EDITION
Dr Latifa Habib Lassoued