DR. Mazin Daghestani

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Antenatal care High Risk Assessment
DR. Mazin Daghestani
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Normal pregnancy

• Definition
• Embryo
• Fetus
• Gravidity
• Parity
• Abortion
• Immature infant
• Preterm/premature infant
• Term
• Post term
• Date/Post date

• Birth rate
• Fertility rate
• Neonatal period
• I, II III
• Perinatal period
• Perinatal mortality rate
• Maternal mortality rate

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Diagnosis of pregnancy
Sign symptoms of PRESUMPTIVE /PROBABLE
manifestations

• Pregnancy test
• Biological
• Immunological
• Radioimmunoassay for HCG
• Serum vs urine

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Antenatal care is the clinical assessment of
mother and fetus during pregnancy, for the
purpose of obtaining the best possible outcome
for both the mother and the fetus

• The aims of antenatal care
• Assessment and management of maternal risk and
  symptoms
• Assessment and management of fetal risk
• Prenatal diagnosis and management of fetal
  abnormalities
• Diagnosis and management of perinatal
  complications
• Decision regarding timing and mode of delivery
• Education regarding pregnancy and childbirth

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Frequency of antenatal visits

• 12 weeks booking viability uss
• 16 weeks-blood screening (MW)
• 18 weeks-dating detailed uss
• 24 weeks-
• 28 weeks- FBS, auto ab
• 30 weeks
• 32 weeks- growth uss
• 34 weeks
• 36 weeks
• 38 weeks
• 40 weeks
• 41 weeks -

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booking visit (first visit) The aim obtain a
comprehensive history and physical
examination establish the gestational
age identify the maternal and foetal risk
factors History A FULL obstetric history
particularly LMP (last menstrual period) EDD
(estimated delivery date) Past obstetric,
gynaecological, medical and surgical
history Family history Social history ( inquire
about smoking, alcohol, drugs) Identify factors
and categories which make patient high or low
risk.
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Assessment of gestational age Nagels rule
(EDD) Subtract 3 months from the date of the
last menstrual period and add 7 days( 14 days in
Arabic months). If the cycle was longer than 28
days, the number of additional days are added to
the days used in the rule Do the opposite if the
cycle is shorter Biparietal diameter accurate
/- 3 weeks ( useful between wks 7-12) Crown rump
length accurate /- 1 week (useful between wks
7-12) Fundal height correspond to gestational
age in weeks .
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Measurement Symphyseal Fundal height

• Evidence supports either palpation or S- F
  measurement at every AN visit to monitor fetal
  growth
• measurement should start at the variable point
  (F) and continue to the fixed point (S)
• SF measurement should be recorded in a consistent
  manner (therefore cms at RWH)

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Fetal Presentation and Descent

• Check presenting part beginning around 30 weeks
• Descent of presenting part is important as term
  approaches

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Auscultation of fetal heart

• Listening to fetal heart is of no known clinical
  benefit, but may be of psychological benefit to
  mother (Consensus opinion)
• Should be offered at each visit after about 20
  weeks

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Routine BP measurement

• HT is defined when systolic BP is 140mmHg /or
  DBP is 90 mmHg or there is an incremental rise of
  30 systolic or 15 diastolic
• Automated devices ambulatory devices should not
  be used (Mercury devises seem best)

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Urinalysis by dipstick for proteinuria - evidence

• high incidence of false ve and - ve using
  dipsticks cf 24 hr urine collection
• reliable in detecting highly variable elevations
  in protein in pre-eclampsia
• Gribble et al AJOG 1995 173 214-7

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Urinalysis by dipstick forn proteinuria - evidence

• no statistical differences in rates of PAH, fetal
  distress, abruptio placentae, neonatal outcome in
  those with absent, mild or marked proteinuria by
  dipstick
• US and Canadian Guidelines recommend screening
  for pre-eclampsia by BP measurement rather than
  dipstick

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Urinalysis by dipstick for proteinuria -
guidelines

• Routine screening for proteinuria in low risk
  pregnant women not recommended IV
• assessment hypertensive pregnancies requires
  estimation of total protein in 24-hr collection
  IV
• If detect hypertension then use dipstick for
  testing proteinuria

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Routine weighing at A/N visits - evidence

• weighing at every antenatal visit routine
  practice for many years
• No conclusive evidence for weighing at each
  visit. Maternal weight not clinically useful
  screening tool for detection of IUGR, macrosomia
  or pre-eclampsia IV
• Weighing at booking or other times may be
  indicated eg anaesthetic risk assessment (done
  BIV at RWH) or maternal weight concerns

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Initial recommended tests

• FBE
• MCHC/MCV (Thal screen. Ferritin and Hb
  electrophoresis if low)
• Blood group/Ab screen
• HIV (level 1 evidence)
• Hep B
• Syphilis (ideally prior 16 weeks)
• Rubella Abs

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• Urine testing- either 2 step or MSUdipstick
• PAP if due
• Consider
• Hep C
• Ferritin
• Vit D levels - common in patients at RWH
• addit Thal screen
• dating US

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Hepatitis C screening

• Should be offered to all at increased risk
• history of injecting drugs
• partner who injected drugs
• tattoo or piercing
• been in prison
• blood t/f later positive for Hep C
• long-term dialysis or organ transplant before 7/92

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Prenatal testing

• Down screening
• Screening - early US, 15-17 week MSST, Early
  combined screening(first trimester MSST and early
  US)
• diagnostic testing - CVS, amniocentesis
• Other testing according to history eg for CF,
  Fragile X, Thalassaemia, Huntington's disease

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Prenatal screening for Downs syndrome

• All women should be offered screening
  irrespective of age III/IV
• counselling given by appropriately trained staff
  and specific to age of each woman III/IV

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Down syndrome screening

• Screening should
• include accurate dating by 1st T u/s IV
• either by 2nd T biochem, or nuchal translucency
  alone or combination III
• notify result irrespective of risk in
  understandable format II
• if increased risk should be offered further
  counselling and diagnostic testing within 72 hrs
  or ASAP IV

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Downs syndrome screening

• Quality of counselling is of primary importance,
  non-directional, if chooses screening, should be
  single-step III
• Nuchal translucency should be performed at 11-14
  weeks by trained operators and risks derived in
  conjunction with gestation and maternal age IV

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Other recommended tests

• 26 weeks (at hospital)
• Gestational diabetes screening -
• AB screen on all women
• 36 weeks
• GBS screen
• (Ab if RH -ve has been ceased)

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Screening for GDM

• In absence of high level evidence to either
  support or abandon screening reasonable to
• not offer screening
• selectively offer screening to all with risk
  factors
• offer screening to all
• if screening do so between 24-28 weeks
• RWH screen all women at 26 weeks

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Prevention of Early Onset GBS

• Swabs should be taken between 35-37 weeks III
• Intrapartum antibiotics recommended if
• lt37 weeks
• ruptured membranes gt18 before delivery
• maternal temperature ?38 C
• previous GBS colonisation, bacteruria or infant
  with GBS III

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Antenatal anti-D prophylaxis

• Prophylactic Anti-D at 28 and 34 weeks gestation
• No level I evidence
• Level II and III evidence would suggest that the
  1.5 percent immunisation rate could be reduced to
  0.1-0.2 through antenatal prophylaxis (Huchet et
  al, 1987Bowman and Pollock, 1978 Hermann et al,
  1974)
• www.health.gov.au/nhmrc/publications/pdf/wh27.pdf

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Investigation routine test Blood group and Rh
type ( if positive, appropriate
management) CBC Urine analysis- to prevent UTI
affecting pregnancy) MSU HBs Ag ( if a mother has
it, 70-90 chance of foetus getting it, 90
chance of being chronic carrier. Prevent by
treating newborn of HBs AGve mother with B
immune globulin and hep B vaccine) Rubella Syphili
s U/S Determine foetal crown rump length and
thus gestational age Identify multiple
gestation Identify gross abnormalities/ markers
of genetic disease. Cervical cytology
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2-Screening tests Anaemia Gestational DM (best
carried out between 24 and 28 weeks, observe 1
hr after 50g glucose solution. A reading of 126
mg/dl or greater is abnormal, according to the
amended WHO recommendations 1999 regarding DM,
as is HbAlc of greater than 90. In these cases
proceed to glucose tolerance test) Antibodies Tri
ple test Alpha feto protein in normal serum,
oestriol, HGG ( to detect neural tube defect
or chromosomal defect, 16-18 weeks) Hb
electrophoresis Tuberculin skin testing Urine
culture- for glucose, ketones and protein,
bacilli Cervical culture N gonorrhoea, group B
streptococci, Chlamydia trachomatis, Mycoplasma
hominis Toxoplasma antibody test HIV
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HIV Voluntary Counseling and Testing

• Voluntary HIV counseling and testing should be
  available to every pregnant woman--for public
  health reasons as well as for the benefit to the
  individual woman.
• Pre and post-test counseling is an essential part
  of managing HIV in pregnancy.

Source WHO and UNAIDS 1999.
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Benefits of Voluntary HIV Counseling and Testing

1. If the HIV test is positive, the woman can get
   early counseling and treatment
2. Allows appropriate follow-up and treatment of
   child
3. Enables a woman to make decisions regarding
   continuation of the pregnancy and future
   fertility
4. May allow the institution of anti-retroviral
   (ARV) therapy

Source WHO and UNAIDS 1999.
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Benefits of Voluntary HIV Counseling and Testing
continued

1. Provides the opportunity to implement strategies
   that attempt to prevent transmission to the child
2. Can inform partner and enable him to get
   counseling and testing
3. Women can take precautions to prevent
   transmission to partners
4. If the HIV test is negative, the woman can be
   guided in appropriate HIV prevention

Source WHO and UNAIDS 1999.
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Syphilis

• Maternal-fetal transmission may be as high as
  80.
• Incidence of adverse effects on the fetus/infant
  due to untreated maternal syphilis reported in
  some studies was
• Spontaneous abortion 20
• Perinatal death 30
• Congenital syphilis 25
• Source WHO 1991.

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Syphilis continued

• A study in Zambia found syphilis to be the single
  most common cause of fetal wastage. The adverse
  outcomes of syphilis were halved by a fairly
  incomplete program of screening and treatment.

Sources Hira et al 1990 Tinker and Koblinsky
1993.
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Syphilis continued

• Even where prevalance is relatively low (i.e., as
  in most industrialized countries) an antenatal
  syphilis screening program is a cost-effective
  intervention.
• Initiation of treatment should occur at the same
  visit as the screening.

Source Wang and Smaill 1989.
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Tuberculosis

• Infants born to women with tuberculosis (TB) have
  an increased risk of morbidity and mortality in
  the neonatal period.

Source Figueroa-Damian and Arredondo-Garcia 2001.
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Severe anemia

• Mild or moderate anemia is not correlated with
  adverse pregnancy outcomes
• Severe anemia, however, (hgb lt7 g/dL or hct lt20)
  is associated with increased preterm delivery,
  inadequate intrauterine growth, increased
  perinatal mortality and increased maternal
  mortality.

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Severe anemia continued

• Providers can screen for anemia by
• Hemoglobin (hgb) by thin film/smear
• Hematocrat (hct) test
• Hemoglobin Color Scale, or
• Clinical observation of the inferior conjunctiva
  of the eye, the nail beds and the palm. If any of
  these are pale, the woman is severely anemic.

• Other symptoms include shortness of breath and
  signs of heart failure.

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Tetanus Toxoid

• Tetanus toxoid is
• An effective, stable, cheap toxoid which has been
  available for gt 50 years and is produced in many
  developing countries.
• Effective in preventing neonatal tetanus (NNT),
  which causes approximately half a million
  deaths/year) and maternal tetanus, which is
  estimated to cause 30,000 deaths annually.

Sources Fauveau V et al 1993 Bennett JV 2000.
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Iron Deficiency

• Globally among all populations, iron deficiency
  (and its manifestation in anemia) is the single
  most prevalent nutrient deficiency condition. The
  World Health Organization (WHO) estimates put
  anemia prevalence at 52 among pregnant women.

• Source MotherCare, John Snow, Inc. 2000.

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Iron Folate Supplements

• The International Nutritional Anemia Consultative
  Group, WHO and UNICEF have endorsed the following
  guidelines
• All women should consume daily iron folate
  supplements for 6 months during pregnancy.
• Where anemia prevalence is lt40, women should
  receive supplements of 60 mg iron and 400
  micrograms of folate
• In areas where anemia prevalence is high among
  pregnant women (?40), women should continue the
  same dosage for 3 months into postpartum.

Sources Stoltzfus and Dreyfuss 1998 McDonagh
1996.
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3-Specific nutritional advice 0.4 mg Folic Acid
per day ( it prevents tube defects) 30 mg ferrous
iron 60 mg ferrous iron 2 times a day ( anaemic
patients) Supplement copper and zinc in anaemic
patients Avoid Vitamin A in huge amounts as it is
teratogenic
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Nutrition Requirements

• Good antenatal nutrition includes
• Meeting the caloric needs
• Eating foods which supply specific
  micronutrients
• Providing micronutrient supplementation

• An underweight mother increases the likelihood of
  a low birth weight (LBW) baby low iron intake
  contributes to anemia.

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Models of antenatal care

• At each visit midwives and doctors should offer
  information, consistent advice, clear
  explanations and provide opportunity to ask
  questions III/IV
• More likely to be satisfied with A/N care when
  perceive care givers are kind, supportive,
  courteous, respectful, recognise individual needs
  IV

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Complications Cannot Be Reliably Predicted

• No formula or scoring system can reliably
  distinguish those who will develop complications
  from those who will not.

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Complication Readiness is Key to Survival

• Nepal Study
• Less than 50 of families of women who died in
  pregnancy, delivery or postpartum, recognized the
  problem.
• 36 decided within 2 hours to seek care and get
  transport.
• 15 decided in 2 to 23 hours to seek care and get
  transport.
• 29 made the decision and arranged transport 1 to
  8 or more days after recognition of a
  life-threatening complication.

Source MOH, Nepal 1998.
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Complication Readiness is Key to Survival
continued

• The interval from onset to death for antepartum
  hemorrhage can be approximately 12 hours.
• The interval from onset to death for postpartum
  hemorrhage can be two hours.
• The hours required for making arrangements (which
  could have been made prior to the emergency) may
  define the line between survival and mortality.

Sources Maine 1991 MOH, Nepal 1998.
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Danger Signals

• Families of pregnant women need to know how to
  recognize the signs of complications as well as
  what to do and where to get help
• In Nepal, less than 50 of families of women who
  died recognized the problem.

Source MOH, Nepal 1998.
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• On subsequent visits
• Check
• Bp 0 urine analysis 0 weight?
• Ask for
• 0 FM 0 Maternal complaints
• Examine
• 0 abdomen/obstetric 0 listen/see FH USS if
  required
• Advice
• Treatment of complaint health education

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Obstetric Screening

Investigations
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Screening

• 1. Infections

2. Blood disorders Sickle cell
Thalassaemia
Syphilis Hepatitis H.I.V. Rubella
3. Fetal anomalies Structural e.g. N.T.D
4. Chromosomal abnormalities Downs
T18 T13
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OB Screening/Investigations

• Non Invasive
• B-HCG . Urine 14 days post ovulation, serum 7-9
  days .. doubling time..
• Alpha feto protein.
• Triple test AFP, Unconjugated oestriol
  B-HCG
• Ultra Sound scan

• Invasive
• Amniocentesis
• Chorionic villus biopsy
• Chordocentesis

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OB Screening/Investigations
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Ultra Sound Scan

• Indications of use
• pregnancy location
• viability
• fetal number
• dating
• anomaly
• placental localization, amniotic fluid
• fetal growth and wellbeing
• during invasive procedures

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OB Screening/Investigations
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Invasive Procedure
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Invasive Procedure

• Amniocentesis
• carried at 15-18 wks. Failure rate lt 1..
  Culture time 10-12 days
• For chromosomal analysis Downs etc
• Miscarriage rate 0.5-1.... Experience and USS
• Anti-D

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Invasive Procedure

• Fetal blood sampling
• Ultra sound guided. Cord insertion into the
  placenta
• Only in specialist centres
• indications
• Rh iso-immunisation
• non-immune hydrops
• Fetal infection
• Rapid karyotyping in some IUGR
• Anti-D
• Fetal loss 1.

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Invasive Procedure
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Assessment of fetal state

• Assessment of gestational age and fetal growth
• menstrual history unreliable in up to 45 of
  women
• serial fundal height measurement provides a
  guide to fetal growth
• USS crown-rump length before 14 weeks
• USS BPD serial measurement every 2 weeks for
  fetal growth. Unreliable after 28 weeks for
  dating
• USS head/abd ratio, 2 weeks serial HC AC for
  fetal growth .. IUGR AClt but initially HC .
• USS femur length, more precise guide to
  gestational age than BPD

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Fetal Well-being

• Principles
• the ideal scheme to assess FWB should
• Take account of cycles of normal fetal behavior
• detect impending harm accurately and in time to
  intervene to prevent it
• give reassurance preferably up to 7 days
• avoid causing unnecessary anxiety
• allow detection of specific causes e.g hypoxia,
  infection, malfn
• produce measurable benefits in reducing
  perinatal loss/injury
• such system is likely to involve tests which
  assess several fetal systems, CVS, NS,, RS and
  use gt1 modality

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Fetal Well-being

• Fetal Movement Count
• Fetal Heart Recording.. CTG
• Biophysical Profile BPP scoring
• Doppler studies

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Biophysical Profile

• BPP uses FHR monitor and real time USS to
  assess
• fetal breathing movement
• discrete body or limb movement
• fetal tone
• FHR
• amniotic fluid volume
• Amniotic fluid volume is most important
• Fetal breathing movement is the first to
  disappear in asphyxia
• 7 days reassurance in low risk, only 24 hours in
  high risk preg

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Clinical Indications for Doppler Studies

• most useful in assessing IUGR
• identify only the sub-group which is hypoxemic
  bec/of inadequate placental function and may be
  abnormal for up to 18 weeks before any fetal
  problem is observed
• no proven role in population screening for
  increased risk of pre-eclampsia or IUGR

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