Anatomy and Physiology of Pregnancy

1
Anatomy and Physiology of Pregnancy
AND-2 Nursing Care of Childbearing Family

• Lectures 1
• N. Petrenko, MD, PhD

2
The Start of It All
3
In either case, the process will inevitably
involve a sperm and an egg
4
Or.for those women who get tired of waiting for
the right man
5
Pregnancy is a normal physiologic process . . .

• . . . not a disease!

6
Signs of pregnancy

• Presumptive (generally subjective)
• Probable (objective)
• Positive (diagnostic)

7
Presumptive symptoms of pregnancy (felt by
woman)

• Cessation of menses
• Nausea with or without vomiting
• Morning sickness
• Frequent urination
• Fatigue
• Breast tenderness, fullness, tingling
• Maternal perception of fetal movement
  (Quickening) 18-20w, 16 w

8
Probable signs of pregnancy (observed by
examiner)

• Changes in the size, shape, and consistency of
  the uterus (Hegar sign-softening of the cervix )
• Enlargement of the abdomen
• Changes in the cervix (Goodell sign-softening of
  the cervix )

9
Probable signs of pregnancy (observed by
examiner)

• Bluish or purplish coloration of the vaginal
  mucosa and cervix (Chadwicks sign-a dark blue to
  purplish-red congested appearance of the vaginal
  mucosa )
• Palpation of Braxton-Hicks contractions
• Outlining the fetus manually
• Endocrine tests of pregnancy

10
Positive signs of pregnancy(noted by examiner,
confirm pregnancy)

• Identification of the fetal heart beat separately
  and distinctly from that of the mother (10-12 w)
• Perception of fetal movements by the examiner
  (18-20 w)
• Visualization of pregnancy on ultrasound
• Fetal recognition on X-ray

11
Presumptive signs of pregnancy

• Increased skin pigmentation chloasma, linea
  nigra
• Appearance of striae on abdomen and breasts

12
Adaptation to pregnancy
13
Reproductive system Breast

• Uterus increase size, shape and position,
  softness of cervix, discoloration of cervical
  mucosa, leukorrhea)
• Breast tenderness, fullness, tingling
  enlargement, nipple and areola hyperpigmentation,
  Montgomerys tubercles, colostrum (16 w)

14
Cardiovascular System

• Stroke Volume ? 50
• Cardiac Output ? 30-50 (6.21.0 L/min)
• Nonpregnant is 4.3?0.9 L/min
• Elevated upward and rotated forward to the left
• More auddible splitting of S1,S2,S3 after 20w
• Heart Rate ? 15 (? 10-20 bpm) (14-20 w)
• Sinus arrhytmia, premature atrial contraction,
  premature ventricular systole

15
Cardiovascular System

• Blood Pressure
• I trim same as prepregnancy
• II trim till 20 w ? 3-5 mmHg systolic and 5-10
  mmHg diastolic
• III trim returns to the patients prepregnant
  level
• Supine hypotension

16
Hematologic Changes

• Blood Volume ? 45 (? 1450-1750 ml)
• Protects the mother from devastating hemorrhage
  at delivery
• Plasma Volume ? 45-50 (? 1200-1300 ml)
• Serves to dissipate fetal heat production
• Red Cell Mass ? 18-30 (? 250-450 ml)
• Necessary to ? O2 transport to meet fetal needs
• Based on the above, pregnancy normally results in
  a physiologic anemia
• Hgb 10-12 g/dL (nonpregnant 12-15 g/dL)
• Hct 32-40 (nonpregnant 35-47)

17
Hematologic Changes

• WBC ?
• 1st Trimester 3,000-15,000/mm3
• (mean 9500/ mm3)
• 2nd 3rd Trimesters 6,000-16,000/mm3
• (mean 10,500/ mm3)
• Labor 20,000-30,000/mm3

18
Hematologic Changes

• Fibrin ? 40 at term
• Plasma Fibrinogen (Factor I) ? 50
• Clotting time Unchanged
• Coagulation Factors V, VII, VIII, IX, X, XII all
  ?
• Coagulation Factors XI, XIII both ? slightly
• Prothrombin time Unchanged or ? slightly
• Platelets Unchanged
• Fibrinolitic activity ?

19
Respiratory System

• Respiratory rate unchanged or sligly increase
• Tidal volume ? 30-40
• Vital capacity unchanged
• Inspiratory capacity ?
• Exspiratory capacity ?
• Total lung capacity unchanged or sligly decrease
• Oxygen consumption ?15-25

20
Respiratory Changes During Pregnancy

• pH slight ? to 7.40-7.45
• Remains roughly at nonpregnant level because the
  ? PaCO2 is compensated for by ? renal excretion
  of bicarbonate (HCO3)
• Serum HCO3 ? (18-31 mEq/L)

21
Renal System

• Kidneys enlarge with a length ? of 1 cm as
  measured by intravenous pyelography
• Renal pelves urether dilate
• Renal Plasma Blood Flow
• ? 30-50 by the end of the first trimester
• GFR
• ? 30-50 by the end of the first trimester
• The ? in Renal Plasma Flow and GFR are
  responsible for decreases in the following
• Uric acid (serum) 4.5 mg/dL
• BUN (serum) 12 mg/dL
• Creatinine (serum) 0.5-0.6 mg/dL
• Creatinine Clearance 150-200 mL/min

22
GI System

• Appetite
• I trim ?
• II trim ? because ? metabolic needs
• Pica (Nonfood craving)
• Mouth
• Gums hyperemic, spongy, swollen, bleeding,
  nonspecific gingivitis, ptyalism
• Esophagus, Stomac, intestines
• Hiatal hernia (7-8 month)
• Gastric emptying become slower
• ? hypochloric acid
• Acid indigestion or hearburn (pyrosis)
• Constipation
• Hemorrhoids

23
GI System

• Gallbladder
• decreased tone
• development of stones
• Liver
• intrahepatic holestasis
• Pruritus gravidarum (severe itching) with or
  without jandice
• Abdominal discomfort
• Pelvic heaviness
• Displacement of appendix

24
Integumentary System

• Darcening of nipples, areola, axillae, vulva
• Facial melasmachloasma
• Linea Nigra
• Striae gravidarum
• Palmar erythema (Caucasian, African-American)

25
Musculoskeletal System

• Change in posture
• Waddling walk
• Back Pain
• Slight relaxation and increased mobility of the
  pelvic joints
• Diastasis recti abdominis

26
Neurological Changes

• Compression of pelvic nerves or vascular stasis
  caused by enlargement of the uterus may result in
  sensory changes in the legs.
• Dorsolumbar lordosis may cause pain because of
  traction on nerves or compression of nerve roots.
• Edema involving the peripheral nerves may result
  in carpal tunnel syndrome during the last
  trimester. The syndrome is characterized by
  paresthesia (abnormal sensation such as burning
  or tingling) and pain in the hand, radiating to
  the elbow. The sensations are caused by edema
  that compresses the median nerve beneath the
  carpal ligament of the wrist.
• Acroesthesia (numbness and tingling of the hands)
  is caused by the stoop-shouldered stance.
• Tension headache is common when anxiety or
  uncertainty complicates pregnancy. However,
  vision problems, sinusitis, or migraine may also
  be responsible for headaches.
• Light-headedness, faintness, and even syncope
  (fainting) are common during early pregnancy.
  Vasomotor instability, postural hypotension, or
  hypoglycemia may be responsible.
• Hypocalcemia may cause neuromuscular problems
  such as muscle cramps or tetany.

27
Endocrine System

• Pituitary and placental hormones.
• ? estrogen and progesterone
• suppress secretion of FSH LH
• amenorrhea After implantation, the fertilized
  ovum and the chorionic villi produce hCG, which
  maintains the corpus luteum's production of
  estrogen and progesterone until the placenta
  takes over their production (Creasy Resnik,
  1999).
• Progesterone Estrogen
• maintaining pregnancy (relaxing smooth muscles,
  decrease uterine contractility)
• Deposition of the fat in subcutaneous tissues
  over the maternal abdomen, back, and upper
  thighs.
• promote the enlargement of the genitals, uterus,
  and breasts and increases vascularity, causing
  vasodilation.
• relaxation of pelvic ligaments and joints.
• decrease secretion of hydrochloric acid and
  pepsin, which may be responsible for digestive
  upsets such as nausea.
• Prolactin ?
• Initiation of lactation however, the high levels
  of estrogen and progesterone inhibit lactation by
  blocking the binding of prolactin to breast
  tissue until after birth.
• Oxytocin ? as the fetus matures
• stimulate uterine contractions during pregnancy,
  but high levels of progesterone prevent
  contractions until near term
• stimulates the let-down or milk-ejection reflex
  after birth in response to the infant sucking at
  the mother's breast.
• Human chorionic somatomammotropin (hCS) human
  placental lactogen (hPL)
• acts as a growth hormone, and contributes to
  breast development.

28
Endocrine System

• Thyroid gland.
• ? gland activity and hormone production.
• moderate enlargement of the thyroid gland caused
  by hyperplasia of the glandular tissue and
  increased vascularity
• Thyroxine-binding globulin increases as a result
  of increased estrogen levels (20 weeks).
• Total (free and bound) thyroxine (T4) ? between 6
  and 9 weeks of gestation and plateaus at 18 weeks
  of gestation. Free T4 and free triiodothyronine
  (T3) return to nonpregnant levels after the first
  trimester. Despite these changes in hormone
  production, the pregnant woman usually does not
  develop hyperthyroidism .
• Parathyroid gland.
• slight hyperparathyroidism, a reflection of
  increased fetal requirements for calcium and
  vitamin D. The peak level of parathyroid hormone
  occurs between 15 and 35 weeks of gestation when
  the needs for growth of the fetal skeleton are
  greatest. Levels return to normal after birth.
• Pancreas.
• Maternal insulin does not cross the placenta to
  the fetus. As a result, in early pregnancy, the
  pancreas decreases its production of insulin.
• Placental hormones (hCS, estrogen, and
  progesterone).
• Adrenal glands.
• aldosterone ?, resulting in reabsorption of
  excess sodium from the renal tubules.
• Cortisol ?

29
Gravida and Para

• Gravida means a woman who has been, or currently
  is, pregnant
• Para means a woman who has given birth
• Nulligravida never been pregnant
• Primigravida pregnant for the first time
• Primipara has delivered once
• Multipara has delivered more than once

30
G T P A L

• G GRAVIDA (how many pregnancies)
• T TERM (how many term deliveries)
• P PRETERM (how many preterm deliveries)
• A ABORTIONS (how many abortions, spontaneous
  or induced)
• L LIVING how many children currently living

31
Term, Preterm, Abortion

• TERM means delivery occurring in weeks 38-42
• PRETERM means delivery occurring in weeks 20-37
• ABORTION means delivery occurring before 20 weeks
• POSTTERM means delivery occurring after week 42

32

• Duration 280 days 40 weeks 10 lunar months 9
  calendar month
• 1st Trimester 1-13 weeks
• Accepting reality of pregnancy
• 2nd Trimester 14-26 weeks
• Resolving feelings about her own mother defining
  herself as a mother
• 3rd Trimester 27-40 weeks
• Active preparation for childbirth and baby

33
Assessment of Gestational Age

• By LMP
• By physical exam
• By ultrasound

34
Nageles Rule

• Subtract 3 months from that date then add 7 days
• 1st day of LNMP (last normal menstrual period)
• Example LNMP September 10, 2006
• Expected Due Date (EDD) June 17, 2007

35
Uterine Sizing

• 6 weeks globular with softening of the isthmus,
  size of a tangerine
• 8 weeks globular, size of a baseball
• 10 weeks globular with irregularity around one
  cornua (Piskaceks sign), size of a softball
• 12 weeks globular, size of a grapefruit

36
Uterine Sizing

• Uterine enlargement
• 12 weeks At Symphysis
• 16 weeks Midway between symphysis and
  umbilicus
• 20 weeks At the umbilicus
• 36 weeks - Near xyphoid process

37
Uterine Sizing
38
Accuracy of Dating by Ultrasound
Gestational Age weeks) Ultrasound Measurements Range of Accuracy
lt 8 Sac size 10 days
8-12 CRL 7 days
12-15 CRL, BPD 14 days
15-20 BPD, HC, FL, AC 10 days
20-28 BPD, HC, FL, AC 2 weeks
gt 28 BPD, HC, FL, AC 3 weeks
39
Review of Systems 1st Trimester

• Nausea
• Vomiting
• Headaches
• Dizziness
• Cramping
• Urinary frequency

• Pain with urination
• Changes in discharge (amount, color, odor)
• Pruritis
• Bleeding

40
Review of System 2nd Trimester

• Gums bleeding
• Nose bleeding
• Constipation
• Fetal movement

• Cramping
• Bleeding
• Dysuria
• Abnormal discharge
• pruritis

41
Review of Systems 3rd Trimester

• Indigestion
• Swelling
• Leg cramps
• Fetal movement
• Difficulty sleeping

• Contractions
• Bleeding
• Calf pain
• Headaches
• Epigastric pain
• Visual changes

42
History - Menstrual

• LMP
• Sure of date?
• Normal in length flow
• Other helpful tidbits
• Date of conception
• ER sonogram

• Menarche
• Interval
• Length
• Recent birth control or lactation

43
Obstetric History

• Dates of all pregnancies (include previous
  miscarriage or termination)
• GA
• Gender, weight
• Length of labor
• Coping techniques
• Route of delivery
• Special events AP, IP, PP, Neo

44
Gynecologic History

• Last Pap
• Abnormal pap
• Gyn surgery or problems (e.g. infertility)
• Family planning methods
• Sexually transmitted infections

45
Medical/Surgical History

• Serious illnesses
• Hospitalizations
• Surgery
• Drug allergies or unusual reactions
• Meds since LMP

46
Family History

• Maternal
• Diabetes
• CAD
• Pre-eclampsia
• Preterm delivery
• Cancers (breast, ovarian, colon)
• Depression, bipolarity
• Twins
• Anesthesia reactions

• Maternal or Paternal
• Birth defects
• Mental retardation
• Bleeding disorders
• Chromosomal abnormalities (e.g. Dpwn Syndrome)

47
Vital Signs

• Elevated BP suggests the presence of
  pre-eclampsia.
• Elevated BP may be defined as a persistently
  greater than 140 systolic or 90 diastolic.
  Usually, if one is elevated, both are elevated.
• Elevated temperature suggests the possible
  presence of infection.
• Many pregnant women normally have oral
  temperatures of as much as 99. These mild
  elevations can also be an early sign of
  infection.
• While a pregnant pulse of up to 100 BPM or
  greater may be normal, rapid pulse may also
  indicate hypovolemia.

• Temperature
• Blood pressure
• Respirations
• Radial pulse

48
Additional Measurements

• Height
• Weight
• BMI (Body mass index )
• BMI Categories
• Underweight lt18.5
• Normal weight 18.5-24.9
• Overweight 25-29.9
• Obesity BMI of 30 or greater

49
The First Prenatal Visit History

• Past medical history
• Family medical history
• Gynecologic history
• Past OB history
• Exposures to infections, teratogens, genetic
  problems
• Social history
• Nutritional status

50
The First Prenatal Visit Exam

• HEENT
• Fundoscopic exam
• Teeth
• Thyroid
• Breasts
• Lungs
• Heart
• Abdomen
• Extremities

• Skin
• Lymph nodes

51
The First Prenatal Visit Pelvic Exam

• Vulva
• Vagina
• Cervix
• Uterine size
• Adnexae
• Rectum
• Labs
• Pap
• GC chlamydia

• Clinical pelvimetry
• Diagonal conjugate
• Ischial spines
• Sacrum
• Subpubic arch
• Gynecoid pelvic type?

52
Bones and Joints of the Pelvis
53
The Diagonal Conjugate

• The obstetric conjugate extends from the middle
  of the sacral promontory to the posterior
  superior margin of the pubic symphysis. This is
  the most important diameter of the pelvic inlet.
• The diagonal conjugate extends from the subpubic
  angle to the middle of the sacral promontory and
  can be measured clinically to estimate the
  obstetric conjugate.

54
The Ischial Spines

• The transverse diameter, between the ischial
  spines, is a measurement of the dimensions of the
  pelvic cavity

55
The Pelvic Outlet

• Subpubic arch
• Bituberous (transverse) diameter
• Inferior pubic rami

56
The First Prenatal Visit Labs

• ABO blood type
• D (Rh) type
• Antibody screen
• CBC
• Rubella
• VDRL or RPR
• HBsAg
• HIV (optional)
• Hemoglobin electrophoresis (as appropriate)

57
The First Prenatal Visit Counseling

• What to expect during the course of prenatal care
• Risk factors encountered
• Nutrition
• Exercise
• Work
• Sexual activity

• Travel, seat belts
• Smoking cessation
• Avoidance of drugs and alcohol
• Warning signs
• Where to go or call in case of problems
• Prenatal vitamins

58
The Return Prenatal Visit

• REVIEW THE CHART!
• Calculate the EGA
• Check the labs
• Review weight gain
• Review blood pressure
• Review results of UA

59
Leopold's Maneuvers - are used to determine the
orientation of the fetus through abdominal
palpation.

• .

• 1. Using two hands and compressing the maternal
  abdomen, a sense of fetal direction is obtained
  (vertical or transverse).

60
2. The sides of the uterus are palpated to
determine the position of the fetal back and
small parts.
61
3. The presenting part (head or butt) is palpated
above the symphysis and degree of engagement
determined
62
4. The fetal occipital prominence is determined.
63
Measuring Fundal Height
64
Auscultating Fetal Heart Tones
65
The Routine OB Visit Schedule

• Every 4 weeks until 28 weeks
• Every 2 weeks from 28 until 36 weeks
• Every week from 36 weeks until delivery
• Six weeks postpartum

66
Other Routine OB Labs

• 15-20 weeks
• 24-28 weeks
• 35-37 weeks

• Quad Screen
• Diabetes Screen
• HH
• Rhogam workup injection
• Group B strep culture

67
Pregnancy is a normal physiologic process, not a
disease . . .

• however, pregnancy tends to be UNCOMFORTABLE.
• Your challenge is to differentiate common
  discomforts of pregnancy from pathology!

68
????? ?? ?????!
69
Nausea with or without Vomiting

• Starts at 4-6 weeks, peaks at 8-12 weeks,
  resolves by 14-16 weeks
• Causes unknown may be rapidly increasing and
  high levels of estrogen, hCG, thyroxine may have
  a psychological component
• Rule out hyperemesis gravidarum

70
Nausea and vomiting in early
pregnancy

• Most cases of nausea and vomiting in pregnancy
  will resolve spontaneously within 16 to 20 weeks
  of gestation.
• Nausea and vomiting are not usually associated
  with a poor pregnancy outcome.

A
71
Nausea and vomiting in early pregnancy

• If a woman requests or would like to consider
  treatment, the following interventions appear to
  be effective in reducing symptoms
• non-pharmacological
• ginger
• P6 acupressure
• pharmacological
• antihistamines.

A
72
Ptyalism

• Excessive salivation accompanied by nausea and
  inability to swallow saliva
• Cause unknown may be related to increased
  acidity in the mouth

73
Fatigue

• Causes unknown may be related to gradual
  increase in BMR
• Rule out anemia, thyroid disease

74
Backache

• Women should be informed that exercising in
  water, massage therapy might help to ease
  backache during pregnancy.

A
75
Upper Backache

• Cause increase in size and weight of the breasts
• Relief well-fitting, supportive bra

76
Low Backache

• Cause weight of the enlarging uterus causing
  exaggerated lumbar lordosis
• Rule out pyelonephritis (CVAT)

77
Leukorrhea

• Definition a profuse, thin or thick white
  vaginal discharge consisting of white blood
  cells, vaginal epithelial cells, and bacilli
  acidic due to conversion of an increased amount
  of glycogen in vaginal epithelial cells into
  lactic acid by Doderleins bacilli
• Rule out vaginitis, STI, ruptured membranes

78
Urinary Frequency

• 1st trimester increased weight, softening of the
  isthmus, anteflexion of the uterus
• 3rd trimester pressure of the presenting part
• Rule out UTI

79
Heartburn

• Relaxation of the cardiac sphincter due to
  progesterone
• Decreased GI motility due to smooth muscle
  relaxation (progesterone)
• Lack of functional room for the stomach because
  of its displacement and compression by the
  enlarging uterus
• Rule out GI disease

80
Heartburn

• Women who present with symptoms of heartburn in
  pregnancy should be offered information regarding
  lifestyle and diet modification.
• Antacids may be offered to women whose heartburn
  remains troublesome

GPP
A
81
Constipation

• Decreased peristalsis due to relaxation of the
  smooth muscle of the large bowel under the
  influence of progesterone
• Displacement of the bowel by the enlarging uterus
• Administration of iron supplements

82
Constipation

• Women who present with constipation in pregnancy
  should be offered information regarding diet
  modification, such as bran or wheat fibre
  supplementation.

A
83
Hemorrhoids

• Relaxation of vein walls and smooth muscle of
  large bowel under influence of progesterone
• Enlarging uterus causes increased pressure,
  impeding circulation and causing congestion in
  pelvic veins
• Constipation

84
Hemorrhoids

• Women should be offered information concerning
  diet modification.
• If clinical symptoms remain troublesome, standard
  hemorrhoids creams should be considered.

GPP
85
Leg Cramps

• Cause unknown. ? inadequate calcium, ?
  Imbalance in calcium-phosphorus ratio
• Relief straighten the leg and dorsiflex the foot

86
Dependent Edema

• Cause impaired venous circulation and increased
  venous pressure in the lower extremities
• Rule out preeclampsia

87
Varicosities

• Impaired venous circulation and increased venous
  pressure in lower extremities
• Relaxation of vein walls and surrounding smooth
  muscle under the influence of progesterone
• Increased blood volume
• Familial predisposition

88
Varicose veins

• Varicose veins are a common symptom of pregnancy
  that will not cause harm and
• Compression stockings can improve the symptoms
  but will not prevent varicose veins from emerging.

A
89
Vaginal discharge

• Women should be informed that an increase in
  vaginal discharge is a common physiological
  change that occurs during pregnancy.

GPP
90
Vaginal discharge

• If vaginal discharge is associated with itching,
  soreness, offensive smell or pain on passing
  urine there may be an infective cause and
  investigation should be considered.

GPP
91
Vaginal discharge

• A 1-week course of a topical imidazole is an
  effective treatment and should be considered for
  vaginal candidiasis infections in pregnant women.

A
92
Vaginal discharge

• The effectiveness and safety of oral treatments
  for vaginal candidiasis in pregnancy is uncertain
  and these should not be offered.

GPP
93
Insomnia

• Discomfort of the enlarged uterus
• Any of the common discomforts of pregnancy
• Fetal activity
• Psychological causes

94
Round Ligament Pain

• Round ligaments attach on either side of the
  uterus just below and in front of insertion of
  fallopian tubes, cross the broad ligament in a
  fold of peritoneum, pass through the inguinal
  canal, insert in the anterior portion of the
  labia majora
• When stretched, they hurt!

95
Hyperventilation and Shortness of Breath

• Causes
• Increase in the BMR
• Pressure of the uterus on the diaphragm
• Changes in the oxygen-carbon dioxide balance
• Exertion of carrying extra weight
• Rule out asthma, pneumonia, TB, anxiety

96
Supine Hypotensive Syndrome
97

• Screening for hematological conditions

98
Anemia

• Pregnant women should be offered screening for
  anaemia.
• Screening should take place early in pregnancy
  (at the first appointment) and at 28 weeks.
• This allows enough time for treatment if anaemia
  is detected.

B
99
Anemia

• Hemoglobin levels outside the normal range for
  pregnancy (that is, 11 g/dl at first contact
  and 10.5 g/dl at 28 weeks)
  should be investigated and iron
  supplementation considered if indicated.

A
100
Blood grouping and
red cell alloantibodies

• Women should be offered testing for blood group
  and RhD status in early pregnancy.

B
101
Blood grouping and
red cell alloantibodies

• If a pregnant woman is RhD-negative, offer
  partner testing to determine whether the
  administration of anti-D prophylaxis is necessary.

B
102
Blood grouping and
red cell alloantibodies

• It is recommended that routine antenatal anti-D
  prophylaxis is offered to all non-sensitized
  pregnant women who are RhD negative.

NICE 2002
103
Blood grouping and
red cell alloantibodies

• Women should be screened for atypical red cell
  alloantibodies in early pregnancy and again at 28
  weeks regardless of their RhD status.

D
104
Blood grouping and
red cell alloantibodies

• Pregnant women with clinically significant
  atypical red cell alloantibodies should be
  offered referral to a specialist centre for
  further investigation and advice on subsequent
  antenatal management.

GPP
105
Screening for fetal anomalies
106
Screening for structural
anomalies

• Pregnant women should be offered an ultrasound
  scan to screen for
  structural anomalies, ideally between 18 and 20
  weeks gestation, by an appropriately trained
  sonographer and with equipment of an appropriate
  standard.

A
107
Screening for Downs syndrome

• Pregnant women should be offered screening for
  Downs syndrome with a test which provides the
  current standard of a detection rate above 60
  and a false-positive rate of less than 5.

B
108

• The following tests meet this standard
• from 11 to 14 weeks
• nuchal translucency (NT)
• the combined test (NT, hCG and PAPP-A)
• from 14 to 20 weeks
• the triple test (hCG, AFP and uE3)
• the quadruple test (hCG, AFP, uE3, inhibin A)

B
109
Screening for infections
110
Asymptomatic bacteriuria

• Pregnant women should be offered routine
  screening for asymptomatic bacteriuria by
  midstream urine culture early in pregnancy.
• Identification and treatment of asymptomatic
  bacteriuria reduces the risk of preterm birth.

A
111
Asymptomatic bacterial vaginosis

• Pregnant women should not be offered routine
  screening for bacterial vaginosis because the
  evidence suggests that the identification and
  treatment of asymptomatic bacterial vaginosis
  does not lower the risk for preterm birth and
  other adverse reproductive outcomes.

A
112
Chlamydia trachomatis

• Pregnant women should not be offered
  routine screening for asymptomatic chlamydia
  because there is insufficient evidence on its
  effectiveness and cost effectiveness.

C
113
Cytomegalovirus

• The available evidence does not support routine
  cytomegalovirus screening in pregnant women and
  it should not be offered.

B
114
Hepatitis B virus

• Serological screening for hepatitis B virus
  should be offered to pregnant women
• So that effective postnatal intervention can be
  offered to infected women to decrease the risk of
  mother-to-child-transmission.

A
115
Hepatitis C virus

• Pregnant women should not be offered
  routine screening for hepatitis C virus because
  there is insufficient evidence on its
  effectiveness and cost effectiveness.

C
116
HIV infection

• Pregnant women should be offered screening for
  HIV infection early in antenatal care because
  appropriate antenatal interventions can reduce
  mother-to-child transmission of HIV infection.

D
117
Rubella

• Rubella-susceptibility screening should be
  offered early in antenatal care to identify women
  at risk of contracting rubella infection and to
  enable vaccination in the postnatal period for
  the protection of future pregnancies.

B
118
Streptococcus group B

• Pregnant women should not be offered routine
  antenatal screening for group B streptococcus
  (GBS) because evidence of its clinical
  effectiveness and cost effectiveness remains
  uncertain.

C
119
Syphilis

• Screening for syphilis should be offered to all
  pregnant women at an early stage in antenatal
  care because treatment of
  syphilis is beneficial to the mother and fetus.

B
120
Toxoplasmosis

• Routine antenatal serological screening for
  toxoplasmosis should not be offered because the
  harms of screening may outweigh the potential
  benefits.

B
121
Toxoplasmosis

• Pregnant women should be informed of primary
  prevention measures to avoid toxoplasmosis
  infection, such as
• Washing hands before handling food
• Thoroughly washing all fruit and vegetables,
  before eating
• Thoroughly cooking raw meats
• Wearing gloves and thoroughly washing hands after
  handling soil and gardening
• Avoiding cat faeces in cat litter or in soil.

C