ANC تفريغ

Antenatal Care
(ANC)
Ghada Al Yousif; MBBS, SBFM, ABFM, PDFFM, MPH
Assistant Professor
Women’s Health , Family & Community Medicine Consultant
Department of Family and Community Medicine
College of Medicine, Imam Abdulrahman Bin Faisal University
gfalyousif@iau.edu.sa
15:43
Definition of Antenatal care

Comprehensive health supervision of a pregnant
woman before delivery
Or it is planned examination, observation and

guidance given to the pregnant woman from
conception till the time of labor.
AAFP
Presentation Title
Year 5 Revised Curriculum (2017-2018): Family Medicine Rotation Saturday, March 21, 2020
15:43
Whey ?
§ To reduce maternal and perinatal mortality and
morbidity rates
§ To improve the physical and mental health of

women and children
Presentation Title
15:43
Importance of Antenatal Care

§ To ensure that the pregnant woman and her
fetus are in the best possible health.
§ To detect early and treat properly

complications
§ Offering education for parenthood
§ To prepare the woman for labor, lactation and

care of her infant Prepare her psychologically for
labor, massaging the nipple for
lactation, and educating her
about the misconception of
taking care of a baby
Presentation Title
15:43
What ?
§ Care from a skilled attendant and continuity of care
- Pre- natal care that is provided by a small team; is coordinated; and follows an evidence-based, informed
process results in fewer prenatal admissions, improved prenatal education, and greater satisfaction with care.
AAFP
§ Preparation for birth and potential complications
§ Promoting health and preventing disease During the 1st 3 months: Folic acid
The shift to Iron, Calcium.. etc
– Tetanus toxoid, nutritional supplementation, tobacco and alcohol use, etc
§ Detection of existing diseases and treatment

– HIV, syphilis, tuberculosis, other co-existing medical diseases (e.g., hypertension, diabetes)
§ Early detection and management of complications

- Preeclampsia, gestational Diabetes
Presentation Title
15:43
Chan FY Study , AAFP

Shared antenatal care between Family Health
Services and Hospital(Consultant) Services for
Low Risk Women:
§ Decrease in workload to hospital clinics
§ Diagnosis of IUGR, malpresentation, pregnancy
induced hypertension àimproved
§ Number of NST, hospital admission, duration of
stay -àreduced
Presentation Title
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When ?
The first visit or initial visit should be made as
early in the pregnancy as possible.
Return Visits:
§ Once every month till 28 w. 1st and 2nd Trimester
§ Once every 2 weeks till the 36 w

§ Once every week, till labor.
§ Although women in developed countries often have seven to 12 prenatal visits, a multi- national trial showed
that decreasing the visits to a minimum of four did not increase adverse outcomes, although it slightly
decreased patient satisfaction with care . AAFP
Which is very imprortant to build a strong doctor-patient relationship based on trust
Presentation Title
15:43
Assessment
History Examination Investigation
Presentation Title
15:43
Diagnosis of Pregnancy
§ Clinical Diagnosis
– Signs & Symptoms of early Pregnancy
Symptoms that make you suspect pregnancy:
- missed period
§ Investigations - Fatigue
- Nausea Vomiting (unlikely in the very beginning tho) and abdominal pain
-Morning sickness
- Breast enlargement and pain
- increased sleep
- dizziness
- Urinary symptoms similar to UTI ( increased frequency) due to sudden
hormonal changes
- PMS symptoms but more severe ( becomes a drama queen)
Presentation Title
15:43
Presumptive Signs of Pregnancy

Symptoms
§ Cessation of menstruation / Amenorrhea
• Nausea and vomiting – Changes in appetite
• Fatigue
• Urinary frequency
• Breast enlargement and tenderness
§ Mood Changes Emotionally unstable
Presentation Title
Will be further explained
in the clinical teaching 15:43
lecture
Presentation Title
15:43
Pregnancy Tests Blood test reveals before than urine test
§ Urine Pregnancy Test (12 to 14 days) After Ovulation
§ Blood Pregnancy Test (11 days )

§ For B –HCG (human chorionic gonadotropin)
§ American Pregnancy Association
Presentation Title
FYI 15:43
False positive urinary pregnancy

§ Proteinuria test
§ Pelvic tuberculosis
§ Drugs stimulating LH release from pituitary as
penicillin and phenothiazine's
§ Immunologic diseases as systemic lupus
erythematosisbecause Ig M interacts with test
reagents
§ Perimenopausal women with high LH
§ Excessively alkaline urine
§ HCG producing tumors as choriocarcinoma
§ Hematuria as hemoglobin is a protein
Presentation Title
FYI
DD
§ Early Pregnancy § Late Pregnancy
– Causes of – Pelviabdominal
amenorrhea swelling
– Causes of – Pseudocyesis
symmetrical
enlargement of the
uterus
• myomas,
• hematometra,
• adenomyosis,
• extrauterine mass.
The Initial Visit 15:43
§ Medical history Mainly chronic diseases

§ Menstrual history Menstrual Hx:
- First day of Last menstrual period (LMP) to
calculate the gestational age
§ Physical exam - Regular/ Irregular
- age of menarche
§ Investigations - amount
- OCP use
– Diagnostic tests
– Screening Tests
§ Assess risk factors and building up a strategy
for the antenatal care
§ Health Education
Presentation Title
15:43
Important Demographic Data

§ Age High risk of complications if the patient is above 35 (Down syndrome) , or below 17
(prematurity, C-section, Preeclampsia)
§ Occupation Such as Radiologist and exposure to radiation

Studies show that high educated women take more care of themselves and
§ Education the baby than uneducated ones (study could be biased :)
§ Residence living in Jubail leads to possible exposure to toxic materials that could affect
the fetus
§ Ethnicity
§ Race Beliefs that could harm her or her embryo
§ Religion
§ Pets Toxoplasmosis
Presentation Title
Will be further explained in
clinical teaching, but 04:38
familiarize yourself with it
Last menstrual period

Expected day
of delivery 1st day of LMP
Presentation Title
Year 5 Revised Curriculum (2020-2021): Family Medicine Rotation Sunday, December 6, 2020
15:43
Medical and Family History

Includes Both husband and wife
§ Information to obtain
– Prior or current health issues
– Medications and allergies
– Possible inherited diseases in the families
– Significant health issues in family members
– Use of tobacco, alcohol, drugs
Presentation Title
15:43
Menstrual History
§ What is the concept of ‘Reliable Dates’ ?
Presentation Title
15:43
Expected Date of Delivery

§ Duration of pregnancy
– 280 days or 40 weeks
§ Naegele’s rule
– Add seven days to the first day of the LMP
and subtract three months [or add 9 months]
LMP +7 days +9 months (or -3 month)
Jan, Feb, and March: (+9)
rest of the months: (-3)
Presentation Title
15:43
Example :
§ Using Naegele’s rule calculate the EED
(Expected Date of Delivery) if the LMP was
20 September 2017:
§ 27 May 2018
§ 20 July 2018
§ 20 April 2018
§ 27 Jun 2018
Presentation Title
15:43
Trimester 1 month of pregnancy = 4.5-5 weeks
1 wk. -13th week +6 days 14th -28th week

+6 days
29th -40th week
7th day of week 14
Presentation Title
15:43
PE Very important to detect gestational hypertension, preeclampsia,
§ Vital signs… most important …complication ?

Vital signs:
§ Wt. &Ht … complication ? - Heart rate
- blood pressure
- Temperature
§ AN examination - Respiratory rate ( normally
increased during pregnancy)
- Urine Dipstick: detect protein
- Palpate for position and glucose
-S-F HIGHT (FH)

Further Explained
in clinical teaching
- FHR Fetal Heart rate
§ specific examination
Presentation Title
Further Explained 15:43
Other indicators of gestational age

§ FHT with Doppler at 10–12 weeks
§ Fetal movement felt at about 20 weeks
§ Fundal height correlation with gestational age
§ Ultrasound : Dating U/S is a first trimester US
– Gestational sac
– CRL accuracy of ±5–7 days
– BPD
– FL
– HC
– AC
– HL
– EFW
Presentation Title
15:43
Very important statement
§ Ultrasound measurement of the embryo or fetus in

the first trimester (up to and including 13 6/7 weeks
of gestation) is the most accurate method to
establish or confirm gestational age.
§ ACOG
Presentation Title
15:43
Further Explained
Presentation Title
15:43
Further Explained in clinical teaching
Why 38 is above 40? To prepare for delivery

‫ﯾﻨﺰل راس اﻟﺒﯿﺒﻲ ﺑﺎﻟﺤﻮض‬
(Engagement)
+ - 3 is acceptable ( will be further explained later
no worries)
20th week: umbilical
12th week landmark: on the symphysis pubis
Presentation Title
Further Explained in clinical teaching 15:43
Measurement Symphysis 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 in cms)
Presentation Title
Further Explained in clinical teaching
§ Causes of oversized § Causes of undersized

uterus (larger than period uterus (smaller than period
of amenorrhea): of amenorrhea):
– Wrong dates. – Wrong dates
– Polyhydramnios.
– Oligohydramnios
– Hydatidiform mole.
– Macrosomic fetus. – Fetal death
– Concealed accidental – IUGR or Small fetus
hemorrhage. – Pregnancy during period of
– Twins. amenorrhea as lactation or
– Tumors as fibroids and ovarian
injectable contraception
cysts.
– Fetal malformations as – Malpresentations as
hydrocephalus. transverse lie
Laboratory Analysis and Testing
First visit
§ Blood Work First visit
– Blood type and Rh status
– Antibody screen • Other Testing
(Coombs’ test)
– CBC – Ultrasound
abnormal result (IgG positive)
– Rubella titer means the patient is immunized. If – UA/UC
– Hepatitis B itimmunized
is normal, she needs to be
after delivery (MMR is Rh incompatibility:
If the mother is negative and the father is positive, The fetus could be
– Syphilis contraindicated during pregnancy).
Patient should abstain from getting
positive, and thus the body will form antibodies against the D-antigen during
delivery, which will complicate the next pregnancies
– Sickle cell pregnant during the 1st month of Prevention:
– FBS vaccination. Anti-D ( Rhogam) injection in week 28, and during the first 72 hrs post
delivery.
You can order HbA1C in early pregnancy if Exceptional cases where you give the injection early regardless of the week:
you suspect diabetes, but usually fasting - abortion
blood glucose is enough - bleeding
- trauma
- ectopic pregnancy
-amniocentesis
- secretions
15:43
FYI
Presentation Title
http://
Year 5 Revised Curriculum (2017-2018): Family Medicine www.aafp.org/test/fpcomp/FP-E_382/pt1-s1.html#t1
Rotation Saturday, March 21, 2020
15:43
FYI
Presentation Title
Further explained in
clinical teaching
15:43
Presentation Title
15:43
Medication Must be given. Actual needed dose is 400 microgram but prescribed as 1mg.
In special situations such as family Hx of neural tube defect, Folic acid deficiency,
uncontrolled diabetes, anti-seizure medications and other medication that increase the folic acid
§ Folic Acid demand —> 4mg is the needed dose but given as 5mg
Stop medication after 1st trimester
§ Calcium To all patient in the 2nd trimester (14th week) Instructions for the patient:
- do not take the calcium and iron together, should be a
4 hrs difference between them
§ Iron If anemic, start in the 1st trimester along with the folic
acid. If not anemic, start in the 2nd trimester along with - do not take iron with milk nor caffeine for 1 hr
the calcium
- take the iron with vitamin c
§ B6 Navidoxine: B6 + Antihistamine. Used to relief
symptoms of nausea and vomiting, safe during
- increase fiber intake and water intake to prevent
pregnancy. Should be taken before bed to prevent the
sedating side effects of antihistamine constipation
§ ASA But do not give unless needed. Try alternative medicine - do not take the pill on an empty stomach to prevent
first such as ginger 1-2 cups a day. Acupuncture could gastritis
Aspirin in also relief symptoms
case of
- tell the patient the the stool may turn black
preeclampsia Peak of Nausea and vomiting: week 7-8
§ The evedence ??
Presentation Title
Gravidity and Parity 15:43
§ G +P +A A: abortion
§ Gravida–number of pregnancies
§ Para–number of births after 20 weeks
– Five-digit system FYI
• G–total number of pregnancies
• T–full-term pregnancies (37–40 weeks)
• Preterm deliveries (20–36 weeks)
• A–abortions and miscarriages (before
20weeks)
• L–living children
Presentation Title
15:43
Management of common symptoms of

pregnancy
§ Nausea and vomiting in early pregnancy
§ Heartburn Divide meals instead of 3 heavy meals
into 5-6 light meals
§ Constipation Normacol, not recommended during the 1st trimester

Increase water and fiber intake
§ Haemorrhoids Avoid it by avoiding constipation
§ Varicose veins Wear compressing socks
Normal vaginal discharge during pregnancy due to increased progesterone

§ Vaginal discharge level:
Whitish, liquid, not cheesy appearance, no itchiness. it is normal to plug the
cervix to prevent vaginal infection from transmitting to the fetus
§ Backache Due to increased pressure on the uterus which changes the position
of the uterus posteriorly pressuring the back, may present with
sciatica like pain.
If persistent after delivery: chiropractor 👩⚕
Presentation Title
15:43
Other important testing points :

§ Goal
§ prevent dome complications of Pregnancy
Presentation Title
Pre-eclampsia 15:43
§ Blood pressure measurement and urinalysis for protein should be

carried out at each antenatal visit to screen for pre-eclampsia.
§ Risk factors for pre-eclampsia should be determined:
• age 40 years or older
• nulliparity
• pregnancy interval of more than 10 years
• family history of pre-eclampsia
• previous history of pre-eclampsia
• body mass index 30 kg/m2 or above
• pre-existing vascular disease such as hypertension
• pre-existing renal disease
• multiple pregnancy.
Presentation Title
04:38
Presentation Title
Recommendation 04:38
Prevention
The American College of Obstetricians and Gynecologists (ACOG) and the

Society for Maternal–Fetal Medicine make the following recommendations:
§ Low-dose aspirin (81 mg/day) prophylaxis is recommended in women at high
risk of preeclampsia and should be initiated between 12 weeks and 28 weeks of
gestation (optimally before 16 weeks) and continued daily until delivery.
Not recommended in the 1st month due risk of bleeding and abortion
§ Low-dose aspirin prophylaxis should be considered for women with more than
one of several moderate risk factors for preeclampsia.
§ Low-dose aspirin prophylaxis is not recommended solely for the indication of
prior unexplained stillbirth, in the absence of risk factors for preeclampsia.
§ Low-dose aspirin prophylaxis is not recommended for prevention of fetal growth
restriction, in the absence of risk factors for preeclampsia.
§ Low-dose aspirin prophylaxis is not recommended for the prevention of
spontaneous preterm birth, in the absence of risk factors for preeclampsia.
§ Low-dose aspirin prophylaxis is not recommended for the prevention of early
pregnancy loss.
Presentation Title
15:43
Gestational Diabetes
Gestational diabetes: diabetes after week
20. if diabetes occurs before week 20, then
this is DM-2
• ACOG, in collaboration with the USPSTF, screening for

overt diabetes early in pregnancy in those who are at risk
i.e., previous history of gestational diabetes, obesity, or
known glucose intolerance by A1C or fasting blood
glucose
• Screening in all pregnant women at 24 to 28 weeks’
gestation with a 50-g glucose load. An abnormal one-hour
test result should be followed by confermatory testing with
a three-hour glucose tolerance test.
Presentation Title
15:43
FYI
DIPSI – 2 Steps When do we perform 2 step test? In case of previous Hx of gestational

diabetes, obese, glucose intolerance, high HbA1C and fasting blood
glucose
Patient is not fasting
Presentation Title
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ACOG – 1 step
Fasting for 9 hours
92 mg/dl
180 mg/dl
153 mg/dl
Start diet and exercise
Presentation Title
15:43
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15:43
Other important testing points :

§ GROUP B STREPTOCOCCUS …35-37 wk ..
Low vaginal swap between week 35-37
WHEY? Ifsepticemia
+ve and patient is asymptomatic: give ampicillin IV during delivery because it may lead to
of the baby
§ Repeat U/A & U/C with CBC
Presentation Title
15:43
Screening for Birth Defects

§ Screening for Down Syndrome
ØFirst-trimester ultrasound screening for nuchal translucency
(NT) ,a fluid collection seen at the back of the neck, is a
predictor of Down syndrome and several other structural
anomalies, including congenital cardiac defects,
diaphragmatic hernias, and abdominal wall defects.
ØNT measurement is 77% sensitive for the detection of
Down syndrome
ØValid between 10 4/7 and 13 6/7 weeks’ gestation, but
optimal measurement is obtained at 12 to 13 weeks’
gestation.
Presentation Title
15:43
§ 2 first-trimester serum markers, free maternal

serum beta-HCG and maternal serum pregnancy-
associated plasma protein A (PAPPA).
§ These 3 tests, weighted by maternal age,

sensitivity increases to 82% to 87%
Presentation Title
15:43
§ Second-Trimester
ØTriple screening test:
§ Decreased maternal serum alpha-fetoprotein level.
§ Increased intact beta-human chorionic gonadotropin (beta-
hCG) levels.
§ Estriol LOW
§ The sensitivity for this screening test is 70% for Down
syndrome
ØThe quadruple screen adds testing for inhibin A, which is
elevated in Down syndrome pregnancies. Adding this test
increases sensitivity for Down syndrome to 81% at a 5%
false-positive rate.
Presentation Title
15:43
§ Combined first- and second-trimester screening

can increase sensitivity for Down syndrome, and
several strategies have been developed to
combine first-trimester and traditional second-
trimester quadruple screening.
Presentation Title
15:43
FYI
Presentation Title
15:43
Screening for Birth Defects

§ Cytogenetic Testing
Ø When test results suggest a high risk of aneuploidy, a cytogenetic sampling
of fetal cells through invasive genetic testing is recommended via
amniocentesis (second trimester) or CVS (first trimester).
2nd trimester
Ø Amniocentesis typically is obtained between 15 and 20 weeks’ gestation.
Ø Chorionic villous sampling typically is performed at or after 10 weeks’1st trimester
gestation through the end of the first trimester.
Ø The risk of fetal loss is higher with CVS compared with amniocentesis (1%
versus 0.5%) but may be similar when performed at centers with
experienced clinician.
Presentation Title
15:43
POSTTERM PREGNANCY ‫ اﺳﺒﻮع و ﻟﺴﺔ ﻣﺎوﻟﺪت‬٤٠ ‫ﻋﺪت‬
§ A Cochrane review of induction at 41 weeks’

gestation versus expectant management to 42
weeks’ gestation concluded that perinatal
death was less common among women
induced at 41 weeks, although it was rare in
both
§ What to do as F/U ?
Presentation Title
15:43
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15:43
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15:43
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15:43
§ https://www.acog.org/Resources-And-Publications/Committee-
Opinions/Committee-on-Obstetric-Practice/Methods-for-Estimating-the-
Due-Date
§ https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSu
mmaryFinal/asymptomatic-bacteriuria-in-adults-screening
§ https://www.nice.org.uk/guidance/cg62/chapter/1-Guidance#screening-
for-infections
§ http://www.aafp.org/test/fpcomp/FP-E_382/pt1-s2-s2.html
§ https://www.aafp.org/afp/2014/0615/p965.html
Presentation Title

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Antenatal Care

Definition of Antenatal care

Or it is planned examination, observation and

§ To improve the physical and mental health of

Importance of Antenatal Care

§ To detect early and treat properly

§ Offering education for parenthood

§ To prepare the woman for labor, lactation and

§ Preparation for birth and potential complications

– Tetanus toxoid, nutritional supplementation, tobacco and alcohol use, etc

§ Detection of existing diseases and treatment

§ Early detection and management of complications

Chan FY Study , AAFP

§ Once every 2 weeks till the 36 w

History Examination Investigation

Presumptive Signs of Pregnancy

Pregnancy Tests Blood test reveals before than urine test

§ Urine Pregnancy Test (12 to 14 days) After Ovulation

§ Blood Pregnancy Test (11 days )

False positive urinary pregnancy

§ Medical history Mainly chronic diseases

Important Demographic Data

§ Occupation Such as Radiologist and exposure to radiation

Last menstrual period

Medical and Family History

Expected Date of Delivery

Trimester 1 month of pregnancy = 4.5-5 weeks

1 wk. -13th week +6 days 14th -28th week

PE Very important to detect gestational hypertension, preeclampsia,

§ Vital signs… most important …complication ?

-S-F HIGHT (FH)

Other indicators of gestational age

Very important statement

§ Ultrasound measurement of the embryo or fetus in

Further Explained in clinical teaching

Why 38 is above 40? To prepare for delivery

20th week: umbilical

12th week landmark: on the symphysis pubis

Measurement Symphysis Fundal height

§ Causes of oversized § Causes of undersized

Stop medication after 1st trimester

Management of common symptoms of

§ Constipation Normacol, not recommended during the 1st trimester

§ Haemorrhoids Avoid it by avoiding constipation

§ Varicose veins Wear compressing socks

Normal vaginal discharge during pregnancy due to increased progesterone

Other important testing points :

§ Blood pressure measurement and urinalysis for protein should be

The American College of Obstetricians and Gynecologists (ACOG) and the

• ACOG, in collaboration with the USPSTF, screening for

DIPSI – 2 Steps When do we perform 2 step test? In case of previous Hx of gestational

Patient is not fasting

Start diet and exercise

Other important testing points :

§ Repeat U/A & U/C with CBC

Screening for Birth Defects

§ 2 first-trimester serum markers, free maternal

§ These 3 tests, weighted by maternal age,

§ Combined first- and second-trimester screening

Screening for Birth Defects

POSTTERM PREGNANCY ‫ اﺳﺒﻮع و ﻟﺴﺔ ﻣﺎوﻟﺪت‬٤٠ ‫ﻋﺪت‬

§ A Cochrane review of induction at 41 weeks’

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