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Antenatal Care

DR. Yasir Katib


MBBS, FRCSC Perinatologest

Antenatal care (ANC) goals and strategy

Explain the components and objectives of prenatal goals Describe the frequency and aim of each prenatal visit Genetic counseling and its available tools Risks and benefits of the genetic tests

ANC Objectives
To ensure the birth of a healthy baby with minimal risk for the mother by 1. Early, accurate estimation of GA 2. Identification of the patient at risk for complications 3. Ongoing evaluation of the health status of both mother and fetus 4. Anticipation of problems and intervention, if possible, to prevent or minimize morbidity 5. Patient education and communication

ANC

Prenatal care is not a single intervention Quantity" Vs. Quality" of ANC A systematic review of observational studies and randomized trials concluded that there was no conclusive evidence that prenatal care improved birth outcomes Randomized trials have also shown that enhanced prenatal care did not result in improved outcomes compared to routine prenatal care

ANC Components
1. 2.

3.
4. 5.

6.

HISTORY PHYSICAL EXAMINATION LABORATORY TESTS DIAGNOSTIC IMIGING PATIENT EDUCATION MEDICATIONS

HISTORY

Personal and demographic information Current pregnancy history (dating) Past obstetrical history (time, place, GA, complications, sex, weight& currant status) Personal and family medical history Past surgical history Genetic history Menstrual and gynecological history Psychosocial information

Physical examination
A complete physical examination Specially Uterine size and shape Evaluation of the adenexea Baseline blood pressure, weight, and height

LABORATORY TESTS 1st visit

1. 2. 3. 4.

A standard panel of laboratory tests


(Routine) CBC Blood gp & antibodies screen HbS Ag Rubella VDRL Urine C&S Cervical PAP smear

5.
6. 7.

LABORATORY TESTS 1st visit


1. 2. 3.

In high risk population Chlamydia swab HIV TFT

LABORATORY TESTS others


1. 2. 3. 4. 5. 6.

N. gonorrhea TB Toxoplasmosis HCV BV Others HB electrophoresis, cystic fibrosis, phenylalanine level etc

Follow-up visits
Major goals (PET, malpresentation) Components 1. Wt, B/P, SPH, FH auscultation, FM, lie, presentation 2. Patients concerns 3. Education 4. Risk identifications

Presentation & lie

Follow-up visits
Uncomplicated pregnancies Every 4 weeks until 28 wks Every 2 to 3 weeks from 28 to 36 wks Weekly until delivery

Follow-up visits
Laboratory follow-up GDM screening at 24-28 wks CBC & antibodies screen GBS screening (recto-vaginal swab) at 35-37 wks

DIAGNOSTIC IMIGING
Ultrasound Minimum requirement Usefulness Limitations Others MRI

1st Trimester U/S


1. 2. 3. 4. 5.

Confirm pregnancy Viability Assess GA (Dating) Multiple gestations (chorionicity / amnionicity) Maternal pelvic anomalies
AIUM Standards and Guidelines

2nd Trimester U/S


Fetal normality: Head shape and size and internal structures (cavum pellucidum, cerebellum, ventricular size at atrium < 10 mm) Spine: longitudinal and transverse Abdominal shape and content at level of stomach Abdominal shape and content at level of kidneys and umbilicus Renal pelvis < 5 mm anteriorposterior measurement Longitudinal axis abdominalthoracic appearance (diaphragm and bladder) Thorax at level of a four-chamber cardiac view Arms: three bones and hand (not counting fingers) Legs: three bones and foot (not counting toes)

VALUE OF PRENATAL GENETIC DIAGNOSIS: Why do we do it?

Reassurance
Increases options

Antenatal fetal treatment


Preparation for outcome

Avoidance of obstetric complications


Selective termination

Maternal age-based screening


Rationale

70%
Chance of DS

10
1/200 risk of = miscarriage 1/200 chance of abnormality

30%

100

1000 15 20 25 30 35 40 45 Maternal age (yrs)

Assessment of Background Risk Maternal Age


10 1

Trisomy 21 47xxx/xxy/xyy Trisomy 18 Trisomy 13 45x

Risk %
0.1 0.01 0.001 0.0001

Triploidy 25 30 35 40 44 Years Courtesy Dr J Johnson and the Fetal Medicine Foundation

20

Assessment of Backround Risk Gestational Age


%
100

47xxx/xxy/xyy
80 60

Trisomy 21
40 20 0 10
Snijders et al 1999

45x Trisomy 18 Trisomy 13 Triploidy


14 18 25 30 35 Weeks
Courtesy Dr J Johnson and the Fetal Medicine Foundation

40

Prenatal Screening Modalities

Screening at 11-20 wks

10

12

14

16

18

20 wks

Allows adjustment of age-related risk Improved detection rate

Courtesy Dr J Johnson and the Fetal Medicine Foundation

A- Non-invasive prenatal diagnostic tests


1. 2.

3.
4.

Nuchal Screen Nuchal plus biochemistry Maternal Serum Screen Ultrasound

1-

Nuchal Translucency

the skin is deficient in elasticity. . . . . . too large for the body


Langdon Down

Observations on an ethnic classification of idiots. Clinical Lecture Reports, London Hospital 1866;3:259.

Courtesy Dr J Johnson and the Fetal Medicine Foundati

Nuchal Translucency

Gestation 11-14 wks CRL 45-84 mm

Mid-sagittal view
Image size >75%

Neutral position
Away from amnion

Maximum lucency
Calipers on-to-on
Courtesy Dr J Johnson and the Fetal Medicine Foundation

FETAL CENTRE

Fetal Nuchal Translucency


Significance of increased nuchal fluid

Chromosome abnormalities Birth defects (cardiac, d.hernia) Genetic syndromes Increased mortality (> 3.5 mm)

Courtesy Dr J Johnson and the Fetal Medicine Foundation

Pathophysiology of increased nuchal translucency


Abnormal or delayed lymphatic development
Venous congestion Cardiac failure

Altered composition of extracellular matrix


Failure of lymphatic drainage due to fetal hypokinesia Fetal anemia or hypoproteinemia Congenital infection
Courtesy Dr J Johnson and the Fetal Medicine Foundation

2-

First Trimester Biochemical Markers


PAPP-A: Pregnancy associated plasma protein A
Produced by placental trophoblast Increases in 10-14 week period Lower in DS pregnancies (0.43 MOM) Associated with 42 % DR at 5% FPR.

Free - hCg: Free subunit of human chorionic gonadotrophin.


Placental protein Decreases in T1 like total hGC Higher in DS pregnancies (1.79 MOM) Associated with 23% DR at 5% FPR
Courtesy Dr J Johnson and the Fetal Medicine Foundation

Screening at 11-14 wks


Fetal NT + Maternal age + hCG + PAPP-A at 11-14 wks Invasive Testing 5%
%

Detection Rate
100 72% 80 60% 60 40 20 0 Ag e hCG PAPP-A Age hCG PAPP-A Age NT All 89%

30%

Courtesy Dr J Johnson and the Fetal Medicine Foundation

3- Maternal Serum Screen

Three biochemical markers


BHCG AFP Estriol

Gives age adjusted risk Screens for Downs and NTD 15-20 wks

MSS

1/1

1/378

Risk = age X OR BHCG X OR uE3 X OR AFP

MSS Limitations

Sensitivity 70 % Specificity 95% ( False positive 5%)

Two reasons for a false positive: Wrong dates Twins

4- Ultrasound

Ultrasound screening 18-20 weeks

(detailed scan)

B- INVASIVE TECHNIQUES FOR EARLY PRENATAL TESTING

Chorionic Villus Sampling Amniocentesis

Amniocentisis

http://wchs.health.wa.gov.au/health/a/amnio.htm

Amniocentisis

Performed at or more 15 weeks Takes 2-3 weeks for Karyotype Pregnancy loss risk 1/200 Can get result of trisomies 13,18,21 and Turners Syndrome X0 in 48 hours with FISH (Florescent Insitu Hybridization)

Chorionic Villus Sampling


Performed at 10-14 weeks Takes 2-3 weeks for the result Pregnancy loss rate 1/100 Operator experience important Link to limb abnormalities (still controversial) Placental mosaicism up to 3%, but little effect on outcome

Post Test
A standard panel of laboratory tests (Routine) dose not include 1. Rubella 2. TFT 3. VDRL 4. Urine C&S 5. Cervical PAP smear

Post Test
First trimister scan does not include 1. Fetal morphology 2. Viability 3. Assess GA (Dating) 4. Multiple gestations (chorionicity / amnionicity) 5. Maternal pelvic anomalies

Post Test
Which of the following is not a cause for an abnormal MSS a) Downs syndrome b) IUFD c) Twins d) Wrong dates e) Congenital heart disease

Post Test
A false positive on the MSS occurs in 1/20 tests

True False

Post Test
List Two advantages of Amniocentesis over CVS

Decreased miscarriage rate Lower risk of mosaicism No association with limb reductions

Post test
Which of the following tests is the best at detecting Downs Syndrome
1. 2. 3.

MSS Nuchal Nuchal plus PAPP A and Free BHCG

Post Test
What is the miscarriage rate with amniocentesis?

0.5% 3% 5% 10%

Post Test
List one advantage of CVS over amniocentesis

Early results