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ANTENATAL CARE

PROF. DR. CRIU DORU IOAN

ANTENATAL CARE

PRINCIPLES AND PRACTICE OF ANTENATAL


CARE

Antenatal care has two main objectives, medical and educational.


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It is a form of predictive medicine. Beginning pregnancy in good
health will improve the chance of a healthy outcome. As well as
general measures, specific dietary action can be taken to reduce
maternal complications and the incidence of fetal abnormality, for
example good glucose control in diabetes mellitus or dietary folic
acid supplementation. The latter reduces the incidence of neural
tube defects. Regular attendance and treatment during pregnancy
help to maintain the womans health, prevent anaemia, confirm
normal progress, facilitate the diagnosis of complications of
pregnancy and prevent some of the difficulties of delivery, thus
reducing maternal and fetal mortality and morbidity.

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2. It is a form of health education. The doctor and midwife have
a duty to allay the pregnant womans fears, to instruct her in
the care of her body, to inform her about the process of birth,
the care of the newborn infant and eventually about methods
of family planning. This time can also be used to advise
women on a variety of other health matters such as diet,
smoching, alcohol or the timing of their next cervical smear.
Repeated visits offer a unique opportunity for building up a
personal relationship and feeling of confidence which are just
as valuable as any technical expertise.

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Selection of high risk women


Women who require antenatal supervision and confinement in the best
equipped hospitals include those with:
Age over 40;
Parity more than 5;
Bad obstetrics history, of stillbirths, fetal abnormality or recurrent miscarriages;
History of pre- term labour;
Major medical disorders such as cardiac disease, diabetes and severe
hypertension;
Rhesus iso- immunization;
Intrauterine fetal growth retardation;
Multiple pregnancy;
Malpresentations;
Previous caesarean section, myomectomy or hysterectomy;
Previous gynaecological operations such as repair of prolapse, stess
incontinence, fistula or third degree tear.

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Examination at the first antenatal visit

The woman should attend an experienced obstetrician as


soon as possible after pregnancy is diagnosed.
This is particularly important for the estimation of maturity
(see below).
At the first visit a careful medical and obstetric history
should be obtained and a general medical examination
should be made as well as a detailed obstetric examination.
Blood and urine tests should be carried aut.

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History
Previous serious illnesses. E. g. rheumatic fever, jaundice,
renal disease, tuberculosis.
Previous surgical operations- particularly abdominal
operations.
Family history of multiple pregnancy, fetal abnormality,
diabetes or hypertensions.
Obstetric history, with details of date and place of birth,
maturity of pregnancy, duration of labour, mode of delivery,
birth weight and an account of any complications.
Menstrual history should pay particular attention to the date of
the last period and the date of stopping the contraceptive pill.
Social circumstances, employment and dietary habits, with
special reference to smoching, alcohol, drugs and medicines.

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General examination
Height, weight and general physical appearance.
Presence of oedema or varicose veins.
Condition of the brests.
State of the teeth.
Pulse and blood pressure.
Heart sounds and murmurs.
Any evidence of respiratory disease.

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Obstetric examination

This should be made with the woman lying comfortably and


the bladder ampty so that accurate abdominal findings can be
recorded.
The height of the fundus uteri, if papable, should be noted.
If the pregnancy is more than 20 weeks advanced, the mother
is likely to be aware of fetal movement and the fetal parts are
often palpable.
Before the 12th week the fundus uteri is not palpable
abdominally.
It was formerly the practice to perform an internal
examonation to assess uterine size; this is no longer
necessary if reliable ultrasound is available at the clinic as
part of the first antenatal assesment.

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Blood tests
Haemoglobin;
ABO grouping;
Rhesus grouping and antibody screen;
Syphilitic serology;
Rubella antibody titre;
Serum alphafetoprotein (AFP) and human chorionic
gonadotrophin (hCG) estimation if the pregnancy is between
15 and 20 weeks;
In susceptible patients, tests are done for thalassaemia,
sicklecell trait and haemoglobin H;
Women at high risk from hepatitis B and HIV infection should
have tests for these and the results assessed before proceeding
to the other routine blood tests.

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Urine tests

In addition to simple tests, using reagent strips, for protein,


sugar and acetone, a bacteriological examination should be
made to detect asymptomatic basteriuria.
This can easily be done by the Dipslide technique, which
allows the examination of large numbers of specimens, only
the positive culture- medium slides requiring more detailed
examination.

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Advice

On conclusion of the examination, the obstetrician should


outline to the woman the arrangement for further antenatal visits
and indicate the facilities availible to her.
She may be given a supply of iron and folic acid tablets (ususlly
a combined tablet: 150mg iron+ 300g folic acid) and may also
be instructed to take fluoride tablets to aid the nutrition of her
babys teeth.
The first antenatal visit is time- cosuming and should not be
overloaded with detail.
Women attending an antenatal clinic have a high expectation of
delivering a healthy baby after an uncomplicated pregnancy, but
many anxieteies may arise along the way. The first visit to the
antenatal clinic should allay many fears. In particular, the sight
of the baby on ultrasound scan provides strong reassurance.

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The question of tests for fetal abnormality must be handled


with great care by the doctor and midwife; clear information
should be given but there should be no attempt to put
pressure on the woman to reach a decision about these tests.
Throughout pregnancy one of the main sources of anxiety is
poor communication.
Doctors and midwives must be aware of the worries that
pregnant women have and time must be taken to answer
questions in clear language.These is no point in excluding all
kinds of pathology by elegant tests if the woman cannot
sleep for worry about her delivery.
The doctor and midwife must have a positive, reassuring
attitude. This will build up the atmosphere of mutual trust
which is the basis of succesful practice.

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Examination at subsequent antenatal visits


These visits should take place at intervals of 4 weeks until the 28th
week, then at intervals of 2 weeks until the 36th week, then weekly until
delivery.
At each visit to hospital the following observations should be made:
Blood pressure (levels above 140/90 mmHg are usualy considered
abnormal);
Urine tests for protein and sugar;
Oedeam (if present, the cause of the oedema should be elicited);
Abdominal examination should include: estimation of the fundal height
or, better, of fetal size in relation to gestational age; the presenting part
and its level above the pelvic brim, any excess or deficiency in the
amount of amniotic luid; auscultation of the fetal heart.
Fetal movement;
Haemoglobin should be estimated at 28 and 38 weeks;
Rhesus antibodies.

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Diagnosis of pregnancy and estimation of


gestational age

Diagnosis of early pregnancy

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Clinical
It is well to answer clinically two questions about every woman
who attends:
Is she pregnant?
Is the pregnancy intrauterine or extrauterine?

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The simptoms of early pregnancy (amenorrhoea, nausea, tingling of


the breast) are too well known to require detailed repetition. Often a
woman may merely have a vague feeling of pregnancy which
precedes other symptoms.
Clinical signs include:
Breast changes. Fullness and distension of superfical veins, darkening
of aerolae and turgidity of nipples, enlargement of sebaceous glands
surrounding the nipple forming Montgomerys tubercles.
Bluish discoloration of vagina;
Pulsation in the vaginal fornices;
Softening of the cervix;
Uterine enlargement. The uterus becomes soft, cystic and globular
and enlarges progressively.
Internal ballotement;
Fetal heart sounds can be heard with ordinary stethoscope from 20
weeks onwards.

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Urine tests
The presence of hCG in the urine of pregnant women has
been used since 1927 as a means of detecting pregnancy.
Modern tests are imunological. Numerous urine tesing kits
are available over the pharmacy counter. While these are
coneveint and quik, women should always see their family
doctors for further assesment and advice. Sensitive
radioimmunoassays are now available to detect and measure
the beat sub- unit of hCG in maternal serum. A positive result
may be obtained as soon as 10 days after fertilzation.
These urine tests are very sensitive. False positives may occur
due to technical errors, or in women over 40 years of age.

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Ultrasound
Ultrasound was first employed in obstetrics and gynaecology by Ian Donald of
Glasgow.
It gives more detailed information about early pregnancy than other technique.
Now many units use both transabdominal and transvaginal scanning to give the
clearest possible early pregnancy views.
A gestation sac shows up as a white ring within the uterus as early as 52 weeks
after the first day of the last period.
The fetus can be seen from 6 weeks onwards and its crown- rump length measured.
The action of the fetal heart can be shown from as early as the 7th week using
transvaginal ultrasonography.
The placenta can be identified from 10 weeks onwards.
Absence of fetal ecoes and fetal heart pulsation leads to the diagnosis of blighted
ovum. This diagnosis must only be made when there is absolutely no doubt that
the pregnancy has failed. It is recommended that there should be two scans about 1
week apart before reaching this diagnosis.
Ultrasonic examination should be done in all cases where the uterine size differs
from the expected from the dates.

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Estimation of gestational age


If a woman attends during the first 12 weeks of pregnancy and has the
clinical and ultrasonic examinations described, the gestational age of
pregnancy can be assessed with accuracy.
Many diffivult obstetric cases present for the first time late in pregnancy.
The womans recollection of her last period may be vague; she may not
remember when she first felt the baby move; the uterine size might not
correspond with the alleged dates. In a case of this kind, antenatal
monitoring tests will be valueless unless an attempt is made to assess
maturity.
Clinical estimation of fetal size offers a rough at least to about 28 weeks
but becomes increasingly inaccurate thereafter.
Ultrasound measurement;
X- ray;
Amniocentesis may be used to assess fetal lung maturity, which is related to
the amount of fetal pulmonary surfactant (lecithin) in the amniotic fluid.

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ANTENATAL FETAL MONITORING

Is afashionable concept but it is as well to ask who is to be monitored and for


what.
Selection of women for monitoring
1.
Previous history of perinatal death.
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Previous history of baby with mintal or physical retardation.
3.
Previous history of small- for- dates baby.
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Pre- eclampsia, hypertension or chronic renal disease in present pregnancy.
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Diabetes.
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Other chronic medical disorders, such as epilepsy and connective tissue diseases.
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Antepartum haemorrhage.
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Multiple pregnancy.
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Clinically small- for- dates fetus in present pregnancy.
10. Raised AFP in this pregnancy when no fetal abnormality has been noted on
detailed ultrasonography.
11. Uncertaines dates.

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Objecives of antenatal fetal monitoring
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If normal growth and development are present, to avoid
unnecessary intervention.
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To give warning of intrauterine risks to the fetus.
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To assess the ability of the fetus to survive after birth.
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To help in selecting the correct time and method of delivery,
when it is apparent that the risk of contiuing in utero exceeds
the risk of extrauterine life.
Methods of monitoring
. Some techniques were designed to detec fetal growth
retardation, others to assess featl well- being and still others
are said to do both.
. Methods of antenatal monitoring should be atraumatic and
acceptable to the woman.

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Detection of fetal growth retardation


Is an important aspect of antenatal care.
Babies that are small- for- dates are, asa a group, at increased risk of:
Perinatal death (especially intrauterine death);
Asphyxia during labour;
Neonatal hypoglicemia;
Long- term neurological and intelectual impairment.
Methods of detection
Clincal. Abdominal palpation during routine antenatal acre allows detection
of about 50% of small- for-dates fetuses. As with other techniques,
knowledge of gestational age is vital. The obstetrician should note:
1. Tape measurement of symphisis- fundal height.
2. The amount of amniotic fluid. If oligohydramnios is present, the uterus
feels tight around the baby, which is often hyperflexed.
Ultrasound.

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Assessment of fetal well- being


Featl activity. Fetal movements tends to stop 24 to 48 hours before
intrauterine death and recording of the level of fetal activity by the
mother herself has been found useful in assessing fetal well- being.
Antepartum cardiotocography, has beesn used extensively in
recent years as atest of fetal well- being, but has not made the
impact on perinatal morbidity and mortality which had been
hoped. Non- stress testing, as opposed to stress testing which
usually requires the use of oxytocin. The prinicipal usefulness of
the test is that if the trace shows normal baseline fetal heart rate
(120- 160/min), normal variability and is reactive (forur
accelerations in response to fetal movement within 20 minutes) the
fetus will almost certainly be alive 1 week later. The converse, an
abnormal trace, is more difficult to interpret as it may or may not
be associated with hipoxia. It must be interpreted within the
overall clinical context.

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The biophysical profile, use both diagnostic: ultrasound and


cardiotocography to compile picture by assessing fetal
behaviour ( breathing, general movements and tone),
amniotic fluid volume and cardiovascular response. Each of
these five components is scored from 0 to 2 to give a profile
score of up to 10.
Doppler ultrasound. There is much interest in measuring
blood flow velocities in fetal and maternal vessels, especially
in those supplying the placenta. Both feto- placental and
utero- placental circulations should be of low resistance.
Resistance may increase as an early feature of pathological
pregnancies and be identified by Doppler ultrasound study.

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FETAL ABNORMALITY AND ITS DETECTION
Although the great majority of severaly abnormal embryos are discarde by spontaneous
miscarriage during early pregnancy or mid- pregnancy, a substantial number survive.
2% of newborn babies have one or more malformation, 1% have a single gene disorder
and 1% will prove to be mentally handicapped.
Prenatal diagnosis of fetal abnormality can, depending on the individual disorder and
individual circumsatnces, be beneficial in a number of ways:
The pregnancy can be terminated if the abnormality is sufficiently severe, if the
diagnosis is made sufficiently early, and if the parents wish this.
Inappropriate caesarean section can be avoid when the fetus has a lethal abnormality
(renal agenesis).
The parents can be given forewarning of the abnormality and its possible saquelae. This
gives time to prepare for any specialist care which may be required or the possibility of
neinatal death.
Delivery can be planned to take place close to a pediatric surgical unit or some other
centre with special skills.
The existence of some abnormalities points to the likelihood of others are commonly
found in association with chromosomal abnormalities. Further investigations may be
indicated.

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The most important fetal abnormalities encountered by the


obstetrician are:
Down syndrome.
This is the most common chromosomal abnormality in the
newborn.
The risk of Down syndrome increases above the maternal age
of 35:1/380 at age 35, 1/100 at age 40, 1/25 at age 45.
If a younger mother has a baby with Down syndrome, the
recurence risk is a 1% unless there is parental translocation
when the risk of having another child with Down syndrome
increases to 10 %.
Other trisomies are encountered from time to time: trisomy 13
(Patau syndrome) and trisomy 18 (Edwards syndrome). These
are usually lethal.

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Malformations of the central nervous system.

The most common are anencephalus, spina bifida and


hydrocephalus although several other types of abnormality
may also be found.
The cause is probably multifactorial.
Recurence risks are 55 after one affected baby and 10% after
two.
It is hoped that the introduction of routine folic acid
supplementation will reduce the incidence considerably over
the next few years.

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Teratogenesis

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1. Infections

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2. Metabolic factors

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3. Radiation

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4. Drugs

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Estabilished teratogens

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Probable teratogens

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The detection of fetal abnormality

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