OBSTETRICS I

Chapter one:
Normal pregnancy
 Contents
1. Normal Pregnancy
2. Physiological changes of pregnancy
3. Pregnancy Diagnosis
4. Factors Affecting Fetal Growth
5. Focused Antenatal Care
6. Antenatal Fetal Surveillance
7. HIV/AIDS and PMTCT

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 Pregnancy
Definition:
 The period from conception to birth.
 Usually lasts 40 weeks from LNMP-Delivery.

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 Pregnancy …
Lasts up to 12/14 12/14 WEEK-24/28 24/28 week-
weeks WEEKS Delivery

1st 3rd
trimester 2nd
trimester
trimester

Based on time of pregnancy termination

Before 24 weeks----------prevable
24-37 weeks -------preterm
 37-42weeks--------term
01/30/2021
After 42weeks-----------post term
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 TERMS in pregnancy
 Gravidity (G) refers to the number of times a
woman has-been pregnant.
 parity (P) refers to the number of pregnancies
that led to a birth at or beyond 20 weeks’ GA
or of an infant weighing more than 500 g.

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 Dating of Pregnancy
• The GA of a fetus is the age in weeks and days
measured from the last menstrual period
(LMP).
• Classically, the Nagele rule for calculating the
estimated date of confi nement (EDC), or
estimated date of delivery (EDD), is to subtract
3 months from the LMP and add 7 days.

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 Physiological
changes of pregnancy

 During normal pregnancy, almost every organ system

undergoes anatomical and functional changes

 The understanding of these adaptations to pregnancy remains

a major goal of obstetrics
 Many of these physiological adaptations could be perceived
as abnormal in the non pregnant woman.
For example, cardiovascular changes during pregnancy may
mimic thyrotoxicosis.
.

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  On the other hand, these same adaptations may lead to
ventricular failure if there is underlying heart disease.

physiological adaptations of normal pregnancy can be

misinterpreted as pathological and can also unmask or worsen
preexisting disease

 The normal values for several hematologic, biochemical, and

physiologic indices during pregnancy differ markedly from those in
the non pregnant range

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 CARDIAC OUTPUT

 Increased as early as the fifth week of pregnancy,

 decrease systemic vascular resistance

 increase in heart rate.

 Significantly raised Between weeks 10 and 20 .

 Reaches about 40% above non pregnant levels by 20 to 24 weeks, .
 Stroke volume increases 25–30% , reaching peak values at 12–24 weeks'
gestation
 elevations in cardiac output after 20 weeks depend critically on the rise in
heart rate.

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Maximum cardiac output
15% rise in heart rate
24% increase in stroke volume
 higher in the lateral recumbent position than supine
20 percent increase when the pregnant woman was moved from
her back onto her left side. .
 about 20% greater in twin pregnancy than for singletons as a result
of greater stroke volume (15%) and heart rate (3.5%) .
 increases in labor in association with painful contractions
 increased transiently at delivery
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 Blood Volume
 increases markedly during pregnancy.
 averaged about 40 to 45 percent above non pregnant levels
 expansion begins early in the first trimester, increases
rapidly in the second trimester, and plateaus at about the
30th week.
volume expansion results from
 an increase in both plasma (50%) and
 erythrocytes (20-30%) averaging about 450 mL as
a result of ↑plasma erythropoietin levels
RBC mass begins to increase at the start of the second
trimester and continues to rise throughout pregnancy. By
the time of delivery it is 20% to 30% above non pregnant
levels
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.
 Causes for ↑in plasma volume
 increased estrogen production by the placenta
 Progesterone - poorly understood mechanism
 magnitude of the increase varies according to the size of the
woman, the number of prior pregnancies, and the number of
fetuses she is carrying.
 for example 50% in singleton pregnancies ,70% with a twin
gestation
 Important functions of the ↑ Blood Volume.
 meet the demands of the enlarged uterus with its
greatly hypertrophied vascular system.

 protect mother, and fetus, against deleterious

effects of impaired venous return in the supine and
erect positions.

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of
 Blood Pressure
 Systemic arterial pressure declines slightly
 Diastolic pressure decreases more markedly
 Decrease begins in the first trimester, reaches its nadir
in mid pregnancy, and returns toward non pregnant
levels by term

 Pulse pressure widens

 Systolic and diastolic pressures (and mean arterial pressure)

increase to pre pregnancy levels by about 36 weeks .

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Blood pressure, varies with posture

highest when the gravid woman is sitting and somewhat lower when she is lying
down

 When elevations in blood pressure are clinically detected during pregnancy, it is

customary to repeat the measurement with the patient lying on her side.

 In the lateral position, the blood pressure cuff around the brachial artery is
raised about 10 cm above the heart.

This leads to a hydrostatic fall in measured pressure, yielding a reading about 7

mmHg lower than if the cuff were at heart level, as occurs during sitting or supine
measurements.

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
Red Blood Cells Hematologic System

RBC mass expands by about 20-30%, or by 450 mL of erythrocytes for

average pregnant woman
increase is greater with iron supplementation and multiple gestation
.


Physiologic anemia of pregnancy
maternal hemoglobin levels average 10.9 ± 0.8 (SD) g/dL
in the second trimester and 12.4 ± 1.0 g/dL at term.

White Blood Cells
total blood leukocyte count increases from a pre pregnancy level
of 4,300– 4,500/L to 5000–12,000/L in the last trimester
Counts in the 20,000–25,000/L range can occur during labor.
primarily involves the polymorph nuclear form
 The cause of the rise in the leukocyte count, has not been
established.
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 Polymorph nuclear leukocyte chemo taxis may be impaired .
 Reduced polymorph nuclear leukocyte adherence
 Basophile counts decrease slightly
 Eosinophil counts, remain unchanged.
Platelets
studies have reported increased production of platelets
accompanied by progressive platelet consumption.
counts fall below 150,000/L in 6% of gravidas in the third
trimester.
pregnancy-associated thrombocytopenia, which appears to
be caused by increased peripheral consumption, resolves
with delivery and is of no pathologic significance.
Levels of prostacyclin (PGI2), a platelet aggregation inhibitor,
thromboxane A2, an inducer of platelet aggregation and a
vasoconstrictor are increased

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 Clotting Factors
Circulating levels of several coagulation factors increase

Fibrinogen (factor I) and factor VIII levels increase markedly,

 factors VII, IX, X, and XII increase to a lesser extent.

Plasma fibrinogen concentrations begin to increase from non pregnant

levels (1.5–4.5 g/L) during the third month of pregnancy and
progressively rise by nearly 2-fold by late pregnancy (4–6.5 g/L).

 The high estrogen levels of pregnancy involved in the increased

fibrinogen synthesis by the liver.

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 Respiratory system `
The major respiratory changes in pregnancy involve three factors:
 mechanical effects of the enlarging uterus
 increased total body oxygen consumption
 respiratory stimulant effects of progesterone
 The diaphragm rises about 4 cm during pregnancy
Sub costal angle widens appreciably
The rib cage is displaced upward, increasing the angle of the
ribs with the spine.
 Transverse diameter of the thoracic cage increases about 2 cm.
The thoracic circumference increases about 6 cm, but not
sufficiently to prevent a reduction in the residual volume of air in
the lungs created by the elevated diaphragm.

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 DYSPNEA OF PREGNANCY

 dyspnea is a common symptom in pregnancy,

experienced at some time during pregnancy by as many
as 60% to 70% of women.
 The underlying pathophysiology remains unclear.
 The frequent onset during the 1st or 2nd trimester
excludes mechanical factors.
 The marked change in PCO2 to unusually low levels may
result in the sensation of dyspnea.

 PCO2 decreases from 40 to 35

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 RENAL PHYSIOLOGY
ANATOMIC CHANGES IN THE URINARY TRACT
 urinary collecting system, undergoes marked dilation , as is
readily seen on intravenous urograms
 begins in the 1st trimester, is present in 90% of women at
term,
 persist until the 12th to 16th postpartum week.
 Progesterone appears to produce smooth muscle relaxation
in various organs, including the ureter.
 As the uterus enlarges, partial obstruction of the ureter
occurs at the pelvic brim in both the supine and the upright
positions.
 More on the right side probably b/c of dilated ovarian venous
pluxus
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 Clinical significance
Retained urine leads to collection error
Mistaken for obstructive uropathy
More virulent upper urinary tract
infection
 Elective pyelography should be
postpone after 12 weeks post partum

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 Gastrointestinal system
Mouth

pH and the production of saliva is unchanged


Ptyalism, associated with the loss of 1 to 2 L of saliva per day.
inability of the nauseated woman to swallow normal amounts of
saliva

pregnancy does not cause or accelerate the course of dental caries.


hypertrophied , hyperemic , spongy friable gums
bleed after tooth brushing,
gingivitis of pregnancy

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 Stomach
 Tone and motility are decreased
 Scientific evidence regarding delayed gastric emptying is inconclusive.
 Emptying time longer in pregnant women with heartburn
 Increased delay is seen in labor
 increase in gastro esophageal reflux disease and dyspepsia
 Reflux of acidic secretions into the lower esophagus
 Decreased lower esophageal tone
 Lower intra esophageal pressure
 Higher intra gastric pressures
 Esophageal dysmotility
 gastric compression from the enlarged uterus

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 decreased risk of peptic ulcer disease
 increased placental histaminases synthesis
 increased gastric mucin production
 reduced gastric acid secretion
 enhanced immunologic tolerance of Helicobacter
pylori
Intestines
 Reduced motility of small intestine
Increased oral -cecal transit time
increased water and sodium absorption in the colon
Unchanged absorption of nutrient from small bowel
Increased absorption of calcium and iron
The appendix, is displaced upward and somewhat laterally

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 Skin

 Striae gravid arum or stretch marks

 reddish, slightly depressed streaks
 in the skin of the abdomen ,breasts and thighs.
 In multiparous women, in addition to the reddish striae
 glistening, silvery lines representing
 cicatrices of previous striae are seen.
 Linea alba

 becomes markedly pigmented

 brownish-black color
 called linea nigra

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. Continued…..
chloasma or melasma gravid arum
 irregular brownish patches of varying size on face,
neck
 called mask of pregnancy.
 Pigmentation of the areola and genital skin may also be
accentuated

 pigmentary changes usually disappear, or at least regress after

delivery

 melanocyte-stimulating hormone, is believed to cause this changes

 Estrogen and progesterone also are reported to have melanocyte-
stimulating effects.
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 Breasts
In the early weeks breast tenderness and tingling.

After the second month,

 breasts increase in size,
 veins become visible just beneath the skin.
 nipples become larger, deeply pigmented, and erectile.
After the first few months
 colostrum a thick, yellowish fluid expressed from the
nipples by gentle massage.
 areola become broader and deeply pigmented.
 glands of Montgomery,
 a number of small elevations Scattered through the areola
 hypertrophic sebaceous glands.
prepregnancy breast size and volume of milk production do
not correlate
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 Weight Gain

increase in weight
 the uterus and its contents
 the breasts
 blood volume and extra vascular extracellular fluid.
 increase in cellular water new fat and protein,

 the average weight gain during pregnancy is

approximately 12.5 kg

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 Pregnancy Diagnosis
Three main approaches.
1. History and physical examination,
2. Laboratory evaluation, and
3. Ultrasonography

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 History and Physical Examination
The woman should describe her usual
menstrual pattern, including:
date of onset of last menses,
duration,
flow, and frequency
May confuse the diagnosis of early pregnancy:
Atypical last menstrual period, contraceptive
use, and a history of irregular menses.

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 History and Physical Examination…
 Enlarged uterus upon bimanual examination
breast changes, and
softening and enlargement of the cervix (Hegar
sign; 6 wk).
Bluish discoloration of the cervix from venous
congestion (Chadwick sign; 8-10 weeks).
A gravid uterus may be palpable lower abdomen
if the pregnancy has progressed; 12 weeks.

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 Clinical Symptoms of Pregnancy
 Amenorrhea
 Fetal movement
 Breast tenderness
 Nausea
 Vomiting
 Abdominal enlargement
 Urinary complaints

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 CLINICAL SIGNS OF PREGNANCY
Positive signs of pregnancy:
Identification of fetal heartbeat,
 Auscultation - 19 weeks
 Doppler technology- 10 weeks
 Sonography
Maternal perception of fetal movement, and
Ultrasonographic demonstration of pregnancy

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 Px Assay
o Early pregnancy factor
o β-hCG – ELISA
o Urinary and serum follicle-stimulating
hormone

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 Laboratory Evaluation
• Pregnancy test can be done on either urine or
blood (7-12 days). 
• Pregnancy tests find the presence of human
chorionic gonadotropin hormone (hCG).
• This is a hormone made by the placenta about 10
days after fertilization.
• Levels of the hCG hormone approximately
double every two days during the first 60 days
of pregnancy.
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 Human Chorionic Gonadotropin
  Glycoprotein
  Composed of 30% carbohydrate
  α and β subunits covalently bonded
  80% Homology with luteinizing hormone
  Produced by embryo at 8-cell stage
  Produced by syncytiotrophoblast -10 days
  Peaks at about 10 weeks’ gestation (~100,000
mIU/ml)
  Level falls after 10 weeks until term (~20,000 -
30,000 mIU/ml)
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 Ultrasonographic Demonstration of Px

Can be seen as early as 4–5 weeks’ gestation

(GS)
Fetal cardiac activity by 6 menstrual weeks’
gestation
The fetal brain can be seen by 8 weeks.
The crown–rump length can be used
accurately to assess gestational age up to
approximately 12 weeks.

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 WARNING!!!
 Rising human chorionic gonadotropin (hCG)
levels
 Empty uterus observed on sonography
 Abdominal pain, and vaginal bleeding in 1st
TM

Ectopic pregnancies

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 Factors Affecting Fetal Growth

Definition
GROWTH: Net increase in size/ mass of tissues
OR multiplication of cells OR increase in
intracellular substance .
DEVELOPMENT: Maturation of function e.g.:
maturation of Nervous system and indicates
acquisition of variety of skills .

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 IUGR
It is a condition in which a fetus is unable to
achieve its genetically determined potential
size
Represents a deviation and reduction in
expected fetal growth.

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 Types of IUGR
ASYMMETRICAL:
Weight is more affected than length with “ HEAD SPARRING “
pattern.
It is due to maternal factors such as Pre eclampsia , chronic
Htn .
Occurs due to insult mostly in 3rd trimester.
SYMMETRICAL:
Weight, length and HC are affected at birth.
It is due to factors intrinsic to the fetus
e.g.: chromosomal anomaly , congenital infection, ...
Occurs due to insult in 1st trim.

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 Factors Affecting Fetal Growth
GENETIC:
40 % contribution . e.g Tall parents have tall children and
obese parents have obese children;
ENVIRONMENTAL: 60 % Contribution
SEX: Boys have a good growth compared to girls .
HORMONES: Fetus secretes T4 from 12th week of
gestation .
– Insulin has a impt role in tissue accretion and
differentiation.
– Glucocorticoids help in pre-partum maturation of organs

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 Factors Affecting Fetal Growth…
FETAL GROWTH FACTORS:
 Secreted by fetal tissue &act by autocrine/paracrine
mechanism.
 Most imp is IGF –I & IGF – II(Insulin like growth factor).
 GROWTH PROMOTING- EGF( Epidermal growth factor ),
TGFα(Transforming growth factor ) , PDGF( Platelet
derived growth factor ) , FGF( Fibroblast like growth
factor) , NGF ( Nerve growth factor).  GROWTH
INHIBITING- TGFβ, MIS (Mullerian inhibiting substance),
Inhibin.
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 Factors Affecting Fetal Growth…
 1st cause of IUGR is chromosomal anomaly.
 2nd is Malformations.
PLACENTAL FACTORS:
 Fetal weight is directly proportional to placental
weight at term. Other changes in placenta :-
1. Total vilious surface area increases.
2. Diffusion distance decreases.
3. Fetal capillaries dilates.
4. Resistance in feto-placental vasculature falls.

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 Factors Affecting Fetal Growth…
MATERNAL FACTORS:
 Hx of mother’s own fetal and childhood growth.
 Maternal antenatal under nutrition
 Micro nutrients like zinc and Vit C has a role in
growth.
 Adequacy of iron stores should be ensured
before pregnancy rather than trying to correct
the deficiency state.

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 MATERNAL FACTORS…
 Age:- teenage or elderly.
 Parity:- nulliparous mother- high risk for SGA
 Obstetric complications:– PIH, Pre-eclampsia,
GDM
 Chronic systemic illness:– CRF, CHF, Anemia of
chronic diseases.
 TORCH infections during pregnancy:- All girls
must receive Rubella and Tetanus vaccines.

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 Development Of The Fetus
Embryology :
Is the study of prenatal development, beginning with
gametogenesis up to the formation of full-term fetus.
Periods of development
divided in to
1. Prenatal period – before
birth
2. Postnatal period – after
birth
 Prenatal Period
 Takes 38 weeks from conception to birth (average)
 Gynecologic timing has been from LNMP, therefore refers to 40 weeks “gestational”
age
 LNMP is on average two weeks before ovulation
 Subdivided in to three
1. Pre-embryonic period
2. Embryonic period
3. Fetal period
 Pre-embryonic period
oFrom fertilization to 7th day or
oFrom zygote formation to the implantation of blastocyst.
 Embryonic period:
o 2nd -8th weeks
o all major organ systems appear.
 Fetal Period:
o Includes the remaining weeks of development prior to birth
o The fetus continues to grow
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o Its organs increase in complexity
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 Week 1 post conception
• Zygote divides repeatedly moving down tube toward
uterus (cleavage)
• The daughter cells are called blastomeres
• Morula: The solid cluster of 12-16 blastomeres at
about 72 hours
• Day 4: late 60 cell morula enters uterus, taking up
fluid becoming blastocyst

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 Blastocyst stage
_____inner cell mass

• Two distinct types of cells ______trophoblast

– Inner cell mass: forms the embryo

– Trophoblast: layer of cells surrounding the cavity which
helps form the placenta
• Implantation on about day 6 post conception
– Trophoblast erodes uterine wall
– Takes 1 week to complete
• If inner cell mass of a single blastocyst divides:
monozygotic (identical) twins

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 Week 2
• Inner cell mass divides into
epiblast and hypoblast
• 2 fluid filled sacs
– Amniotic sac from epiblast
– Yolk sac from hypoblast
• Bilaminar embryonic disc: area
of contact
(gives rise to the whole body)

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Week 3

• Bilaminar to trilaminar disc

• Three primary “germ” layers: all body tissues
develop from these
• Ectoderm
• Endoderm
• Mesoderm
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• Closure of neural tube: begins at end of week 3; complete by
end of week 4 (folic acid important for this step)
• Extends cranially (eventually brain) and caudally (spinal cord)
• Neural crest, lateral ectodermal cells, pulled along and form
sensory nerve cells and other structures

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 Major derivatives of the embryonic germ layers

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 By 8 weeks, about 2 months, all
major organs are in place in at
least a rudimentary form; this is
why drugs early in pregnancy are
so important to avoid – many
cause birth defects; baby is a little
over 1” long (below right)

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 Focused Antenatal Care
Definition of ANC
• General health care given to pregnant women
to promote and maintain optimal health of
the mother throughout the pregnancy, labor
and puerperium with having and rearing of
healthy baby

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 FOCUSED ANC
 FANC emphasizes the quality of care rather than the quantity
 For normal pregnancies only 4 visits (WHO).
 The major goal of FANC is to help women maintain normal
pregnancies through:
1.Health promotion and disease prevention

2.Early detection and treatment of complications and existing diseases

3.Birth preparedness and complication readiness planning

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 Why Disease Detection and Not Risk
Assessment?
Risk approach is not an efficient or effective
strategy for MMR reduction. “Risk factors” :
cannot predict complications: usually not direct cause
do not appear to be good indicators of which women will
experience complications
Majority of women who experienced complication were
considered “low risk;” vast majority of women considered to be
“high risk” gave birth without experiencing a complication
All pregnancies should be regarded as “at risk”

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 Health Promotion and Disease Prevention
• Counseling about
– Immunization against tetanus
– Iron and folate supplementation.
– How to recognize danger signs, what to do, and where to get help
– PITC
– The benefit of skilled attendance at birth
– Breastfeeding
– Establish access to FP
– Protection against malaria with ITN
– Good nutrition, Protection against iodine deficiency
– Risks of using tobacco, alcohol, local stimulants, and traditional
remedies
– ƒHygiene and infection prevention practices

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 Early detection and treatment of
complications and existing Diseases:
 Pre-existing health conditions that may affect pregnancy
outcome, require immediate treatment or require a more
intensive level of monitoring and follow-up care over the
course of pregnancy.
 Early detection and treatment of new compliant

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 Birth Preparedness and Complication
Readiness:
~ 15% of women will develop a life-threatening
complication.
So, every woman and her family should have a plan for
the following:
– A skilled attendant at birth
– The place of birth and how to get there including how to access
emergency transportation
– Items needed for the birth
– Save money
– Support during and after the birth (e.g., family, friends)
– Potential blood donors in case of emergency.

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 The Basic Component of the FANC
• The FANC model categorizes pregnant women
into 2 groups:
– those eligible to receive routine ANC (called the
basic component); and
– those who need specialized care based on their
specific health conditions or risk factors

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MAKING GOOD CLINICAL DECISIONS AT ANC
• THE STEPS
– gather information (history, physical exam, labs, US etc)

– interpreting information gathered

– developing a care plan

– implementing care plan

– evaluating care plan

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 First visit
 should occur in the first trimester, around or preferably
before 16 wks of GA
 Detailed hx and physical exam
 Takes 30-40min
 Use the FANC classifying checklist. If a woman has:
– none of the conditions listed on the classifying form
-eligible to basic component.
– any one condition - specialized care
– Reclassification is possible (both ways)

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 Only one routine VE is recommended
 Confirm pregnancy
 Good dating
 Identify and treat STI
 FeFol (60mg of elemental Fe, 400mcg of folate/d)
 TT, Malaria prevention
 Lab – U/A, CBC, BG, Rh, VDRL, HBsAG, S/E, PITC, urine culture,
U/S, Pap smear
 Tell danger sign, complication readiness, In case of
unexpected symptoms mother should be advised to seek
care.
 Record, Appoint

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 Dating Pregnancy
A. Menstrual EDD
B. Dating by ultrasound
 Benefits of a dating scan:
1. Accurate dating women with irregular menstrual cycles or
poor recollection of LMP.
2. Reduced incidence in induction of labor for ‘prolonged
pregnancy’
3. Maximizing the potential for serum screening to detect fetal
abnormalities
4. Early detection of multiple pregnancies
5. Detection of otherwise asymptomatic failed pregnancy

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 Other pregnancy milestones
 Fetal heart sound – fetoscope, Doppler
 Fundal height
 Date of quickening
 Urine or serum pregnancy test

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 The second visit
 should be 24-28 Weeks
 expected to take 20 mnts
Contents
1. History review, assess danger sign
2. Physical examination
3. Tests-U/A, coobms test if Rh negative, OGTT
4. Assess for referral
5. Interventions-iron, TT----
6. Tell danger sign (repeat), questions and answers
7. Record, appoint

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 The third visit
 Should take place at around 30-32 wks
 Expected to take 20mnts
content
1. History
2. Physical examination
3. Tests-U/A, Hemoglobin test for all women
4. Interventions-iron,TT2, anti D
5. Tell danger sign, complication readiness, birth plan,
questions and answers
6. Maintain records & appointment

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 The fourth visit
Should be the final visit
 Between 36-38 wks.
 Breech should be discovered (ECV)
Content
1. History, danger sign
2. Physical examination
3. Test-U/A
4. Interventions-iron
5. Advice- complication readiness, post partum visit,
BF, Contraception, delivery plan, danger sign,
questions and answers
6. ?appoint

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 Late enrolment and missed visits
• Should have in their first visit all activities recommended for
the previous visit(s), as well as those which correspond to the
present visit
• Take more time than regular
• Determine the reason for missed appointment.

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 Antenatal Fetal Surveillance
 A successful antenatal fetal testing program
would ideally reduce the fetal and neonatal
outcomes of asphyxia.
 The only antenatal surveillance technique
recommended for all pregnant women, with and
without risk factors, is maternal awareness of
fetal movements.

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Antenatal Fetal Surveillance Indications

Previous obstetrical history  Current Px
Maternal Hypertensive disorder of pregnancy  Maternal Post-term pregnancy (>42
Placental abruption weeks)
Fetal Intrauterine growth restriction  Hypertensive disorders
Stillbirth  Pre-pregnancy diabetes

Fetal  Insulin requiring gestational
diabetes
Decreased fetal movement
 PPROM
Intrauterine growth restriction
 Iso-immunization
Suspected Oligohydramnios/ Polyhydramnios
 Abnormal maternal serum
Multiple pregnancy screening (hCG or AFP)
Preterm labour  Vaginal bleeding
 Morbid obesity
 Advanced maternal age
 Assisted reproductive technologies
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 Antenatal Fetal Surveillance …
ANTENATAL FETAL TESTING TECHNIQUES:
Fetal movement counting
Non-stress test
Contraction stress test
Biophysical profile and/or amniotic fluid volume
Maternal uterine artery Doppler
Fetal umbilical artery Doppler.

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 1. Fetal Movement Counting
 Decreased placental perfusion and fetal
acidemia and acidosis are associated with
decreased fetal movements.
 This is the basis for maternal monitoring of fetal
movements.
 The concept of counting fetal movements is
attractive, since it requires no technology and is
available to all women.

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 1. Fetal Movement Counting…
Review of the Evidence (From 24 studies)

 In high-risk pregnancies, the risk for adverse outcomes

in women with decreased fetal movements increased:

 Mortality - OR 44 (95% CI 22.3–86.8);

 IUGR- OR 6.34 (95% CI 4.19–9.58);

 Apgar - 7 at 5 minutes, OR 10.2 (95% CI 5.99–17.3);

 need for emergency delivery – OR 9.40 (95% CI 5.04–17.5)

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 1. Fetal Movement Counting…
Optimal time for testing: Fetal movements
were found to be increased at evening time.
Fetal movements are perceived best when
lying down.
Maternal exercise was not shown to alter fetal
activity.

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 1. Fetal Movement Counting…
Fetuses with normal activity of six or more
movements in the interval of two hours are
almost invariably healthy
Women who report decreased fetal
movements (< 6 distinct movements within 2
hours) should have an evaluation of maternal
and fetal status.

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 1. Fetal Movement Counting…

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 2. Non-Stress Test
The non-stress test is performed during the antenatal
period when the uterus is relaxed, i.e., the fetus is not
exposed to the “stress” of uterine contractions.
The woman should empty her bladder and be
positioned on either a bed or a reclining chair in the
left lateral recumbent position.
The recording should last at least 20 minutes.
The baseline fetal heart rate should be within the
normal range of 110 to 160 bpm.
Moderate variability of 6 to 25 bpm is expected.

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 2. Non-Stress Test …
Normal (reactive) non-stress test includes at
least two accelerations from the baseline
within the 20-minute period of testing that
reach a peak of at least 15 bpm above the
baseline and have a duration from onset to
return to baseline of at least 15 seconds.

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 3. Contraction Stress Test (CST)

The contraction stress test should be considered in the presence of an

atypical non-stress test.


The contraction stress test, or oxytocin challenge test, is a test of fetal

well-being first described by Ray et al. in 1972.


It evaluates the response of the fetal heart rate to induced contractions

and was designed to unmask poor placental function.


Used when maternal conditions such as diabetes or hypertension and

fetal conditions such as growth restriction or postdates.

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 3. Contraction Stress Test …
The CST should not be used if vaginal delivery is
contraindicated.
This test should be performed in hospital where
emergency Caesarean section is available.
The CST may be performed using maternal
nipple stimulation or an oxytocin infusion.

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 4. Sonographic Assessment of Fetus
and Amniotic Fluid Volume
Sonography allows the simultaneous assessment of
several fetal behavioural and physiologic
characteristics.
The BPP is an evaluation of current fetal well-being.
It is performed over 30 minutes and assesses fetal
behaviour by observing fetal breathing movement,
body movement, tone, and amniotic fluid volume.

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 4. Sonographic Assessment of Fetus
and Amniotic Fluid Volume…
The biophysical profile uses ultrasound and
cardiotocography (CTG) , also known
electronic fetal heart rate monitoring to
examine the fetus.
There are five components measured during
the biophysical examination.

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 4. Sonographic Assessment of Fetus
and Amniotic Fluid Volume…
Component  Normal (2 points) Abnormal (0 points)

One or more episodes of fetal No episodes of fetal breathing movements

Fetal Breathing
breathing lasting at least 30 lasting at least 30 seconds during a 30
Movements
seconds within 30 minutes. minute period of observation.

Gross Body 3 or more discrete body or limb Less than 3 body or limb movements in 30
Movement movements within 30 minutes minutes

One or more episodes of active

Slow extension with no return or slow return
extension and flexion of a fetal
Fetal Tone to flexion of a fetal extremity  OR no  fetal
extremity OR opening and closing of
movement
the hand within 30 minutes

A single deepest vertical pocket of

Amniotic Fluid A single deepest vertical pocket of amniotic
amniotic fluid measures greater than
Volume fluid measures 2 centimeters or less
2 centimeters. is present
Non-stress test
Reactive  Nonreactive
(NST)
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 Biophysical Profile Test Score Interpretation
Management
Test Score
ACOG SOGC

10 out of 10  ,  8 out of 10

Deliver for obstetric or maternal
(normal fluid), 8 out of 10  
factors
(NST not done)

If there is normal urinary tract

function  and intact membranes
8 out of 10  Uncomplicated, isolated persistent oligohydramnios
then deliver at term. If < 34 weeks
(abnormal fluid) deliver at 36 to 37 weeks .
intensive surveillance to maximize
maturity

6 out of 10 (normal fluid) Repeat test within 24 hours

At or beyond 37 0/7 weeks of gestation,  further
evaluation and consideration of delivery. Less than Deliver if at term .If < 34 weeks
6 out of 10 
37 0/7 weeks  repeat BPP in 24 hours intensive surveillance to maximize
(abnormal fluid)
maturity

Delivery is usually indicated. Pregnancies at less

than 32 0/7 weeks of gestation, management should
4 out of 10 Deliver
be individualized, and extended monitoring may be
appropriate.

2 out of 10 Deliver Deliver

0 out of 10 Deliver Deliver

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 5. Uterine Artery Doppler
Doppler ultrasound of the uterine arteries is a non-
invasive method of assessing the resistance of vessels
supplying the placenta.
In normal pregnancies: Increase in blood flow velocity
and a decrease in resistance to flow, reflecting the
transformation of the spiral arteries.
In pregnancies complicated by hypertensive disorders,
Doppler ultrasound shows increased resistance to flow,
early diastolic notching, and decreased diastolic flow.

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 6. Umbilical Artery Doppler
In normal pregnancy, the fetal umbilical
circulation is characterized by continuous
forward flow, i.e., low resistance, to the
placenta, which improves with gestational age
as primary.
Resistance to forward flow continues to
decrease in normal pregnancy all the way to
term

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 6. Umbilical Artery Doppler…
Increased resistance to forward flow is characterized by:

Abnormal systolic to diastolic ratio

Pulsatility index (PI) or

Resistance index (RI) greater than the 95th centile and implies decreased

functioning vascular units within the placenta

Umbilical artery Doppler should be available for assessment of the fetal

placental circulation in pregnant women with suspected placental insufficiency

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HIV/AIDS and PMTCT
 Learning Objectives
At the end of this training the MNCH care
provider
• Will be able to provide primary care to:
– HIV-infected pregnant women from ANC to post-
cessation of breast feeding,
– HIV-exposed infants until they are weaned or
are diagnosed with HIV.

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 Timing of Mother to Child Transmission of HIV

During pregnancy
(5-10%)

During labor and delivery (10-20%)

During breastfeeding
(5-10%)

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 WHO’s 4-prong approach to PMTCT

Uninfected
Parents to be

I. Primary prevention
of HIV
HIV infected
woman

II. Prevention of
unintended pregnancy
Pregnant HIV
infected woman

III. Prevention of
MTCT
HIV infected
infant

IV. Linkage to Care

and Support
AIDS and
Death
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 Risk factors for MTCT
Viral
• Viral load (the higher
the viral load, the
greater the risk of HIV
transmission)
• Viral genotype and
phenotype-MTCT is
relatively rare with HIV-2
• Viral resistance
01/30/2021
Maternal
• Maternal immunological status
• Maternal nutritional status
• Maternal clinical status
(including co-infection with an
STI)
• Behavioral factors
• Antiretroviral treatment
Biru A (BSc, MSc) 100
 Risk factors for MTCT
Obstetrical Fetal
• Prolonged rupture of • Prematurity
membrane (longer than • Multiple pregnancy
4 hours)  
• Mode of delivery Infant
• Intrapartum • Breastfeeding
hemorrhage • Gastrointestinal tract
• Obstetrical procedures factors
• Invasive fetal monitoring • Immature immune system

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 Overview
• Understanding Option B+

– Essentials/Rationale

– Benefits

– Challenges

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 What is option B+
Option B+ is
• “test and treat” strategy in which triple ARVs
are started as soon as HIV is detected in a
pregnant woman irrespective of CD4 count and
gestational age
• Treatment (ART) intended to be given for life
• Specific ART regimen that requires just once a
day dosing (either with one or two tablets),
which will result in convenience for the patient
and good drug adherence
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 What are the Benefits of Option B+
•Requires just one/two pills taken once daily

•No need for CD4 test to initiate ART

•Makes breast feeding safer

• Avoids the need for extended infant ARV prophylaxis (Option A)

•Mothers start treatment early, so quality of life and survival are better

•Maintains continuity of care: ANC to post-weaning so improves infant testing as well as

post-partum uptake of FP services.

•Minimize HIV transmission among discordant partnership

•Ongoing treatment of mother will protect future pregnancies from moment of conception.

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 What are the Challenges of option B+
• Treatment is intended to be life long so following
treatment initiation and in the course of following your
clients long term, you will help them build a
commitment to staying on treatment for life.

• Adherence is also very important to prevent occurrence

of treatment failure
• Poor adherence may cause treatment failure.

• Side effects of drugs need to be monitored that may

need prompt management to avoid interruption of
treatment.

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 HIV test and counseling for HIV positive
pregnant/laboring/lactating women
• All women with unknown HIV status coming for MNCH services should
have their HIV status determined.

• Encourage pregnant/lactating women to attend HTC with their partners

and ensure that children of HIV positive mothers are tested.

• Remind pregnant women during pre-test sessions ( individual or group)

that they can decline HIV testing without any subsequent consequence.

• Result of HIV testing should always be offered in a confidential setting.

• Effective post-test counseling of patients testing positive is essential assure

their participation in full PMTCT services.

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 WHO Clinical Staging
• HIV associated conditions are grouped into 4 WHO clinical stages that correlate with
disease progression and likelihood of survival
Stage 1: Asymptomatic
Stage 2: Mild
Stage 3: Moderate
Stage 4: Severe
• It should be part of the baseline assessment (first visit) on entry into a
care and treatment program

• Used to guide decisions on when to start co-trimoxazole prophylaxis

and monitoring patient response (if CD4 not available)

• Following initiation of ART, staging on therapy (T-staging), using the

same clinical parameters, should be performed regularly as a means of
monitoring ARV treatment success or failure.

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 Opportunistic infections(OIs)
• HIV infected pregnant and lactating women can have
opportunistic infections

• Opportunistic infections are caused by microorganisms

which are not harmful to our body when our cell
mediated - immunity is intact

• Any part of our body is vulnerable to develop

opportunistic infections;
• Different opportunistic infections occur at different
levels of immunologic compromise.

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 HIV lecture 109
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01/30/2021 Biru A (BSc, MSc) 110
 .
Treatment of Specific Opportunistic infection:
 
Types of illness Treatment
Bacterial infection Antibiotics such as Amoxicillin;
Ceftriaxone, Erythromycin,
Penicillins
Anti-TB drugs

Fungal, infections Antifungals: Nystatin; fluconazole;

Miconazole
Viral infections Anti-virals: Acyclovir;
Protozoal infestation Anti-protozoal: Cotrimoxazole; Anti-
malarials;

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01/30/2021 Biru A (BSc, MSc) 112
 Detailed Option B+ Recommendation in
Ethiopia
Maternal regimen:
1. During pregnancy:
•TDF/3TC/EFV if for the first time
•Continue same ART regimen if already initiated (unless ART provider
agrees to switch to TDF/3TC/EFV)
•If on AZT prophylaxis; Shift to TDF/3TC/EVF
2. During labor and Delivery:
•If on ART continue same regimen of ART
•For women presenting for the first time initiate TDF/3TC/EFV
•If on AZT prophylaxis; Shift to TDF/3TC/EVF
•3. Lactating or post partum.
•Continue ART if started
•Initiate TDF/3TC/EVF if on no treatment
 
Infant regimen: NVP for six weeks post partum
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 Adherence advice:

• Adherence advice should include:

– Providing basic information on HIV and its manifestations;

– Clearly stating benefits and side effects of drugs;

– Identifying when a client should seek urgent help;

– Explaining how medications should be taken;

– Stressing importance of not missing any doses.

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 The likely side effects of option B+ drugs
Very Common side effects
ARV Drug (Warn patients and suggest
ways patient can manage; Be
prepared to manage when
patient seeks care)
Tenofovir(TDF)
Lamivudine(3TC) Nausea; Diarrhea
Efavirenz(EVF) Nausea; Diarrhea;
Strange Dreams
Difficulty Sleeping
Memory problems
Headache; Dizziness
NVP for infants Nausea, diarrhea
01/30/2021 Biru A (BSc, MSc)
Potentially Serious side
effects
(Warn patients to seek
Care)
Renal insufficiency
Effect on fetal bone
Seek care urgently
Yellow Eyes;
Psychosis or confusion
Skin Rash
Seek Care Urgently
Yellow eyes; Skin rash ;
Fever, fatigue and shortness
of breath;
115
 Care of an HIV Exposed Infant

• HIV exposed infants need multiple standardized

care activities to support their normal growth
and development

• To identify HIV infection early and link them to

chronic HIV care if HIV infected, as well as to
prevent opportunistic infections.

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 Components of Services in HEI Care
• Proper review through history and physical exam
• Daily NVP for six weeks
• Testing for HIV infection
• Support for proper infant feeding
• Growth monitoring
• Developmental assessment
• Co-trimoxazole prophylaxis
• Immunization
• Tb risk assessment
• Documenting and reporting

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 Follow-up schedule for HEIs cont’d
Monthly visits for first 6 months
then every 3 months until HIV infection status determined

4-6 weeks 3 months 5 months 9 months 15 months

2 months 4 months 6 months 12 months 18 months

Virologic test

HIV antibody testing

12 months

Follow-up schedule can be modified per local and national guidelines.

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 Key messages
• HIV exposed infants can carry HIV maternal antibodies up-to the age of 18
months.

• HIV antibody rapid test positive result in an infant below 18 months, tells only
infant is exposed. Must be confirmed with positive DNA PCR.

• DNA PCR test should be done at 6wks or at the earliest possible time thereafter,
using Dried Blood Spot(DBS), to identify HIV infection, and repeated to confirm
all positive HIV-antibody tests done prior to age 18 months.
• Negative DNA PCR result in a breast feeding child only indicates that child is
uninfected at time of test. However, infection can occur at any time during
breast feeding.
• Depending on the age of the infant, repeat confirmatory antibody test or DNA
PCR 6 weeks after complete cessation of breast feeding.

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 Key messages
• Most Ethiopian children breast feed up to the age of 24 months
and this should be supported.

• Healthy HIV-exposed infants should be seen every month during

the first 6 months and thereafter should be seen at same time
mother returns to PMTCT for her f/u (every 2 months). Infants
who get sick require more frequent visits and close follow up.

• In PMTCT Option B+ infant and mother pair should continue

their care and follow-up at MNCH till the risk of infection is
over (following cessation of breast feeding).

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 References

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 Thank you

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