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Antenatal care
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics and gynecology
Ain Shams University
3/21/20 ELBO...
Pregnancy can be
•Low risk pregnancy
•High risk pregnancy
•Mother
•Fetus
3/21/20 ELBOHOTY 2
Pathway of care
•Preconception
•Antenatal
•Intrapartum
•Postpartum
3/21/20 ELBOHOTY 3
The aims of antenatal care are to:
1.Provide high-quality information
2.Provide an informed choice about the
pathways of a...
Who?
1.general practitioners
2.community midwives
3.hospital midwives
4.obstetricians.
5.Often health professionals such a...
•Antenatal care should be woman-
centred.
•Care offered to women should be
planned carefully, ensuring the early
detection...
Assigning a care pathway
•Midwife and GP-led models of care
should be offered to women with
uncomplicated pregnancies, but...
Documentation of care
•Structured maternity records should be used
for antenatal care.
•Maternity services should have a s...
The booking appointment
•This usually takes place at the local surgery, hospital or home
depending on accessibility.
•The ...
3/21/20 ELBOHOTY 10
3/21/20 ELBOHOTY 11
Lifestyle considerations
3/21/20 ELBOHOTY 12
3/21/20 ELBOHOTY 13
3/21/20 ELBOHOTY 14
3/21/20 ELBOHOTY 15
Food-acquired infections
• Pregnant women should be offered informa5on on how to reduce the
risk of listeriosis by:
• drink...
3/21/20 ELBOHOTY 17
• the safest 5me to fly is:
• Before 37 weeks, for uncomplicated singlton pregnancy.
• Before 32 weeks, for uncomplicated m...
Alcohol consumption
•Advise women to avoid alcohol especially in first 3
months of pregnancy if possible
•If women choose ...
Risks
• Fertility
• Alcohol may be exerting toxic effects throughout the reproductive process from infertility
through mis...
3/21/20 ELBOHOTY 21
3/21/20 ELBOHOTY 22
3/21/20 ELBOHOTY 23
3/21/20 ELBOHOTY 24
3/21/20 ELBOHOTY 25
Equivalents
•1 unit equals half a pint of ordinary strength
lager or beer, or one shot [25 ml] of spirits.
•One small [125...
Smoking consumption
•Use any appointment or meeting as an opportunity
to ask women if they smoke. If they do, explain how
...
Identifying pregnant women who smoke
action for midwives
• A carbon monoxide (CO) test is an immediate and non-invasive bi...
3/21/20 ELBOHOTY 29
Nico@ne replacement therapy
• Use only if smoking cessation without NRT fails. If they express a clear
wish to receive NRT...
vitamin D
•All women should be informed at the booking
appointment about the importance for their
own and their baby’s hea...
Risks of deficiency
• Pre-eclampsia and neonatal hypocalcaemia are the most prevalent complications
of maternal hypocalcae...
Neonatal
• Fetal lung development and childhood immune disorders Low
maternal vitamin D intake in pregnancy is associated ...
vitamin D
•Healthcare professionals’ should take particular care to check that
women at greatest risk of vitamin D deficie...
Health professionals should not routinely
test people's vitamin D status unless:
•they have symptoms of deficiency
•they a...
Three categories of vitamin D supplementation are
recommended.
• In general,
• vitamin D 10 micrograms (400 units) a day i...
3/21/20 ELBOHOTY 37
• All patients receiving pharmacological doses of vitamin D should have
their plasma-calcium
3/21/20 ELBOHOTY 38
Risks of treatment
• Vitamin D may be inappropriate in sarcoidosis (where there may be
vitamin D sensitivity) or ineffecti...
Folic acid
•Pregnant women (and those intending to
become pregnant) should be informed that
dietary supplementation with f...
5 mg per day is recommended for:
•women who have previously had an infant
with a neural tube defect
•who are receiving ant...
Avoid high dose of vitamin A
•Pregnant women should be informed that vitamin A
supplementation (intake above 700 microgram...
Adverse effects of isotretinoin
• Mood disturbance
• Dryness of skin and mucous membranes
• Facial erythema, eczema, hair ...
Malformations associated with isotretinoin use
• Craniofacial defects:
• ear defects
• eye defects
• cleft palate
• microg...
Management of common symptoms
of pregnancy
3/21/20 ELBOHOTY 45
Nausea and vomiting in early pregnancy
• most cases of nausea and vomiting in pregnancy will resolve spontaneously
within ...
• Heartburn
• Women who present with symptoms of heartburn in pregnancy
should be offered information regarding lifestyle ...
Constipation
• The prevalence of cons5pa5on is es5mated to affect 11–38% of
pregnancies.
• Func5onal (primary) cons5pa5on i...
3/21/20 ELBOHOTY 49
The following circumstances warrant a prompt referral to
a gastroenterologist:
• A change in bowel habit for longer than 6...
3/21/20 ELBOHOTY 51
stop laxatives
• When regular bowel movements occur without difficulty, laxatives can be
withdrawn gradually.
• The reduct...
• Varicose veins
• Women should be informed that varicose veins are a common symptom of
pregnancy that will not cause harm...
Screening at the booking visit
•Screening is not a diagnostic test and the
woman may need to be offered further
tests to c...
Obstetric history
•Planned or not
•Age
•gesta.on
•presen.ng complaint
•history of presen.ng complaint
•history of index pr...
•Domestic violence:
• at any visit you should be alert to signs and symptoms of
domestic violence
• women should also feel...
Red spot system
•An easy and cost-effective way to help women to reveal that
they may be victims of domestic abuse is the ...
3/21/20 ELBOHOTY 58
•Mental disorders:
• any relevant history of mental health disorders,
along with communica8on between healthcare
professio...
Screening for depression and anxiety
3/21/20 ELBOHOTY
At a woman's first contact with primary care
or her booking visit, a...
•Consider asking the following depression
identification questions :
•During the past month, have you often been
bothered ...
History taking
• past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in
the postnat...
Calculation of GA
3/21/20 ELBOHOTY 63
calcula6on of fetal gesta6onal age:
• LMP
• US
• CRL
• Based on day of embryo transfer in IVF
• According to day 3 or 5
3/...
By LMP (Naegele’s rule):
• Prerequisites:
• Sure of her date of 1st day of last menstrual period.
• Regular cycle (at leas...
Late bookers
• NICE recommends that the booking appointment should occur by 10 weeks of
gestation.
• Late bookers are at a...
Women are more likely to book late if they are:
1.black and ethnic minority teenagers (whether born inside or outside the ...
Clinical examination
The following must be examined or asked for during the
antenatal period.
Measurement of weight and bo...
• Breast examination
• Routine breast examination during antenatal care is not recommended for the promotion
of postnatal ...
Migrant women
They should have a medical assessment of their overall health and a
cardiovascular examination at booking
wo...
Pregnant asylum seekers
• They are a highly vulnerable and socially excluded group of women.
• They have complex medical a...
3/21/20 ELBOHOTY 72
3/21/20 ELBOHOTY 73
3/21/20 ELBOHOTY 74
Screening for clinical conditions
• All pregnant women within the UK should be screened for the following
conditions:
• VT...
Identifies Example
Existing conditions that may worsen
during pregnancy
•Medical conditions such as diabetes,
hypertension...
3/21/20 ELBOHOTY 77
Women needing additional care
3/21/20 ELBOHOTY 78
• Screening for pre-eclampsia
• Pre-eclampsia is hypertension associated with proteinuria that occurrs after 20
weeks of g...
3/21/20 ELBOHOTY 80
Blood pressure should be measured as outlined
below:
• remove tight clothing, ensure arm is relaxed and supported at heart...
• All pregnant women should be made aware of the need to seek immediate
advice from a healthcare professional if they expe...
Screening for infections
• asymptomatic bacteriuria
• HIV, rubella, syphilis and hepatitis B
3/21/20 ELBOHOTY 83
Asymptomatic bacteriuria
This is defined as the presence of bacterial colonisation of the urinary tract in the
absence of ...
HIV, syphilis and hepatitis B
• Currently four infections are screened for in the UK:
• human immunodeficiency virus (HIV)...
Screening for haematological disorders
• anaemia
• blood groups and red cell antibodies
• haemoglobinopathies
3/21/20 ELBO...
Diagnosis of anaemia
•Anaemia in pregnancy is defined as
• first trimester haemoglobin (Hb) less than
110 g/l
•second/thir...
haemoglobinopathies
•Sickle cell and thallassaemia are the two most
common haemoglobinopathies in the UK.
•Screening for s...
•MCV is done as a part of CBC
•Screening tests offered for sickle cell depends on it's
prevalence within that area
•high p...
Diagnosis
•Where prevalence of sickle cell disease is high (fetal prevalence above
1.5 cases per 10,000 pregnancies)
• lab...
Further ac@ons
• if the pregnant woman is identified as, or known to be a carrier – offer screening
to the baby’s father a...
3/21/20 ELBOHOTY 92
• In low prevalence areas
• the Family Origin Questionnaire (FOQ) is principally used as a tool to identify
women who are ...
”Low risk“ Family Origins
• United Kingdom (White)
• England, Scotland, Northern Ireland, Wales.
• Northern European (Whit...
Family origin questionnaire is not useful
• Adoption
• If either parent has been adopted, the FOQ information may not
accu...
Bone marrow transplants
•In women who have received a bone marrow transplant,
the haemoglobin results on her blood specime...
•The need for testing of the baby’s father in
possible cases of α0 thalassaemia in both low
and high prevalence areas will...
Tes?ng algorithm for laboratory screening in LOW
PREVALENCE area
3/21/20 ELBOHOTY 98
Testing algorithm for laboratory screening in HIGH
PREVALENCE areas
3/21/20 ELBOHOTY 99
Iron deficiency
• The Hb A2 level may be lowered by up to 0.5% in cases of severe iron deficiency
anaemia, however screeni...
Indications of anti D for all non-sensitised RhD-negative
women
:• Aner birth (500 IU within 72 hours with calculaAon of F...
3/21/20 ELBOHOTY
Screening for gestational
diabetes using risk factors
1. body mass index above 30 kg/m2
2. previous macro...
3/21/20 ELBOHOTY
Diagnosis of GDM based on
OGTT
1. Fasting plasma venous glucose
concentration greater than or equal
to 5....
Screening the fetus
The aims of screening the fetus are to:
•confirm fetal viability, gesta.onal age and diagnose mul.ple
g...
Confirmation of fetal viability and estimation of gestational
age
This is best done by the 'dating scan' and should be off...
Screening for chromosomal abnormali6es-
All women should be offered screening for Down’s, Edwards`
and Patau`s syndromes
C...
Down’s, Edwards` and Patau`s syndromes
• All pregnant women in England should be offered a screening test for
Down`s (1 :1...
Results
• one for Down’s syndrome and another for Edwards’ and Patau’s
syndromes.
• If the screening test shows that the c...
Screening for structural anomalies
•This should be offered between 18 weeks 0 days and 20
weeks 6 days
3/21/20 ELBOHOTY 109
3/21/20 ELBOHOTY 110
3/21/20 ELBOHOTY 111
Screening of fetal wellbeing during pregnancy
Each antenatal visit allows the opportunity to screen for fetal
growth and w...
3/21/20 ELBOHOTY 113
3/21/20 ELBOHOTY 114
3/21/20 ELBOHOTY 115
3/21/20 ELBOHOTY 116
3/21/20 ELBOHOTY 117
3/21/20 ELBOHOTY 118
3/21/20 ELBOHOTY 119
Screening
3/21/20 ELBOHOTY September 2014/March 2015
ANC
• Aims to triage the pregnancy from the booking visit and during subsequent
visists:
• High risk
• Low risk
• All wome...
3/21/20 ELBOHOTY
Serial measurement of SFH is
recommended at each antenatal
appointment from 24 weeks of
pregnancy as this...
3/21/20 ELBOHOTY 123
3/21/20 ELBOHOTY 124
Abnormal growth
• Women with single SFH which plots below the 10th centile or serial measurement
of fetal size which demon...
Sta@c growth
3/21/20 ELBOHOTY September 2014/March 2015
Slow growth
3/21/20 ELBOHOTY September 2014/March 2015
High risk pregnancy
• The likelihood of an adverse outcome (mortality or morbidity) in the mother
and/or the baby is great...
Risk factors for SGA
3/21/20 ELBOHOTY September 2014/March 2015
Vaccination
• Clinical classifications of vaccines.
3/21/20 ELBOHOTY 130
A prepara@on containing an@genic material:
• Dead microorganism (salk vaccine)
• Attenuated (harmless) microorganism (sabi...
3/21/20 ELBOHOTY 132
purified macromolecule vaccines
• inactivated toxins
• Bacterial toxins can be detoxified by formaldehyde treatment and use...
3/21/20 ELBOHOTY 134
3/21/20 ELBOHOTY 135
Rational during the pregnancy
• Toxoids, inactivated virus vaccines and immune globulin preparations
are generally conside...
Vaccines specially indicated in
pregnancy
•Inactivated influenza vaccine
•Pertussis (whooping cough) vaccine
•Inactivated ...
Influenza Vaccination
• Influenza vaccination in pregnancy
• Reduces maternal morbidity and mortality
• improves fetal out...
•Pregnant women should be offered the
diphtheria, tetanus, pertussis (whooping
cough) and polio (dTaP/IPV) vaccine in week...
whooping cough
•Women will now be offered the whooping cough
vaccine by their GP or maternity services from their
20th wee...
Pertussis, Diphteria, Tetanus, Poliomyelitis
• In the UK, Repevax (diphtheria, tetanus, acellular pertussis/
inactivated p...
Vaccines recommended in pregnancy in certain
situa?ons
• _ Hepatitis A vaccine
• _ Hepatitis B vaccine
• _ Meningococcus v...
Hepatitis A
•Formalin inactivated Hepatitis A is recommended if another
high risk condition or indication is present.
•Hig...
Hepatitis B
• Hepatitis B infection in pregnancy may result in severe hepatic disease
for the mother and chronic infection...
Meningococcal vaccine
• There is no evidence that either vaccine, the conjugated or the quadrivalent
vaccine, is unsafe.
•...
Pneumococcal conjugated vaccine
•The use of the pneumococcal conjugated
vaccine is limited among women of child
bearing ag...
Typhoid
•Pregnant women should be advised to
avoid travel to typhoid endemic areas but
may be immunised with the inactive
...
Rabies
•Rabies is virtually always fatal.
•Given the potentially disastrous consequences of
inadequately managed rabies ex...
Yellow fever
•Yellow fever is associated with a high case fatality
rate.
•If travel is unavoidable and the risk of yellow ...
Vaccines contraindicated in pregnancy
• BCG vaccine
• Measles vaccine
• Mumps vaccine
• Rubella vaccine
• Varicella vaccin...
Before the pregnanacy
•MMR vaccine – women should be counselled to avoid
becoming pregnant for 28 days after vaccination.
...
3/21/20ELBOHOTY
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2
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3
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4
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5
Folic
acid
Booking inv.
Hb & Ab
Combined test
+ Early scan Physical exam.
&
Screening
Anomaly scan
3/21/20ELBOHOTY
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6
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7
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8
Considerations for delivery
• Age > 40 years
• the small-for-gestaAonal-age fetus
• placenta praevia
• breech presentaAon
...
Pregnancy after 41 weeks
• Prior to formal induction of labour, women should be offered a vaginal
examination for membrane...
Age > 40 years
•Maternal age 40 years of older
constitutes a moderate risk factor for the
development of pre-eclampsia.
3/...
The risk of antepartum stillbirth at term
• The overall cumulative risk of antepartum stillbirth throughout gestation (fro...
• In presence of another moderate risk factor for PE give low dose aspirin from 12
weeks gestation
• Maternal age 40 years...
Placenta praevia
In approximately 1.5% of women the placenta will cover the cervical os at the 20
week scan. At delivery, ...
Breech presentation
Approximately 3% of singleton pregnancies are breech at term. This percentage
increases with decreasin...
3/21/20 elbohoty
Time of elec*ve deliveryIndication
> 41uncomplicated pregnancies
Around 40 weeksMaternal age > 40 years
<...
Newborn Blood Spot Screening
• The blood spot is taken on day 5 and in exceptional circumstances between day 5
and 8. The ...
Newborn Hearing
• 1 to 2 in 1000 babies in the UK are born with a permanent hearing loss or
deafness in one or both ears
•...
Newborn and Infant Physical Examination
• Screening is offered in the newborn and infant periods : the first by 72 hours o...
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Antenatal care

Antenatal care

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Antenatal care

  1. 1. Antenatal care Ahmed Elbohoty MD, MRCOG Assistant professor of obstetrics and gynecology Ain Shams University 3/21/20 ELBOHOTY 1
  2. 2. Pregnancy can be •Low risk pregnancy •High risk pregnancy •Mother •Fetus 3/21/20 ELBOHOTY 2
  3. 3. Pathway of care •Preconception •Antenatal •Intrapartum •Postpartum 3/21/20 ELBOHOTY 3
  4. 4. The aims of antenatal care are to: 1.Provide high-quality information 2.Provide an informed choice about the pathways of antenatal care 3.screen for maternal complications 4.screen for fetal complications 5.Assess maternal and fetal wellbeing throughout pregnancy 6.Provide advice and education on the normal symptoms of pregnancy 3/21/20 ELBOHOTY 4
  5. 5. Who? 1.general practitioners 2.community midwives 3.hospital midwives 4.obstetricians. 5.Often health professionals such as physiotherapists, social workers HIV physcians, Diabetogists, ……..are involved. 3/21/20 ELBOHOTY 5
  6. 6. •Antenatal care should be woman- centred. •Care offered to women should be planned carefully, ensuring the early detection of problems without becoming over-intrusive. •Women and their husbands/partners have the right to be involved in all decisions regarding their antenatal care. 3/21/20 ELBOHOTY 6
  7. 7. Assigning a care pathway •Midwife and GP-led models of care should be offered to women with uncomplicated pregnancies, but there should be clear referral pathways to specialists when either fetal or maternal problems are detected. 3/21/20 ELBOHOTY 7
  8. 8. Documentation of care •Structured maternity records should be used for antenatal care. •Maternity services should have a system in place whereby women carry their own case notes. •A standardised, national maternity record with an agreed minimum data set should be developed and used. 3/21/20 ELBOHOTY 8
  9. 9. The booking appointment •This usually takes place at the local surgery, hospital or home depending on accessibility. •The booking appointment is usually done by the community midwife •All information collected from the woman and all information given to her should be clearly documented in her maternity notes. 3/21/20 ELBOHOTY 9
  10. 10. 3/21/20 ELBOHOTY 10
  11. 11. 3/21/20 ELBOHOTY 11
  12. 12. Lifestyle considerations 3/21/20 ELBOHOTY 12
  13. 13. 3/21/20 ELBOHOTY 13
  14. 14. 3/21/20 ELBOHOTY 14
  15. 15. 3/21/20 ELBOHOTY 15
  16. 16. Food-acquired infections • Pregnant women should be offered informa5on on how to reduce the risk of listeriosis by: • drinking only pasteurised or UHT milk • not ea5ng ripened so> cheese such as Camembert, Brie and blue- veined cheese (there is no risk with hard cheeses, such as Cheddar, or coEage cheese and processed cheese) • not ea5ng pâté (of any sort, including vegetable) • not ea5ng uncooked or undercooked ready-prepared meals. • Pregnant women should be offered informa5on on how to reduce the risk of salmonella infec5on by: • avoiding raw or par5ally cooked eggs or food that may contain them (such as mayonnaise) • avoiding raw or par5ally cooked meat, especially poultry. 3/21/20 ELBOHOTY 16
  17. 17. 3/21/20 ELBOHOTY 17
  18. 18. • the safest 5me to fly is: • Before 37 weeks, for uncomplicated singlton pregnancy. • Before 32 weeks, for uncomplicated mul5ple pregnancy. • With regard to minimising the risk of DVT during long–haul flights las5ng more than 4 hours , appropriate general advice would be to: • have an aisle seat to facilitate ease of movement • take regular walks around the cabin and/or • carry out in–seat exercises approximately every 30 minutes on a medium or long–haul flight • maintain a good fluid intake and minimise caffeine and alcohol intake to avoid dehydra5on • make a specific individualised risk assessment for thrombosis in pregnant women who are flying. • LMWH for those with significant risk factors such as previous thrombosis or morbid obesity. 3/21/20 ELBOHOTY 18
  19. 19. Alcohol consumption •Advise women to avoid alcohol especially in first 3 months of pregnancy if possible •If women choose to drink alcohol they should be advised to drink no more than 1 to 2 UK units once or twice a week •there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level there is no evidence of harm to the unborn baby •Women should be informed that getting drunk or binge drinking during pregnancy may be harmful 3/21/20 ELBOHOTY 19
  20. 20. Risks • Fertility • Alcohol may be exerting toxic effects throughout the reproductive process from infertility through miscarriage, aneuploidy, structural congenital anomaly, disordered fetal growth, perinatal death, developmental delay and indeed susceptibility to disease in adult life. • Miscarriage and structural congenital malformations • Preterm labour • alcohol consumption both in early pregnancy and in late pregnancy and preterm birth but only at levels of consumption in excess of 10 drinks a week • Fetal growth and development • There is a clear dose response relationship between alcohol consumption in the second half of pregnancy and fetal growth. 3/21/20 ELBOHOTY 20
  21. 21. 3/21/20 ELBOHOTY 21
  22. 22. 3/21/20 ELBOHOTY 22
  23. 23. 3/21/20 ELBOHOTY 23
  24. 24. 3/21/20 ELBOHOTY 24
  25. 25. 3/21/20 ELBOHOTY 25
  26. 26. Equivalents •1 unit equals half a pint of ordinary strength lager or beer, or one shot [25 ml] of spirits. •One small [125 ml] glass of wine is equal to 1.5 UK units 3/21/20 ELBOHOTY 26
  27. 27. Smoking consumption •Use any appointment or meeting as an opportunity to ask women if they smoke. If they do, explain how NHS Stop Smoking Services can help people to quit and advise them to stop. •Offer those who want to stop a referral to NHS Stop Smoking Services. •Pregnant women should be informed about the specific risks of smoking during pregnancy (such as the risk of having a baby with low birthweight and preterm birth). The benefits of quitting at any stage should be emphasised.3/21/20 ELBOHOTY 27
  28. 28. Identifying pregnant women who smoke action for midwives • A carbon monoxide (CO) test is an immediate and non-invasive biochemical method for helping to assess whether or not someone smokes. However, it is unclear as to what consAtutes the best cut-off point for determining smoking status. • Some suggest a CO level as low as 3 parts per million (ppm), others use a cut-off point of 6–10 ppm. • It is important to note that CO quickly disappears from expired breath (the level can fall by 50% in less than 4 hours). As a result, low levels of smoking may go undetected and may be indisAnguishable from passive smoking. • Conversely, environmental factors such as traffic emissions or leaky gas appliances may cause a high CO reading – as may lactose intolerance. • When trying to idenAfy pregnant women who smoke, it is best to use a low cut- off point to avoid missing someone who may need help to quit. 3/21/20 ELBOHOTY 28
  29. 29. 3/21/20 ELBOHOTY 29
  30. 30. Nico@ne replacement therapy • Use only if smoking cessation without NRT fails. If they express a clear wish to receive NRT, use professional judgement when deciding whether to offer a prescription. • Only prescribe NRT for use once they have stopped smoking (they may set a particular date for this). • Only prescribe 2 weeks of NRT for use from the day they agreed to stop. Only give subsequent prescriptions to women who have demonstrated, on re-assessment, that they are still not smoking. • Advise pregnant women who are using nicotine patches to remove them before going to bed. • Neither varenicline or bupropion should be offered to pregnant or breastfeeding women 3/21/20 ELBOHOTY 30
  31. 31. vitamin D •All women should be informed at the booking appointment about the importance for their own and their baby’s health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding. •In order to achieve this, women may choose to take 10 micrograms of vitamin D per day, as found in the Healthy Start multivitamin supplement. 3/21/20 ELBOHOTY 31
  32. 32. Risks of deficiency • Pre-eclampsia and neonatal hypocalcaemia are the most prevalent complications of maternal hypocalcaemia and are clearly associated with substantial morbidity. • A statistical association of glucose intolerance and hypovitaminosis D has been demonstrated. • Maternal vitamin D is important to fetal bone development. • Fetal lung development and neonatal immune conditions such as asthma may relate in part to maternal vitamin D levels. • Vitamin D deficiency (< 37.5 nmol/l) has been associated with a four-fold increased risk of primary caesarean section (caesarean section performed for the first time),34 although this has not been demonstrated in all studies.16 Vitamin D deficiency is also associated with bacterial vaginosis in pregnant women. • Although it is not clear whether maternal vitamin D supplementation will prevent these conditions, a strategy for supplementation and treatment of maternal vitamin D deficiency is proposed. 3/21/20 ELBOHOTY 32
  33. 33. Neonatal • Fetal lung development and childhood immune disorders Low maternal vitamin D intake in pregnancy is associated with wheeze and asthma in the offspring.49 Low cord blood 25(OH)D concentra5ons have been associated with respiratory syncy5al virus bronchioli5s50 and respiratory infec5ons. • Maternal vitamin D levels have been shown to posi5vely correlate with birthweight cen5le. • Neonatal hypocalcaemic seizures Neonatal vitamin D levels are correlated with those of their mother, with maternal vitamin D deficiency increasing the risk of neonatal vitamin D deficiency. 3/21/20 ELBOHOTY 33
  34. 34. vitamin D •Healthcare professionals’ should take particular care to check that women at greatest risk of vitamin D deficiency are following advice to take this daily supplement. These include: • women of South Asian, African, Caribbean or Middle Eastern family origin • women who have limited exposure to sunlight, such as women who are predominantly • housebound, or usually remain covered when outdoors • women who eat a diet particularly low in vitamin D, such as women who consume nooily fish, eggs, meat, vitamin D-fortified margarine or breakfast cereal • women with a pre-pregnancy body mass index above 30 kg/m2. 3/21/20 ELBOHOTY 34
  35. 35. Health professionals should not routinely test people's vitamin D status unless: •they have symptoms of deficiency •they are considered to be at particularly high risk of deficiency (for example, they have very low exposure to sunlight) •there is a clinical reason to do so (for example, they have osteomalacia or have had a fall). 3/21/20 ELBOHOTY 35
  36. 36. Three categories of vitamin D supplementation are recommended. • In general, • vitamin D 10 micrograms (400 units) a day is recommended for all pregnant women (Healthy Start programme). • High-risk women • are advised to take at least 1000 units a day (women with increased skin pigmentation, reduced exposure to sunlight, or those who are socially excluded or obese) • Women at high risk of pre-eclampsia are advised to take at least 800 units a day combined with calcium. There may be particular benefits of vitamin D/calcium supplementation in women at risk of pre-eclampsia if it was associated with hypocalcemia. • Treatment. • For the majority of women who are deficient in vitamin D, treatment for 4–6 weeks, either with cholecalciferol 20 000 iu a week or ergocalciferol 10 000 iu twice a week, followed by standard supplementation, is appropriate. • For women who require short-term repletion, 20 000 iu weekly appears to be an effective and safe treatment of vitamin D deficiency. • A daily dose is likely to be appropriate to maintain subsequent repletion (1000 iu daily). In adults, very high doses of vitamin D (300 000–500 000 iu intramuscular [IM] bolus) may be associated with an increased risk of fractures and such high doses are not recommended in pregnancy 3/21/20 ELBOHOTY 36
  37. 37. 3/21/20 ELBOHOTY 37
  38. 38. • All patients receiving pharmacological doses of vitamin D should have their plasma-calcium 3/21/20 ELBOHOTY 38
  39. 39. Risks of treatment • Vitamin D may be inappropriate in sarcoidosis (where there may be vitamin D sensitivity) or ineffective in renal disease. • Deficient renal 1-α hydroxylation necessitates the use of active vitamin D metabolites, such as 1α-hydroxycholecalciferol or 1,25- dihydroxycholecalciferol. • Specialist medical advice should be sought in such cases. • The limitation to therapy compliance mostly relates to the calcium which has a side effect of tasting of chalk, rather than the vitamin D element of oral therapy. • It is often more appropriate to give vitamin D alone for patient acceptability. However, this is limited by the availability of suitable agents • In pregnancy there is enhanced intestinal calcium absorption. Vitamin D toxicity is manifested through hypercalcaemia and hypercalciuria. Therefore, there is a hypothetical concern that when secondary hyperparathyroidism follows vitamin D deficiency, calcium given with vitamin D may be associated with temporary hypercalcaemia3/21/20 ELBOHOTY 39
  40. 40. Folic acid •Pregnant women (and those intending to become pregnant) should be informed that dietary supplementation with folic acid, before conception and throughout the rest 12 weeks, reduces the risk of having a baby with a neural tube defect (for example, anencephaly or spina bi da). •The recommended dose is 400 micrograms per day. 3/21/20 ELBOHOTY 40
  41. 41. 5 mg per day is recommended for: •women who have previously had an infant with a neural tube defect •who are receiving anti-epileptic medication •who have diabetes •BMI >30 •Malabsorption syndrome (e.g. inflammatory bowel disease) •Women with known MTHFR mutation •Haemoglobinopathy - due to rapid turnover of cells (e.g. beta thalassaemia)3/21/20 ELBOHOTY 41
  42. 42. Avoid high dose of vitamin A •Pregnant women should be informed that vitamin A supplementation (intake above 700 micrograms) might be teratogenic and should therefore be avoided. Pregnant women should be informed that liver and liver products may also contain high levels of vitamin A, and therefore consumption of these products should also be avoided. 3/21/20 ELBOHOTY 42
  43. 43. Adverse effects of isotretinoin • Mood disturbance • Dryness of skin and mucous membranes • Facial erythema, eczema, hair loss, photosensi5vity, skin fragility, • paronychia and pyogenic granuloma • Myalgia and arthralgia • Photophobia, impaired night vision and kera55s • Nausea, coli5s and pancrea55s • Abnormali5es of liver func5on including hepa55s • Eleva5on of triglyceride and cholesterol levels • Bacterial overgrowth, e.g. Staphylococcus aureus • Cutaneous vasculi5s • Acne flare 3/21/20 ELBOHOTY 43
  44. 44. Malformations associated with isotretinoin use • Craniofacial defects: • ear defects • eye defects • cleft palate • micrognathia (small jaw) depressed nasal bridge dysmorphism • ocular hypertelorism (widely spaced eyes) • Central nervous system defects: • Microencephaly • facial nerve palsy • Hydrocephalus • cortical and cerebellar defects • Cardiovascular defects: • Fallot’s tetralogy • septal defects • transposition of the great vessels and aortic arch hypoplasia • Thymic abnormalities: • hypoplasia aplasia and ectopia3/21/20 ELBOHOTY 44
  45. 45. Management of common symptoms of pregnancy 3/21/20 ELBOHOTY 45
  46. 46. Nausea and vomiting in early pregnancy • most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks and that nausea and vomiting are not usually associated with a poor pregnancy outcome. • If a woman requests or would like to consider treatment, the following interventions appear to be effective in reducing symptoms: • non-pharmacological: • ginger • acupressure • pharmacological: • antihistamines. 3/21/20 ELBOHOTY 46
  47. 47. • Heartburn • Women who present with symptoms of heartburn in pregnancy should be offered information regarding lifestyle and diet modification. • Antacids may be offered to women whose heartburn remains troublesome despite lifestyle and diet modi cation. • Constipation • Women who present with constipation in pregnancy should be offered information regarding diet modi cation, such as bran or wheat bre supplementation. • Haemorrhoids • In the absence of evidence of the effectiveness of treatments for haemorrhoids in pregnancy, women should be offered information concerning diet modification. • If clinical symptoms remain troublesome, standard haemorrhoid creams should be considered. 3/21/20 ELBOHOTY 47
  48. 48. Constipation • The prevalence of cons5pa5on is es5mated to affect 11–38% of pregnancies. • Func5onal (primary) cons5pa5on is defined as infrequent bowel mo5on and/or difficulty in passing stool, which is not aEributable to an underlying pathology. • Secondary cons5pa5on results from either pharmacotherapy or a medical condi5on. • Medical condi5ons include • primary disease of the gastrointes5nal tract (such as, anal fissure, colorectal strictures and neoplasia), • metabolic disturbances (such as, hypothyroidism, hypercalcaemia) • neurological disorders. • Some individuals may suffer from irritable bowel syndrome associated with cons5pa5on (IBS-C).3/21/20 ELBOHOTY 48
  49. 49. 3/21/20 ELBOHOTY 49
  50. 50. The following circumstances warrant a prompt referral to a gastroenterologist: • A change in bowel habit for longer than 6 weeks. • Rectal bleeding. • Known history of gastrointestinal disorders such as • inflammatory bowel disease. • A family history of colorectal cancer. 3/21/20 ELBOHOTY 50
  51. 51. 3/21/20 ELBOHOTY 51
  52. 52. stop laxatives • When regular bowel movements occur without difficulty, laxatives can be withdrawn gradually. • The reduction in the dose of laxatives should be guided by the frequency and consistency of the stools. • Gradual withdrawal will reduce the risk of requiring re-initiation of therapy for recurrent faecal loading. • If a combination of laxatives is used, one laxative should be stopped at a time, reducing stimulant laxatives first. • Patients should be aware that the process of weaning off laxatives may take several months. 3/21/20 ELBOHOTY 52
  53. 53. • Varicose veins • Women should be informed that varicose veins are a common symptom of pregnancy that will not cause harm and that compression stockings can improve the symptoms but will not prevent varicose veins from emerging. • Vaginal discharge • Women should be informed that an increase in vaginal discharge is a common physiological change that occurs during pregnancy. If it is associated with itch, soreness, offensive smell or pain on passing urine there may be an infective cause and investigation should be considered. • A 1-week course of a topical imidazole is an effective treatment and should be considered for vaginal candidiasis infections in pregnant women. • The effectiveness and safety of oral treatments for vaginal candidiasis in pregnancy are uncertain and these treatments should not be offered. • Backache • Women should be informed that exercising in water, massage therapy and group or individual back care classes might help to ease backache during pregnancy. 3/21/20 ELBOHOTY 53
  54. 54. Screening at the booking visit •Screening is not a diagnostic test and the woman may need to be offered further tests to confirm a diagnosis •A woman may choose to opt out of some screening tests for personal reasons •Her decision must be respected •However, she must understand the implications of not being tested and this should be documented in her notes 3/21/20 ELBOHOTY 54
  55. 55. Obstetric history •Planned or not •Age •gesta.on •presen.ng complaint •history of presen.ng complaint •history of index pregnancy •past obstetric history •past medical history/past medical history •drug history •family history •social history 3/21/20ELBOHOTY 55
  56. 56. •Domestic violence: • at any visit you should be alert to signs and symptoms of domestic violence • women should also feel safe to discuss issues of domestic violence, which may not have been disclosed on the first visit 3/21/20 ELBOHOTY 56
  57. 57. Red spot system •An easy and cost-effective way to help women to reveal that they may be victims of domestic abuse is the red spot system. •Put the following notice or something with similar wording on the inside of the toilets where the women provide urine samples. Attach a small supply of red dots. •They can discreetly put one on the urine sample and her partner is unlikely to notice that the spot was not on before she went to the toilet even if they do notice it afterwards. •You now know you must find a way of seeing the woman on her own 3/21/20 ELBOHOTY 57
  58. 58. 3/21/20 ELBOHOTY 58
  59. 59. •Mental disorders: • any relevant history of mental health disorders, along with communica8on between healthcare professionals, should be documented in the notes 3/21/20 ELBOHOTY 59
  60. 60. Screening for depression and anxiety 3/21/20 ELBOHOTY At a woman's first contact with primary care or her booking visit, and during the early postnatal period, 60
  61. 61. •Consider asking the following depression identification questions : •During the past month, have you often been bothered by feeling down, depressed or hopeless? •During the past month, have you often been bothered by having little interest or pleasure in doing things? •Also consider asking about anxiety using the 2-item Generalized Anxiety Disorder scale (GAD-2): •During the past month, have you been feeling nervous, anxious or on edge? •During the past month have you not been able to stop or control worrying? 3/21/20 ELBOHOTY 61
  62. 62. History taking • past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in the postnatal period and severe depression • previous treatment by a psychiatrist/specialist mental health team, including inpatient care • a family history of perinatal mental illness. • Other specific predictors, such as poor relationships with her partner, should not be used for the routine prediction of the development of a mental disorder. 3/21/20 ELBOHOTY 62
  63. 63. Calculation of GA 3/21/20 ELBOHOTY 63
  64. 64. calcula6on of fetal gesta6onal age: • LMP • US • CRL • Based on day of embryo transfer in IVF • According to day 3 or 5 3/21/20 ELBOHOTY 64
  65. 65. By LMP (Naegele’s rule): • Prerequisites: • Sure of her date of 1st day of last menstrual period. • Regular cycle (at least the last 3 cycles of average duration and length). • No use of hormonal contraception in the last 3 cycles. • No lactation. • How to calculate: • The 1st day of LMP = day / month / year • The EDD = +7days of LMP / +9 months of LMP / year • To make calculations easier try to use these equations: • 1 month = 4wks + 2days (or 3 days). • 2 months = 8 wks + 5 days. • 3 months = 13 wks. • It overestimate GA • You can modify if the cycle if frequency is not 28 days • For 21 day cycle: The EDD = +9 months of LMP / year so Add one week to the GA • For 35 day cycle: The EDD = +14 days of LMP / +9 months of LMP / year so Remove one week from the GA 3/21/20 ELBOHOTY 65
  66. 66. Late bookers • NICE recommends that the booking appointment should occur by 10 weeks of gestation. • Late bookers are at an increased risk of perinatal mortality and around 20% of women who died from direct or indirect causes booked for maternity care after 20 weeks of gestation. 3/21/20 ELBOHOTY 66
  67. 67. Women are more likely to book late if they are: 1.black and ethnic minority teenagers (whether born inside or outside the UK) 2.from deprived areas 3.single parents 4.are mulAparous 5.have a history of alcohol or substance abuse 6.are of low intelligence 7.are in an abusive relaAonship 8.have difficulty with access to health care 3/21/20 ELBOHOTY 67
  68. 68. Clinical examination The following must be examined or asked for during the antenatal period. Measurement of weight and body mass index: the maternal weight and height should be measured at the first contact visit and BMI calculated routine repeated weighing is not recommended • Female genital mutilation • Pregnant women who have had female genital mutilation should be identified early in antenatal care through sensitive enquiry. Antenatal examination will then allow planning of intrapartum care. 3/21/20 ELBOHOTY 68
  69. 69. • Breast examination • Routine breast examination during antenatal care is not recommended for the promotion of postnatal breastfeeding. • Pelvic examination • Routine antenatal pelvic examination does not accurately assess gestational age, nor does it accurately predict preterm birth or cephalopelvic disproportion. It is not recommended. 3/21/20 ELBOHOTY 69
  70. 70. Migrant women They should have a medical assessment of their overall health and a cardiovascular examination at booking women from countries where genital mutilation is prevalent should be sensitively questioned and examined 3/21/20 ELBOHOTY 70
  71. 71. Pregnant asylum seekers • They are a highly vulnerable and socially excluded group of women. • They have complex medical and psychosocial healthcare needs, often booking late, possibly secondary to dispersal. • Healthcare professionals may have limited knowledge of the asylum process in the UK and therefore at times risk providing suboptimal care for these women. • Studies and government reports have suggested that small yet practical changes can lead to empowerment of these women and improve their health, mental wellbeing and quality of life and that of their babies. 3/21/20 ELBOHOTY 71
  72. 72. 3/21/20 ELBOHOTY 72
  73. 73. 3/21/20 ELBOHOTY 73
  74. 74. 3/21/20 ELBOHOTY 74
  75. 75. Screening for clinical conditions • All pregnant women within the UK should be screened for the following conditions: • VTE: Risk factors • Anaemia (Hb) • gestational diabetes (risk factors) • hypertensive disease and pre-eclampsia (Blood pressure measurment and urine analysis) • blood groups and red cell auto-antibodies • haemoglobinopathies – sickle cell and thallasaemias • infection – asymptomatic bacturia, hepatitis B, HIV, rubella and syphilis • placenta praevia (scan) 3/21/20 ELBOHOTY 75
  76. 76. Identifies Example Existing conditions that may worsen during pregnancy •Medical conditions such as diabetes, hypertension, cardiac conditions, infections •Mental conditions such as depression, bipolar disorders •Social issues such as substance abuse and domestic violence Women at risk of developing conditions that may adversely affect the pregnancy •Gestational diabetes •Pre-eclampsia Identifying conditions with postnatal implications •Social issues •Infection (HIV, hepatitis B) 3/21/20 ELBOHOTY 76
  77. 77. 3/21/20 ELBOHOTY 77
  78. 78. Women needing additional care 3/21/20 ELBOHOTY 78
  79. 79. • Screening for pre-eclampsia • Pre-eclampsia is hypertension associated with proteinuria that occurrs after 20 weeks of gestation and resolves after birth, and chronic hypertension occurs before this. • Blood pressure measurement and urinalysis for protein must be measured at each antenatal visit. • Mothers should be warned of the symptoms of pre-eclampsia (frontal headache, epigastric pain, vomiting and visual disturbances) • Key figures • Pre-eclampsia affects 5–10% of pregnancies • Severe pre-eclampsia affects 1–2% of pregnancies • Eclampsia affects about 1:2000 of pregnant women 3/21/20 ELBOHOTY 79
  80. 80. 3/21/20 ELBOHOTY 80
  81. 81. Blood pressure should be measured as outlined below: • remove tight clothing, ensure arm is relaxed and supported at heart level • use cuff of appropriate size • inflate cuff to 20–30 mmHg above palpated systolic blood pressure • lower column slowly, by 2 mmHg per second or per beat • read blood pressure to the nearest 2 mmHg measure diastolic blood pressure as disappearance of sounds (phase V). • Hypertension in which there is a single diastolic blood pressure of 110 mmHg or two consecutive readings of 90 mmHg at least 4 hours apart and/or significant proteinuria (1+) should prompt increased surveillance. • If the systolic blood pressure is above 160 mmHg on two consecutive readings at least 4 hours apart, treatment should be considered. • 3/21/20 ELBOHOTY 81
  82. 82. • All pregnant women should be made aware of the need to seek immediate advice from a healthcare professional if they experience symptoms of pre- eclampsia. • Symptoms include: • severe headache • problems with vision, such as blurring or ashing before the eyes severe pain just below the ribs • Vomiting • sudden swelling of the face, hands or feet. 3/21/20 ELBOHOTY 82
  83. 83. Screening for infections • asymptomatic bacteriuria • HIV, rubella, syphilis and hepatitis B 3/21/20 ELBOHOTY 83
  84. 84. Asymptomatic bacteriuria This is defined as the presence of bacterial colonisation of the urinary tract in the absence of symptoms It occurs in 2–5% of pregnant women It is associated with pyelonephritis (30%), preterm labour and structural abnormalities of the renal tract (3–5%) Midstream culture should be performed early in pregnancy Treatment reduces the risk of pyelonephritis and preterm labour 3/21/20 ELBOHOTY 84
  85. 85. HIV, syphilis and hepatitis B • Currently four infections are screened for in the UK: • human immunodeficiency virus (HIV) • syphilis • hepatitis B • Maternal blood should be screened at booking and with the woman's consent 3/21/20 ELBOHOTY 85
  86. 86. Screening for haematological disorders • anaemia • blood groups and red cell antibodies • haemoglobinopathies 3/21/20 ELBOHOTY 86
  87. 87. Diagnosis of anaemia •Anaemia in pregnancy is defined as • first trimester haemoglobin (Hb) less than 110 g/l •second/third trimester Hb less than 105 g/l •postpartum Hb less than 100 g/l 3/21/20 ELBOHOTY 87
  88. 88. haemoglobinopathies •Sickle cell and thallassaemia are the two most common haemoglobinopathies in the UK. •Screening for should be offered to women as early as possible in pregnancy (ideally by 10 weeks) 3/21/20 ELBOHOTY 88
  89. 89. •MCV is done as a part of CBC •Screening tests offered for sickle cell depends on it's prevalence within that area •high prevalence is more than 1.5 per 10,000 pregnancies •low prevalence is less than or equal to 1.5 per 10,000 pregnancies). • The designation of high and low prevalence is kept under review based on newborn screening carrier results. • The list of high and low prevalence Trusts can be found at sct.screening.nhs.uk/ evaluationsreviewssurveys. • In Trusts defined as covering high prevalence populations, laboratory sickle cell and thalassaemia screening should be offered to all women. 3/21/20 ELBOHOTY 89
  90. 90. Diagnosis •Where prevalence of sickle cell disease is high (fetal prevalence above 1.5 cases per 10,000 pregnancies) • laboratory screening (preferably high-performance liquid chromatography) should be offered to all pregnant women to identify carriers of sickle cell disease and/or thalassaemia. •Where prevalence of sickle cell disease is low fetal prevalence 1.5 cases per 10,000 pregnancies or below) • all pregnant women should be offered screening for haemoglobinopathies using the Family Origin Questionnaire. • If the Family Origin Questionnaire indicates a high risk of sickle cell disorders, laboratory screening (preferably high-performance liquid chromatography) should be offered. •If the mean corpuscular haemoglobin is below 27 picograms, laboratory screening (preferably high-performance liquid chromatography) should be offered. 3/21/20 ELBOHOTY 90
  91. 91. Further ac@ons • if the pregnant woman is identified as, or known to be a carrier – offer screening to the baby’s father as soon as possible • if the pregnant woman and baby’s father are identified as carriers or affected refer for counselling and offer prenatal diagnosis by 12+ 6 weeks of pregnancy • all babies are offered screening for sickle cell disease as part of newborn blood spot screening • testing can be carried out pre conceptually on request 3/21/20 ELBOHOTY 91
  92. 92. 3/21/20 ELBOHOTY 92
  93. 93. • In low prevalence areas • the Family Origin Questionnaire (FOQ) is principally used as a tool to identify women who are at highest risk of being a carrier or having a baby with a haemoglobin variant or disorder. • In high and low prevalence areas • the FOQ is used as a tool by laboratory staff to help with the interpretation of results, particularly in the interpretation of results indicating possible alpha or beta thalassaemia. • The family origin is also relevant in the interpretation of red blood cell indices and essential for accurate prenatal diagnosis. More information about its use can found in the laboratory handbook: http://sct.screening.nhs.uk/publications • Therefore you need to ask for the family origins of both the woman AND the baby's father going back at least 2 generations (or more if possible). • Women with Sickle Cell Disease • Screening will also identify women with sickle cell disease, who should be considered ”high risk“ requiring specialist care during pregnancy from an Obstetrician and Haematologist, and who should be booked for a hospital delivery. 3/21/20 ELBOHOTY 93
  94. 94. ”Low risk“ Family Origins • United Kingdom (White) • England, Scotland, Northern Ireland, Wales. • Northern European (White) • Austria, Belgium, Denmark, Greenland, Iceland, Ireland (Eire), Finland, France, Germany, Luxembourg, Netherlands, Norway, Sweden, Switzerland. • Some populations of the following countries have Northern European origin (countries listed above) and are also at low risk for haemoglobin variants: • Northern European Origin (White) • Australia, North America (USA, Canada), South Africa, New Zealand. 3/21/20 ELBOHOTY 94
  95. 95. Family origin questionnaire is not useful • Adoption • If either parent has been adopted, the FOQ information may not accurately reflect the true family origins. Such cases should be treated as high risk and have full laboratory screening. • Fertility treatment – donor gametes • If the pregnancy has been achieved by the use of a donor egg then the screening results on the woman will not be informative so the baby’s father should always be tested to ensure that this is not a high risk pregnancy. • If donor sperm has been used then it may be appropriate to refer back to the fertility clinic if the screening results on the woman show that she is a carrier for a haemoglobinopathy. 3/21/20 ELBOHOTY 95
  96. 96. Bone marrow transplants •In women who have received a bone marrow transplant, the haemoglobin results on her blood specimen will not necessarily indicate the gene.c make up of the fetus. •The baby’s father should always be tested to ensure that this is not a high risk pregnancy. •Cau.on should be exercised in the interpreta.on of any haematology results in this instance. •If DNA confirma.on of mother’s status is required then pre- transplant DNA or DNA obtained from hair follicles should be used. 3/21/20 ELBOHOTY 96
  97. 97. •The need for testing of the baby’s father in possible cases of α0 thalassaemia in both low and high prevalence areas will also be determined from the family origin questionnaire in conjunction with the red cell indices. •All women should be screened for thalassaemia using the red cell MCH measurement. 3/21/20 ELBOHOTY 97
  98. 98. Tes?ng algorithm for laboratory screening in LOW PREVALENCE area 3/21/20 ELBOHOTY 98
  99. 99. Testing algorithm for laboratory screening in HIGH PREVALENCE areas 3/21/20 ELBOHOTY 99
  100. 100. Iron deficiency • The Hb A2 level may be lowered by up to 0.5% in cases of severe iron deficiency anaemia, however screening for haemoglobin variants and thalassaemia should proceed without regard to iron deficiency, suspected or proven. • Any decrease in MCH should be regarded as potentially due to a haemoglobinopathy and the Hb A2 should be measured. If the Hb A2 is equal to or greater than 3.5% or if the woman’s haemoglobin is less than 80 g/L and the Hb A2 is between 3.0% and 3.5%, testing of the baby’s father is recommended. It may be appropriate to simultaneously investigate pregnant women for iron deficiency, using ferritin or zinc protoporphyrin (ZPP) but this is not specifically part of the screening protocols. • In pregnant women there is no justification for delaying the investigation • of haemoglobinopathies whilst treating iron deficiency, as this will delay the process of identifying at-risk carrier couples who should be offered prenatal diagnosis. • Justification for above approach • Iron deficiency makes the red cell indices difficult to interpret and so an underlying haemoglobinopathy may be present. Severe iron deficiency anaemia (Hb < 80 g/L) can also reduce the Hb A2 level slightly (up to 0.5%), but in practice this should not interfere with the screening protocol and testing of the baby’s father should still be requested. If the father is found to be iron deficient, this could be a significant clinical finding and he should be referred to his General Practitioner.3/21/20 ELBOHOTY 100
  101. 101. Indications of anti D for all non-sensitised RhD-negative women :• Aner birth (500 IU within 72 hours with calculaAon of FMH) • rouAne antenatal anA-D prophylaxis • At 28 and 34 (500IU) • At 28 (1500 IU) • threatened miscarriage, spontaneous complete or incomplete miscarriage at or aner 12 weeks of gestaAon. • surgical evacuaAon of the uterus or surgical management of ectopic pregnancy • therapeuAc terminaAon of pregnancy, whether by surgical or medical methods • invasive tesAng • APHge • ECV 3/21/20 ELBOHOTY 101
  102. 102. 3/21/20 ELBOHOTY Screening for gestational diabetes using risk factors 1. body mass index above 30 kg/m2 2. previous macrosomic baby weighing 4.5 kg or above 3. previous gestational diabetes 4. family history of diabetes (first-degree relative with diabetes) 5. family origin with a high prevalence of diabetes South Asian (speci cally women whose country of family origin is India, Pakistan or Bangladesh) black Caribbean Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt). 6. Glucosuria +2 or 2 times +1 Confirmatory test: OGT usually at 24 weeks except if previous GDM do at booking or self monitoring 102
  103. 103. 3/21/20 ELBOHOTY Diagnosis of GDM based on OGTT 1. Fasting plasma venous glucose concentration greater than or equal to 5.6 mmol/litre or 2. 2-hour plasma venous glucose concentration greater than or equal to 7.8 mmol/litre. 103
  104. 104. Screening the fetus The aims of screening the fetus are to: •confirm fetal viability, gesta.onal age and diagnose mul.ple gesta.on •Screen for structural and chromosomal anomalies •screen for fetal growth and fetal wellbeing 3/21/20 ELBOHOTY 104
  105. 105. Confirmation of fetal viability and estimation of gestational age This is best done by the 'dating scan' and should be offered between 10 weeks 0 days and 13 weeks + 6 days: the crown–rump length is measured with the fetus in the neutral position if the crown–rump length is above 84 mm, then the head circumference should be used the dating scan will confirm viability, detect up to 80% of lethal abnormalities, detect multiple pregnancies and allow accurate assessment of chorionicity it ensures consistency of gestational age measurements and reduces the need for induction of labour at 41 weeks of gestation it can be incorporated into the combined screening test for Down syndrome between 11 weeks and 13 weeks 6 days.3/21/20 ELBOHOTY 105
  106. 106. Screening for chromosomal abnormali6es- All women should be offered screening for Down’s, Edwards` and Patau`s syndromes Currently, the recommendations are to provide the 'combined test' (nuchal translucency, beta-human chorionic gonadotrophin, pregnancy-associated plasma protein-A) between 11 weeks 0 days and 13 weeks 6 days. For women who book later in pregnancy, the most clinically and cost-effective serum screening test (quadruple test) should be offered between 15 weeks 0 days and 20 weeks 0 days If the probability of the woman to have a baby with Down syndrome > 1/150 offer her a diagnostic test3/21/20 ELBOHOTY 106
  107. 107. Down’s, Edwards` and Patau`s syndromes • All pregnant women in England should be offered a screening test for Down`s (1 :1000), Edwards` (3 :10000) and Patau`s (2:10000) syndromes that meets agreed national standards • The recommended screening strategy in the first trimester for Down`s, Edwards` and Patau`s syndromes is the `Combined test` • Optimum time for screening is when fetal crown rump length (CRL) is between 45.0mm and 84.0mm, which equates to 11+2 and 14+1 weeks • The recommended screening strategy for Down`s syndrome only for women booking later in pregnancy or when it is not possible to measure the nuchal translucency is the `Quadruple test` between 14+2 and 20+0 weeks • The recommended screening strategy for Edwards` and Patau`s syndromes for women booking later in pregnancy or when it is not possible to measure the nuchal translucency is the fetal anomaly ultrasound scan undertaken between 18+0 and 23+0 weeks 3/21/20 ELBOHOTY 107
  108. 108. Results • one for Down’s syndrome and another for Edwards’ and Patau’s syndromes. • If the screening test shows that the chance of the baby having Down’s, Edwards’ or Patau’s syndrome is lower than 1 in 150 this is called a “lower- chance” result. Over 95 out of 100 (95%) screening test results will be lower chance. A lower-chance result does not mean that there is no chance at all of the baby having Down’s, Edwards’ or Patau’s syndrome. • If the screening test shows that the chance of the baby having Down’s, Edwards’ or Patau’s syndrome is higher than 1 in 150 – that is from 1 in 2 to 1 in 150 – this is called a “higher-chance” result. Fewer than 1 in 20 (5%) of screening test results will be higher chance. A higher-chance result does not mean the baby definitely has Down’s, Edwards’ or Patau’s syndrome. 3/21/20 ELBOHOTY 108
  109. 109. Screening for structural anomalies •This should be offered between 18 weeks 0 days and 20 weeks 6 days 3/21/20 ELBOHOTY 109
  110. 110. 3/21/20 ELBOHOTY 110
  111. 111. 3/21/20 ELBOHOTY 111
  112. 112. Screening of fetal wellbeing during pregnancy Each antenatal visit allows the opportunity to screen for fetal growth and wellbeing. The following should be performed during each antenatal visit: •from 24 weeks – measurement of the symphysis–fundal height •from 36 weeks – abdominal palpation for presentation There is no evidence that the following practices have any benefit in routine antenatal care: •routine auscultation of the fetal heart •routine monitoring of fetal movements (however, a woman should contact her midwife or hospital if she notices a reduction in fetal movements) • The evidence does not support the routine use of antenatal electronic fetal heart rate monitoring (cardiotocography) for fetal assessment in women with an uncomplicated pregnancy and therefore it should not be offered. • The evidence does not support the routine use of ultrasound scanning after 24 weeks of gestation and therefore it should not be offered.3/21/20 ELBOHOTY 112
  113. 113. 3/21/20 ELBOHOTY 113
  114. 114. 3/21/20 ELBOHOTY 114
  115. 115. 3/21/20 ELBOHOTY 115
  116. 116. 3/21/20 ELBOHOTY 116
  117. 117. 3/21/20 ELBOHOTY 117
  118. 118. 3/21/20 ELBOHOTY 118
  119. 119. 3/21/20 ELBOHOTY 119
  120. 120. Screening 3/21/20 ELBOHOTY September 2014/March 2015
  121. 121. ANC • Aims to triage the pregnancy from the booking visit and during subsequent visists: • High risk • Low risk • All women should be assessed at booking for risk factors for SGA fetus/neonate to identify those who require increased surveillance. 3/21/20 ELBOHOTY September 2014/March 2015
  122. 122. 3/21/20 ELBOHOTY Serial measurement of SFH is recommended at each antenatal appointment from 24 weeks of pregnancy as this improves prediction of SGA. SFH should be plotted on a customised rather than a population-based chart as this may improve prediction of SGA neonate. Abdominal palpation has limited accuracy for the prediction of SGA neonate & thus should not be routinely performed for this purpose. For low risk pregnancies 122
  123. 123. 3/21/20 ELBOHOTY 123
  124. 124. 3/21/20 ELBOHOTY 124
  125. 125. Abnormal growth • Women with single SFH which plots below the 10th centile or serial measurement of fetal size which demonstrates slow or static growth by crossing centiles should be referred for ultrasound measurement of fetal size. 3/21/20 ELBOHOTY Routine fetal biometry is thus not justified. September 2014/March 2015
  126. 126. Sta@c growth 3/21/20 ELBOHOTY September 2014/March 2015
  127. 127. Slow growth 3/21/20 ELBOHOTY September 2014/March 2015
  128. 128. High risk pregnancy • The likelihood of an adverse outcome (mortality or morbidity) in the mother and/or the baby is greater than that in the general population 3/21/20 ELBOHOTY September 2014/March 2015
  129. 129. Risk factors for SGA 3/21/20 ELBOHOTY September 2014/March 2015
  130. 130. Vaccination • Clinical classifications of vaccines. 3/21/20 ELBOHOTY 130
  131. 131. A prepara@on containing an@genic material: • Dead microorganism (salk vaccine) • Attenuated (harmless) microorganism (sabine, MMR, .. • Toxoid (harmless form of toxin) (DPT) • Recombinant DNA techniques (HPV) • Subunits 3/21/20 ELBOHOTY 131
  132. 132. 3/21/20 ELBOHOTY 132
  133. 133. purified macromolecule vaccines • inactivated toxins • Bacterial toxins can be detoxified by formaldehyde treatment and used to stimulate immunity. Examples include diphtheria toxoid and tetanus toxoid. • conjugate vaccines • Conjugate vaccines or carbohydrate vaccines are polysaccharides. As the glycans tend to be poorly immunogenic, they are conjugated to a carrier protein to increase their immunogenicity. Examples include Haemophilus influenzae vaccine, Neisseria meningitidis vaccine and Streptococcus pneumoniae vaccine. • subunit vaccines. • Sub-unit vaccines – make use of the most antigenic subunit of the organism. These can be produced by genetic engineering • for example Dane particle from the surface antigen of hepatitis B virus (hepatitis B vaccine). 3/21/20 ELBOHOTY 133
  134. 134. 3/21/20 ELBOHOTY 134
  135. 135. 3/21/20 ELBOHOTY 135
  136. 136. Rational during the pregnancy • Toxoids, inactivated virus vaccines and immune globulin preparations are generally considered safe for administration to pregnant women because there is neither evidence nor biological plausibility of harmful effects on the fetus or pregnancy. • Nevertheless, if prompt administration is not medically indicated, it is preferable to delay administration of these agents until the second trimester to allow for completion of the critical period of fetal organogenesis 3/21/20 ELBOHOTY 136
  137. 137. Vaccines specially indicated in pregnancy •Inactivated influenza vaccine •Pertussis (whooping cough) vaccine •Inactivated polio vaccine •Diphtheria toxoid •Tetanus toxoid 3/21/20 ELBOHOTY 137
  138. 138. Influenza Vaccination • Influenza vaccination in pregnancy • Reduces maternal morbidity and mortality • improves fetal outcomes including reduced likelihood of perinatal death, prematurity and low birth weight, • prevents influenza in the infant up to 6 months of age through transfer of maternal antibodies and potentially improves long-term adult outcomes for the infant • The nasal spray vaccine is live attenuated virus and contraindicated during pregnancy, while intramuscular vaccine is killed virus and can be given in the first trimester.3/21/20 ELBOHOTY 138
  139. 139. •Pregnant women should be offered the diphtheria, tetanus, pertussis (whooping cough) and polio (dTaP/IPV) vaccine in weeks 28–38 of their pregnancy (ideally in weeks 28– 32), for each pregnancy. •The pertussis vaccine can be given at the same time as the influenza vaccine but pertussis vaccination should not be given early in order to offer the vaccines at the same time as this will compromise the passive protection to the infant.3/21/20 ELBOHOTY 139
  140. 140. whooping cough •Women will now be offered the whooping cough vaccine by their GP or maternity services from their 20th week of pregnancy (almost at 28 weeks). •Pregnant women who receive the whooping cough vaccination produce antibodies to whooping cough which are passed through the placenta to their baby. •The baby then has good protection against whooping cough when it is born. •This protection will wear off and babies should receive their routine whooping cough vaccine from 8 weeks of age3/21/20 ELBOHOTY 140
  141. 141. Pertussis, Diphteria, Tetanus, Poliomyelitis • In the UK, Repevax (diphtheria, tetanus, acellular pertussis/ inactivated polio vaccine [DTap]) was the recommended vaccine for this programme. • Although the optimal timing for the DTaP vaccine administration is between 28 weeks and 32 weeks of gestation, this can be given at any time during the pregnancy. • In July 2014 Repevax was replaced by Boostrix IPV – the 4 in 1 vaccine containing diphtheria toxoid, tetanus toxoid, acellular pertussis and inactivated polio vaccine 3/21/20 ELBOHOTY 141
  142. 142. Vaccines recommended in pregnancy in certain situa?ons • _ Hepatitis A vaccine • _ Hepatitis B vaccine • _ Meningococcus vaccine • _ Pneumococcal vaccine • _ Rabies vaccine • _ Typhoid vaccine • _ Yellow fever vaccine 3/21/20 ELBOHOTY 142
  143. 143. Hepatitis A •Formalin inactivated Hepatitis A is recommended if another high risk condition or indication is present. •High-risk factors for Hepatitis A23 include: • long-term liver disease • haemophilia • intravenous illegal drugs • working with or near sewage • working in institutions where levels of personal hygiene may be poor • working with primates (monkeys, apes, chimps and gorillas) 3/21/20 ELBOHOTY 143
  144. 144. Hepatitis B • Hepatitis B infection in pregnancy may result in severe hepatic disease for the mother and chronic infection for the baby. Hence, if a pregnant woman is in a high-risk category, Hepatitis B vaccination should not be withheld.25 As this is an inactivated subunit vaccine, the risks to the unborn baby are negligible.26 • Women considered to be at risk of Hepatitis B27 and would therefore benefit from vaccination28 are: • women who inject drugs or have a partner who injects drugs • women with multiple sexual partners • women who are close family and sexual partners of a • patient with Hepatitis B • women who receive regular blood transfusions or blood products • women with liver disease or chronic kidney disease • women travelling to high risk countries • female sex workers • women who work in settings that place them at risk of contact with body fluids, such as nurses, doctors, dentists and lab staff. 3/21/20 ELBOHOTY 144
  145. 145. Meningococcal vaccine • There is no evidence that either vaccine, the conjugated or the quadrivalent vaccine, is unsafe. • The usual advice is to avoid vaccinaAon unless the mother is at high risk of disease. • Women considered to be at high risk of meningococcal disease are those: • with funcional and anatomical asplenia • with immunosuppression • with complement deficiency • who travel to high-risk endemic areas • who have contact with infected individuals • who are university students under the age of 25 years. • The vaccines are safe to give to women who are breasseeding. The two available vaccines are Meningococcal Group C conjugated vaccine (MenC) and quadrivalent (ACW135Y) polysaccharide vaccine. • The UK Department of Health recommends that the conjugated vaccine be used in preference to the polysaccharide vaccine because it provides beter and longer lasAng protecAon. 3/21/20 ELBOHOTY 145
  146. 146. Pneumococcal conjugated vaccine •The use of the pneumococcal conjugated vaccine is limited among women of child bearing age. •Ideally the vaccine should be given prior to conception but the indication for administration (patients with functional or anatomical asplenia, sickle cell disease, splenectomy or patients with HIV) are not altered by pregnancy. 3/21/20 ELBOHOTY 146
  147. 147. Typhoid •Pregnant women should be advised to avoid travel to typhoid endemic areas but may be immunised with the inactive parenteral vaccine if such exposure is unavoidable 3/21/20 ELBOHOTY 147
  148. 148. Rabies •Rabies is virtually always fatal. •Given the potentially disastrous consequences of inadequately managed rabies exposure to both mother and baby and the fact that it is an inactivated viral vaccine, pregnancy is not considered a contraindication to postexposure prophylaxis. •Pre-exposure prophylaxis against rabies may be justified during pregnancy, where the risk of exposure to rabies is substantial. 3/21/20 ELBOHOTY 148
  149. 149. Yellow fever •Yellow fever is associated with a high case fatality rate. •If travel is unavoidable and the risk of yellow fever is high, immunization with live attenuated viral vaccine may be considered after discussion with an infectious disease specialist. •Pregnancy is a precaution for yellow fever vaccine administration, compared with other live vaccines which are contraindicated in pregnancy. 3/21/20 ELBOHOTY 149
  150. 150. Vaccines contraindicated in pregnancy • BCG vaccine • Measles vaccine • Mumps vaccine • Rubella vaccine • Varicella vaccine • Vaccinia vaccine • Human papillomavirus vaccine The risk–benefit ratio of administering live vaccines to pregnant women should be weighed individually for each patient in consultation with an infectious disease expert. 3/21/20 ELBOHOTY 150
  151. 151. Before the pregnanacy •MMR vaccine – women should be counselled to avoid becoming pregnant for 28 days after vaccination. •Varicella vaccine – Varicella vaccination prepregnancy or postpartum is an option that should be considered for women who are found to be seronegative for VZV IgG. It is a live attenuated vaccine administered in two separate doses 4–8 weeks apart. •If a woman of reproductive age is vaccinated, she should be advised to avoid pregnancy for 1 month after each dose and to avoid contact with other susceptible pregnant women should a postvaccination rash occur. 3/21/20 ELBOHOTY 151
  152. 152. 3/21/20ELBOHOTY 15 2
  153. 153. 3/21/20ELBOHOTY 15 3
  154. 154. 3/21/20ELBOHOTY 15 4
  155. 155. 3/21/20ELBOHOTY 15 5
  156. 156. Folic acid Booking inv. Hb & Ab Combined test + Early scan Physical exam. & Screening Anomaly scan 3/21/20ELBOHOTY 15 6
  157. 157. 3/21/20ELBOHOTY 15 7
  158. 158. 3/21/20ELBOHOTY 15 8
  159. 159. Considerations for delivery • Age > 40 years • the small-for-gestaAonal-age fetus • placenta praevia • breech presentaAon • pregnancy aner 41 weeks of gestaAon and women who decline inducAon of labour • birth aner caesarean • 3/21/20 ELBOHOTY 159
  160. 160. Pregnancy after 41 weeks • Prior to formal induction of labour, women should be offered a vaginal examination for membrane sweeping. • Women with uncomplicated pregnancies should be offered induction of labour beyond 41 weeks. • From 42 weeks, women who decline induction of labour should be offered increased antenatal monitoring consisting of at least twice-weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth. 3/21/20 ELBOHOTY 160
  161. 161. Age > 40 years •Maternal age 40 years of older constitutes a moderate risk factor for the development of pre-eclampsia. 3/21/20 ELBOHOTY 161
  162. 162. The risk of antepartum stillbirth at term • The overall cumulative risk of antepartum stillbirth throughout gestation (from 20 to 41 completed weeks) for women of all ages is 6.5 per 1000 pregnancies. • The cumulative risks of stillbirth for women younger than 35 years, 35 to 39 years and older than 40 years old, were 6.2, 7.9, and 12.8, respectively. 3/21/20 ELBOHOTY 162
  163. 163. • In presence of another moderate risk factor for PE give low dose aspirin from 12 weeks gestation • Maternal age 40 years or older should be offered serial ultra- sounds for growth and umbilical artery Doppler from 26 to 28 weeks. • Consideration should be given to offering women of advanced maternal age induction of labour from 39 weeks’ gestation (it decreses SB with no increase in CS rate). 3/21/20 ELBOHOTY 163
  164. 164. Placenta praevia In approximately 1.5% of women the placenta will cover the cervical os at the 20 week scan. At delivery, 0.14% will have a placenta praevia. Current recommendations If the placenta extends over the internal os at the routine 20 week anomaly scan, you should offer a transabdominal scan at 32 weeks of gestation. (Transvaginal scanning may give clearer images, especially for the posterior placenta). Women who have had a previous caesarean section must have placental localisation in their current pregnancy in order to exclude placenta praevia. If placenta praevia is present, investigations for praevia accreta may be appropriate. 3/21/20 ELBOHOTY 164
  165. 165. Breech presentation Approximately 3% of singleton pregnancies are breech at term. This percentage increases with decreasing gestational age. Where it is not possible to schedule an appointment for external cephalic version at 37 weeks, it should be scheduled at 36 weeks. • Women undergoing ECV who are D negative should undergo testing for fetomaternal haemorrhage and be offered anti-D 3/21/20 ELBOHOTY 165
  166. 166. 3/21/20 elbohoty Time of elec*ve deliveryIndication > 41uncomplicated pregnancies Around 40 weeksMaternal age > 40 years < 40 weeks + 6 daysGestational DM 37-38 weeks + 6 daysDM > 37Twins dichorionic > 36Twins monochorionic > 35 csTriplets 32-34 csTwins (monoamniontic) 34+0 and 36+6monochorionic twin pregnancies complicated by TTTS > 34 except……Severe PET 37Mild PET > 37PPROM > 37Cholestasis with BA >40 36-37 CSPlacenta previa (Asymptomatic) 34-36weeks +6 CSPlacenta previa with vaginal bleeding 35- 36 weeks + 6 CSPlacenta previa accreta(Asymptomatic) 37Fetal anaemia reciving IUT between 34 & 36 weeks CSConfirmed vasa praevia
  167. 167. Newborn Blood Spot Screening • The blood spot is taken on day 5 and in exceptional circumstances between day 5 and 8. The day of birth is counted as day 0 • The Programme screens for: sickle cell disease (SCD), cystic fibrosis (CF), congenital hypothyroidism (CHT) and six inherited metabolic diseases (IMDs): phenylketonuria (PKU), medium-chain acyl-CoA dehydrogenase deficiency (MCADD), maple syrup urine disease (MSUD), isovaleric acidaemia (IVA), glutaric aciduria type 1 (GA1) and homocystinuria (pyridoxine unresponsive) (HCU) • Good quality spots and all the fields on the card filled in are essential to avoid repeats • Screening is recommended but parents can decline screening for SCD, CF and CHT individually but the six IMDs can only be declined as a group • Babies found to be affected are referred for appropriate timely care • Parents receive all results by six weeks 3/21/20 ELBOHOTY 167
  168. 168. Newborn Hearing • 1 to 2 in 1000 babies in the UK are born with a permanent hearing loss or deafness in one or both ears • Around 1 in 100 babies who have spent at least 48 hours in a special care baby unit, or a neonatal intensive care unit, have a hearing loss in one or both ears • 90% of babies with a hearing loss are born to families with no history of deafness • Early identification is very important for speech, language and social development • All babies born in England should be offered a hearing screen at 0-5 weeks of age • Babies referred from the programme should be seen for a full audiological assessment within 4 weeks of screen completion • GPs should be notified of screen referrals by letter 3/21/20 ELBOHOTY 168
  169. 169. Newborn and Infant Physical Examination • Screening is offered in the newborn and infant periods : the first by 72 hours of age, the second at 6-8 weeks • Screening of eyes, heart, hips, and testes • Examinations are performed by appropriately trained healthcare professionals 3/21/20 ELBOHOTY 169

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