Ante-natal care12121212121212121212121.pptx

ANC

1. Ante-natal care: toward a standard approach Mervat Sheikhelarab Elsedeek Professor of OB& Gyn. Alexandria university

2. Maternity care

3. Ante-natal care is a package of preventive healthcare involving: health promotion , risk assessment , screening , preventive strategies , and education , with the ethos being woman-centred care and informed decision making for the best benefit both mother and offspring.

4. The essential elements of antenatal care include: Evaluation of general health and assessment of risk . Recognition and treatment of underlying or concurrent illness and pregnancy-related complications like hypertensive disorders and impaired glucose tolerance. Screening for conditions and diseases such as anaemia, GDM, UTI and HDP. Preventive measures , including dietary supplementation, vaccination, prevention of isoimmunisation. Health education .

5. 1.Risk assessment

6. The concept of risk In 1978 the WHO had developed the “risk approach” concept as a managerial tool for maternal and child health care, in particular for countries where access to medical care was limited. However , because there are high levels of false positive and false negative results the approach was not successful as a public health measure. Instead an approach of vigilance for all pregnant women is being advocated.

7. 2. Screening

8. The concept of screening Screening, in medicine is: a strategy used in a population to identify an unrecognized disease in individuals without signs or symptoms . Screening is designed to: identify disease in a community early, thus enabling earlier intervention and management in the hope to reduce mortality and suffering from a disease.

9. Principles of screening

10. Screening in pregnancy Anemia. Asymptomatic bacteriuria. Fetal anomalies. GDM. HTN. Aneuploidy? Thrombophilia? PTL?

11. How far should we investigate? Routine ante-natal investigations CBC. Urine C&S. Blood sugar. Blood group and Rh factor. ? Rubella Antibody titer. ? Hepatitis B.

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13. Hematological Changes in pregnancy

14. Physiological Anemia of pregnancy Criteria of Physiological Anemia: 1) Hb ≥10 gm %. 2)RBC ≥ 3.2 million cells / mm3. 3)PCV ≥ 32% 4)Peripheral Smear: Normal morphology.

15. HB (gm/dl) x100 RBCs

16. Asymptomatic Bacteriuria (ASB) ASB is defined as persistent bacterial colonization of the urinary tract without urinary symptoms; defined by >100,000 CFU of a single organism . Pregnant women with untreated ASB in early pregnancy have a 20-40% risk of developing a symptomatic urinary tract infection, usually in the form of pyelonephritis, in later pregnancy . Pyelo increases risk of PTL, low birth weight infants, and fetal mortality. Pyelo places the patient at increased risk for anemia, thrombocytopenia, transient renal insufficiency, postpartum endometritis, sepsis, and ARDS. Treatment of ASB has been shown to reduce subsequent infection by 80-90% and reduce incidence of preterm delivery and low birth weight infants. 2

17. Treatment algorithm As dictated by sensitivity testing. The lab. should be informed about the pregnancy and trimester to test for safe antibiotics. Duration of treatment 5-10 days. Cure should be confirmed by negative culture 1-2 weeks after the end of treatment. Education about predisposing factors to avoid recurrence.

18. Fetal Anomaly Scan (FAS ) Performed 18-20 weeks of pregnancy . Up to 95% of structural anomalies can be excluded from this scan . A check list of standard views is helpful. Fetal brain, face, spine, stomach, kidneys, UB, and extremities should be evaluated in addition to routine biometry, assessment of amniotic fluid, placenta and umbilical cord 3

19. Screening for GDM 4

20. HBA1c, and fructosamine Glycosylated hemoglobin HbA1c: measures the average blood glucose for several weeks prior to testing.   It depends on the half-life of red blood cells which is about 120 days; therefore a test will reflect average blood glucose concentration over an 8-12 week period. It can produce less than accurate results with concurrent health problems like anemia . Fructosamine:   is a sugar-albumin complex that forms in chronic hyperglycemic conditions.  The higher the serum fructosamine concentration, the higher the blood glucose levels have been over the lifespan of the albumin protein, which is 1-2 weeks.

21. Screening for PET Search for risk factors. Regular blood pressure measurement. Regular weighting. Ask for symptoms if you suspected. Serum uric acid. Urine micro albumin (Micral) 5

22. Screening for aneuploidy 6

23. Thrombophilia 7

24. Thrombophilia: congenital Antithrombin III: Anti thrombin deficiency is very rare (prevalence 0.02 %). Protein C: is a natural anticoagulant. It is converted to activated protein C (APC) by thrombin . APC inactivates factors Va and VIIIa. Protein C deficiency is rare (prevalence 0.2%). • Protein S: is the cofactor for the anticoagulant activity of APC. Protein S deficiency is rare (prevalence 0.03-0.13 %). Factor V Leiden mutation and APC Resistance Assay (APCR ): If a patient’s plasma does not produce the appropriate anticoagulant response to APC, this is termed APC Resistance. The most common cause for this is the Factor V Leiden mutation (FVL) which produces a factor V molecule that is resistant to cleavage by APC . Prothrombin Gene Mutation (G-20210-A) causes elevated levels of prothrombin in the circulation. Prothrombin is the precursor of thrombin which is a key enzyme in blood coagulation. This mutation is tested for by PCR. Heterozygotes are common in the Caucasian population (around 3%) and have a small increased risk of thrombosis

25. Thrombophilia: acquired Lupus Anticoagulant and Anti-Cardiolipin antibodies: are carried out to look for Anti-Phospholipid Syndrome (APS). This is an acquired thrombophilic state. APS is an autoimmune disease characterised by thrombosis or pregnancy complications in the presence of anti-phospholipid antibodies. (APA)

26. Should we routinely screen for thrombophilia?

27. WHY shouldn’t thrombophilia screen be routine? Thrombophilia screening is expensive and time-consuming. Testing is often performed without a clear idea of what to do with the results. Positive results often cause unjustified concern to the individual. Conversely, a negative test may provide false reassurance. Therefore it is important that screening is targeted at the right people and the requesting clinician should have a plan of how the results will affect management.

28. Who should have thrombophilia screen? One or more morphologically normal fetal deaths after 12 weeks of gestation • Three or more unexplained consecutive miscarriages before 12 weeks of gestation • One or more preterm births before 34th week due to severe pre-eclampsia, eclampsia or placental insufficiency.

29. Screening for PTL? 8

30. 3. Prevention

31. Prevention NTD. Nutritional deficiencies. PET. Infectious diseases (immunization). Iso immunization. RDS? GBS?

32. Folic acid Supplementation with 0.4 to 0.8 mg of folic acid (4 mg for secondary prevention) should begin at least one month before conception. (A) Supplementation prevents neural tube defects. RDA (in addition to supplements) is 600 mcg of dietary folate equivalents (e.g., legumes, green leafy vegetables, liver, citrus fruits, whole wheat bread) per day. (B) Folate deficiency is associated with low birth weight, congenital cardiac and orofacial cleft anomalies, abruptio placentae, and spontaneous abortion. 1

33. PNV Iron Pregnant women should be screened for anemia (hemoglobin, hematocrit) and treated, if necessary. (B) Iron-deficiency anemia is associated with preterm delivery and low birth weight. Pregnant women should supplement with 30 mg of iron per day. (C ) Calcium Recommended daily intake is 1,000 to 1,300 mg per day. Routine supplementation with calcium to prevent preeclampsia is not recommended . However, calcium supplementation may be beneficial for women at high risk for gestational hypertension or in communities with low dietary calcium intake. (A) Calcium supplementation has been shown to decrease blood pressure and preeclampsia, but not perinatal mortality . 2

34. Vitamin D Vitamin D supplementation can be considered in women with limited exposure to sunlight. However , evidence on the effects of supplementation is limited. DA is 5 mcg per day (200 IU per day ). Vitamin D deficiency is rare but has been linked to neonatal hypocalcemia and maternal osteomalacia. High doses of vitamin D can be toxic . Others: Omega-3 FA?? PNV

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36. Low Dose Aspirin Should it be given to all pregnant women? When to start? When to stop? What is the dose?

37. Low Dose Aspirin   Should it be given to all pregnant women? NO, only in presence of risk factors of PET When to start? Between 12 and 16 weeks When to stop? 2 opinions after placentation is complete i.e. 24, or up to 34 w. What is the dose? Between 70-100mg.

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39. Prevention of Rh iso immunization Anti-D Ig 300 μg IM or IV should be given within 72 hours of delivery to a postpartum non sensitized Rh-negative woman delivering an Rh-positive infant. Additional anti-D Ig may be required for feto maternal hemorrhage (FMH) greater than 15 mL of fetal red blood cells (about 30 mL of fetal blood. (I-A) 2. If anti-D is not given within 72 hours of delivery or other potentially sensitizing event, anti-D should be given as soon as the need is recognized, for up to 28 days after delivery or other potentially sensitizing event. (III-B) 3. 5

40. Ante-natal corticosteroids (ANC) 6

41. For whom?

42. Why not for all? Steroid injections given to pregnant women before premature birth may increase the child’s risk of later behavioural and emotional problems. Researchers have previously established a link between stress in pregnancy and symptoms of attention-deficit/hyperactivity disorder (ADHD) in children. As cortisol is produced in response to stress, it has been suggested by some that cortisol may be responsible for this link.

43. GBS?? Approximately 10 to 30 percent of pregnant women carry GBS in the vagina or rectum or surrounding area. While GBS is generally harmless in healthy adults, it may cause stillbirth and serious infections in babies . Early-onset GBS disease can cause sepsis  , pneumonia, and, less frequently, meningitis. Some of these babies, particularly those with meningitis, will have long-term health problems such as hearing or vision loss, cerebral palsy, or developmental disabilities, and about 5 percent won't survive. 7

44. Screening For this reason, the Centres for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American Congress of Obstetricians and Gynecologists (ACOG) recommend that: All pregnant women – with two exceptions – routinely be screened for GBS at 35 to 37 weeks. The two exceptions are women who have previously had a baby with a GBS disease or who have had a urinary tract infection caused by GBS during their current pregnancy. These women don't need to be screened because they're already considered at high risk and will be automatically treated during labor .

45. algorithm To date, I.V. antibiotics during labor is the only proven strategy  to protect a baby from early-onset group B strep disease . It should be given every 4 hours till birth. Penicillin and Ampicillin are the most common antibiotics given .

46. Why not screen for GBS at first prenatal visit and treat right away if test is positive? The test isn't done until late in pregnancy because the bacteria can come and go. So the result of an early vaginal or rectal culture is not a good predictor of whether or not the genital area will be colonized at birth . Likewise , taking antibiotics long before labor doesn't prevent genital area from becoming colonized again, so – unlike treatment during labor – it doesn't reduce the risk of transmitting the infection to the baby.

47. 4. Education

48. Education during ANC Healthy life style during pregnancy. Danger signs of pregnancy. Answer pregnant women’s questions. Physiology of labor and birth plan. Preparation for and importance of breast feeding. Post partum birth spacing and family planning. Care of newborn.

49. Answering questions

50. Birth Plan

51. Organize activities per trimester and visit not to miss any of them. Consider health resources in screening. Explain, educate, and answer questions much more than requesting investigations and prescribing medications. Over-investigations will result in over-treatment without improvement in outcome.

52. Sources of guidelines Centers for Disease Control and Prevention (CDC ) American Academy of Pediatrics (AAP ). American Congress of Obstetricians and Gynecologists (ACOG ) National institute of clinical excellence (NICE)