anc house

Presented By:

Lecturer of obstetrics and gynecology

Faculty of Medicine-Cairo University

For house officers

Introduction

Pregnancy is considered a normal physiologic event, yet it can be complicated by dangerous pathologic processes in 5-20% of cases.

Many of these conditions & complications are:

• Preventable, or

• Predictable

Screening, early diagnosis, and management of such conditions will help to minimize both maternal morbidity and mortality during pregnancy, labour, and puerperium

Antenatal Care(ANC)

Definition:

Antenatal care: Routine care for the healthy pregnant woman

NICE clinical guideline 6, 2003

ANC is a program of preventive obstetrics with a main objective to ensure a

Safe motherhood, culminating in a

Safe delivery, of a

Healthy foetus.

Objectives of ANC

• Antenatal information

• Lifestyle considerations (Folic Acid)

• Screening for haematological conditions (sickle cell disease and

thalassaemias)

• Screening for fetal anomalies (congenital anomaly registers and

testing for Down’s syndrome)

• Screening for clinical conditions (gestational diabetes)

Who provides care ??!!!

GP-led models of care should be offered for women with an

uncomplicated pregnancy. Routine involvement of obstetricians in

the care of women with an uncomplicated pregnancy at scheduled

times does not appear to improve perinatal outcomes compared

with involving obstetricians when complications arise.

ANC Visits

The Preconception visit

The 1st ANC visit

Return ANC visits

The PNC visit

The Pre-Conception Visit (PCV)

Pregnancy Planning visit:

The aim to allow for pregnancy to start in optimum conditions

Personal & family history including Consanguinity

Presence of chronic disease in couple or family

Health education for appropriate timing of pregnancy

Advice regarding avoidance of harmful and teratogenic factors (drugs, cigarette smoking and alcohol intake…)

Absence or control of chronic medical disorders (as diabetes, hypertension…).

Diagnosis Of Pregnancy

Signs

Pregnancy Test


Quantitative BHCG

Sensitive enough to detect very low concentrations of human chorionic gonadotrophin.

Positive results may be therefore detectable as early as 10 days after fertilisation—that

is, four days before the first missed period.


Ultrasonography

Vaginal ultrasound can detect a sac from five weeks and a fetal cardiac echo a week or so later

The First ANC Visit

Aim: identify important risk factors:

History:

Menstrual: for LMP, calculate GA , and the EDD (Naegle’s formula). Obstetric : Previous pregnancies problems if any Medical : Medical disorders (HTN, DM, Cardiac, Liver, & Renal disorders Surgical : GYN (C.S., myomectomy), & Non GYN surgery Family : e.g. DM, HTN, twins, familial disorders.

General examination: Pulse, temperature and B.P., pallor…etc.

Abdominal Examination: enlarged liver or spleen, hernias,…etc

Vaginal examination: if necessary, e.g.: for suspected pelvic masses, ectopic pregnancy …etc.

Pregnant Cases

ANCHigh Risk Patients

The First ANC Visit

High Risk Pregnancy

High Risk Pregnancy is a pregnancy complicated by a disease or a disorder that may either;

Endanger the life, or

Affect the health, of the mother, the fetus, or the newborn.

Identification of HRP cases;

Thorough history

Careful physical examination

Performing special investigations other than routine pregnancy

Management of HRP;

Referred to a specialized center in maternal and fetal medicine.

Identification of HRP during ANC

A-Conditions detected during history taking:

Age; whether young ( 18) or elderly ( 35) Primigravidas.

Parity; whether nulliparous or grand multipara ( 4)

Previous obstetric difficulties, fetal loss or abnormalities

Medical disorders as; Diabetes mellitus, cardiac or renal disease


B-Conditions observed during general examination

Extreme obesity (BMI > 35 Kg/M²)

Short stature (less than 150 cm)

Hypertension (>140/90)

Cardiac or renal disease (HV disease, RHD, AV Replacement)

Poor weight gain during pregnancy


C-Conditions observed during obstetric examination

Pre- eclampsia (PE)

Antepartum hemorrhage (APH)

Multiple pregnancy

Malpresentations, and malpositions

Feto-pelvic disproportion


D-Conditions detected during routine investigations

Severe anemia: Hb < 8.0 gm/dl

Thrombocytopenia: low platelets < 150.000

Hyperglycemia: FBS > 100 mg%, PPBS > 160 mg%.

Glycosuria and albuminuria (>+)

Rh negative blood typing (when husband is RH +ve)

Screening for fetal anomalies:

Congenital anomalies: US for fetal anatomy survey (FAS)for detection of

Anencephaly, hydrocephalus and NTDs

Limb and skeletal deformities

Cardiac and renal anomalies…etc.

Chromosomal abnormalities: as Down's syndrome: 1st trimester US: 11-13 wks (for NT & NB)

Double & Triple marker screening tests (11 & 15 wks)

Chorionic villous sampling (CVS 1st trimester)

Amniocentesis (2nd trimester).

Screening for infections

TORCH:

Toxoplasmosis (TG)

Rubella (RV)

Cytomegalovirus (CMV)

Herpes simplex (HSV)

Hepatitis B (HBS)

Hepatitis C (HCV)

Human Immunity Virus (HIV).

The First ANC Visit

Routine laboratory tests:

BLD GRP & Rh typing, to identify RH negative patients. CBC : for Hb%, WBCs, and platelets. RBS: fasting and 2 hrs PPBS when necessary. CUA: for pus cells, RBCs, albumin and sugar…etc,

Other tests as: • TORCH antibodies IgG and IgM, • VDRL: for syphilis• HBS & HCV: for hepatitis • HIV, if necessary, especially in the first pregnancy.

Return ANC Visits

Monthly visits : in the first 6 months Biweekly visits: in the 7th & 8th months weekly visits : in the 9th month until delivery.

For a woman who is nulliparous with an uncomplicated pregnancy, a

schedule of 10 appointments should be adequate. For a woman who

is parous with an uncomplicated pregnancy, a schedule of 7

appointments should be adequate.

Return ANC Visits

BP measurement: To detect early GH or PE .

Weight gain:

• Average weight gain during pregnancy is 11-16 Kg.

• Excessive weight gain many denote occult oedema, PE,

• Inadequate weight gain may reflect nutritional deficit or fetal IUGR

L.L. Oedema: Ankle oedema is acceptable in late 2nd and 3rd trimesters.

Fundal level: measured and recorded at each visit after 20 weeks.

FHS: in 2nd trimester by Sonicaid Duplex instrument.

Fundal Level

12 wks: S. Pubis

20 wks: Umbilicus

28 wks: Mid umb. / sternum

36 wks: X. sternum

Return ANC Visits

Warning symptoms:

• Vaginal Bleeding

• Regular menstrual like colicky pains

• Persistent vomiting

• Sudden escape of liquor amnii

• Severe persistent headache, blurring of vision, marked swelling of the LLs

Return ANC Visits

Ultrasonography:

Ultrasonography in pregnancy

1st Trimester Ultrasound

Number

Site

Viablity

Nuchal translucency –congenetal anomalies

Dating


2nd Trimester Ultrasound

Fetal anomaly scan± 3D US

Dating


3rd Trimester Ultrasound

Fetal Weight

Fetal well being

What to write in prescription ??

Drug intake during pregnancy

Drug categories during pregnancy according to FDA classification:

Group A : Safe Group B : Risky in animal, no enough data on humans. Group C : Risk in human cannot be ruled out. Group D : Risky in human pregnancy, but benefits outweigh risks. Group X : Contraindicated in pregnancy, may cause adverse fetal effects.


1st Trimester:

Folic acid 500 microgram

Folic acid 500 tab

Folicap 0.5 mg cap

Cobal F tab


Rest of pregnancy:

Multivitamins Calcium Treat Accordingly

Materna - Mamyvit

Calcitron – Cal-Mag –Caldin-C -Calcimax

Ferrotron –Ferrosanol D-

Hemacaps

Instructions to the Patient

Exercise: Mild to moderate exercise, as walking, and regular daily house work are allowed.

Sleep and rest: Proper night sleep (8 hrs), and adequate periods of afternoon rest are advisable.

Care of teeth: To avoid dental caries caused by increased acidity, and septic foci.

Bowel habit: Avoiding constipation; fresh vegetables and mild laxatives if necessary.

Clothes: Avoid tight and too heavy uncomfortable clothing

Instructions to the Patient

Breasts: • Daily washes as a part of body hygiene. • Nipple massage using lubricant creams to reduce cracking. • Retracted nipple is withdrawn by the thumb and finger using a lubricant.

Sexual intercourse: • Is better minimized in the 1st trimester • It is completely restricted if there is recurrent bleeding, tendency to abortion,

preterm labour, or suspected rupture of the membranes.

Smoking: • Should be strictly avoided • Excessive smoking may result in placental insufficiency, SGA babies, or PTL

Travelling: Only comfortable travelling may be allowed. However, travelling should be avoided in the last month and it is completely prevented in patients with a history of bleeding, threatened abortion, habitual abortion, or premature labour.

Nutrition in pregnancy

Nutritional Requirements :

Caloric requirements average 2300 Kcal/day.

Protein: 80-100 gm/day, Calcium: 1-1.5 gm/day, Iron: 30-60 mg/day.

Vitamins and minerals: Especially B, C, D, K.

Folic acid is important for cell division and replication. In the first few weeks, a dose of 400 ug/day has been shown to effectively reduce the risk of neural tube defects.

Salt restriction, is advisable in cases with marked oedema or tendency to hypertension.

A suitable daily diet in pregnancy should thus include: 400 ml. of milk or its derivatives, one egg, fresh fruits and vegetables, about 120 gm of red meat, fish or liver.

Effect of Malnutrition on Pregnancy

Effect on the mother: Loss of weight and anaemia.

Decalcification of bones, caries of teeth.

Affection of lactation.

Lowered resistance against infection.

Effect on the foetus: Low birth weight infants.

Higher incidence of rickets and anaemia, in severe cases.

Vaccination (immunization) in pregnancy

Live attenuated vaccines are contraindicated.

The vaccines for the following diseases may be given if needed, preferably after the 1st trimester:

• Tetanus, poliomyelitis, rabies,• influenza, cholera and typhoid.

Passive immunization against hepatitis A and B may be given.

COMMON COMPLAINTS DURING PREGNANCY

Morning sickness Heart Burn Constipation Haemorrhoids Headache Breast tenderness Breathlessness Abdominal pain Abdominal cramps

Urinary symptoms LL oedema Leg cramps Varicose Veins Backache Fatigue Vaginal discharge Sweating and hot flushes

Mobile : 01001951615

Email : [email protected]

anc house

Documents

uncomplicated pregnancy

ectopic pregnancy

anc visit return anc

anc visit aim

routine care

care of women

abc antenatal care

models of care