is antenatal care worthwhile? max brinsmead mb bs phd may 2015

Is Antenatal Care Worthwhile?Is Antenatal Care Worthwhile?

Max Brinsmead MB BS PhDMax Brinsmead MB BS PhD

May 2015May 2015

I will not directly answer this I will not directly answer this because:because:

There are no trials of AN care vs no AN There are no trials of AN care vs no AN carecare

Instead I will…Instead I will… Look at what we are we doing in AN careLook at what we are we doing in AN care This requires a diversion into epidemiologyThis requires a diversion into epidemiology Review those parts of AN care that has Review those parts of AN care that has

been tested by rigorous RCT?been tested by rigorous RCT? What will AN care look like in the future?What will AN care look like in the future?

Why do we:Why do we:

Take a history?Take a history? Perform blood tests?Perform blood tests? Measure BP?Measure BP? Perform ultrasound?Perform ultrasound? Palpate the abdomen?Palpate the abdomen? Weigh patients?Weigh patients? Test urine?Test urine?

Antenatal care is designed to:Antenatal care is designed to:

Single out pregnancies that are abnormal, Single out pregnancies that are abnormal, disordered or high risk…disordered or high risk…

In order to provide interventions that will In order to provide interventions that will optimise an outcomeoptimise an outcome

Provide preparation for childbirth and Provide preparation for childbirth and parentingparenting

Screening is:Screening is:

The application of a TEST to an The application of a TEST to an ASYMPTOMATIC population in order to ASYMPTOMATIC population in order to FIND cases of DISEASE or FIND cases of DISEASE or ABNORMALITY.ABNORMALITY.

The objective of screening:The objective of screening:

x = N orm al0 = D isease

x x x 0 x x x 0 x x x 0x x x 0 x x x 0 x x x 0x x x 0 x x x 0 x x x 0x x x 0 x x x 0 x x x 0

The objective of screening:The objective of screening:


x x x x x x x x xx x x x x x x x xx x x x x x x x xx x x x x x x x x

0 0 00 0 00 0 00 0 0


A good screening testA good screening test


x x x 0 0 0x x x 0 0 0x x x 0 0 0x x x 0 0 0

x x x x x xx x x x x xx x x x x xx x x x x x


A typical screening scenario:A typical screening scenario:


0 0 x x x xx x x x x xx x x x x xx x x x x x

x x x x x x x 0x x x x x x x xx x x x x x x xx x x x x x x x

x x x x x x x x x x x xx x x 0 x x x x x x x xx x x x x x 0 x x x x xx x x x 0 x x x x x x x

Characteristics of a TestCharacteristics of a Test

Sensitivity Sensitivity = the chance that the disease = the chance that the disease will be detectedwill be detected

Positive predictive value Positive predictive value = the chance that = the chance that a screen positive individual will have the a screen positive individual will have the diseasedisease

Down syndrome detection:Down syndrome detection:

Sensitivity based on age = 30%Sensitivity based on age = 30% Based on 2Based on 2ndnd trimester triple test = 60% trimester triple test = 60% Based on 1Based on 1stst trimester combined test = 88% trimester combined test = 88%

andand Positive predictive value = 1:10Positive predictive value = 1:10

Antenatal Care as ScreeningAntenatal Care as Screening

UrinalysisUrinalysis


UrinalysisUrinalysis Pre eclampsiaPre eclampsia


UrinalysisUrinalysis BP measuresBP measures

Pre eclampsiaPre eclampsia


UrinalysisUrinalysis BP measuresBP measures

Pre eclampsiaPre eclampsia Pre eclampsiaPre eclampsia


UrinalysisUrinalysis BP measuresBP measures Detection of oedemaDetection of oedema

Pre eclampsiaPre eclampsia Pre eclampsiaPre eclampsia


UrinalysisUrinalysis BP measuresBP measures Detection of oedemaDetection of oedema

Pre eclampsiaPre eclampsia Pre eclampsiaPre eclampsia Pre eclampsiaPre eclampsia


UrinalysisUrinalysis BP measuresBP measures Detection of oedemaDetection of oedema Maternal weight gainMaternal weight gain

Pre eclampsiaPre eclampsia Pre eclampsiaPre eclampsia Pre eclampsiaPre eclampsia


UrinalysisUrinalysis BP measuresBP measures Detection of oedemaDetection of oedema Maternal weight gainMaternal weight gain

Pre eclampsiaPre eclampsia Pre eclampsiaPre eclampsia Pre eclampsiaPre eclampsia Fetal growthFetal growth


HaemaglobinHaemaglobin Red cell indicesRed cell indices RBC antibodiesRBC antibodies Reagin testsReagin tests

AnaemiaAnaemia ThalassaemiaThalassaemia Fetal isoimmunisationFetal isoimmunisation SyphilisSyphilis


Glucose challenge testGlucose challenge test Vaginal swabVaginal swab Hep C testingHep C testing

Gestational diabetesGestational diabetes Group B StreptococciGroup B Streptococci Hep C infectionHep C infection

7 Criteria to test a screening 7 Criteria to test a screening programprogram

Is there a good screening test available?Is there a good screening test available? Is there an intervention available?Is there an intervention available? Is the disease worth detecting?Is the disease worth detecting? Will screen positive patients comply?Will screen positive patients comply? Will the test reach those applicable?Will the test reach those applicable? Has the program been tested by RCT?Has the program been tested by RCT? Can the health system cope with the program?Can the health system cope with the program?

Problems with Screening:Problems with Screening:

FALSE POSITIVESFALSE POSITIVES– And the resources required to deal with themAnd the resources required to deal with them

UNREALISTIC EXPECATATIONSUNREALISTIC EXPECATATIONS– ie misunderstanding about the sensitivity of the ie misunderstanding about the sensitivity of the

testtest

An Evidence Base for Antenatal An Evidence Base for Antenatal CareCare

The Cochrane LibraryThe Cochrane Library

The Cochrane Library on The Cochrane Library on Antenatal CareAntenatal Care

64 Analyses of which:64 Analyses of which:

– 7 evaluate routine antenatal care7 evaluate routine antenatal care– 15 evaluate routine advice during pregnancy15 evaluate routine advice during pregnancy– 16 evaluate management of common minor 16 evaluate management of common minor

problemsproblems– 26 evaluate management of high risk 26 evaluate management of high risk

pregnanciespregnancies

Trials of care for low risk womenTrials of care for low risk women

Ten trials with >60,000 womenTen trials with >60,000 women

– Fewer visits not associated with adverse Fewer visits not associated with adverse outcomeoutcome

– But women less satisfiedBut women less satisfied– Midwife or GP care as good as Specialist careMidwife or GP care as good as Specialist care– And women more satisfiedAnd women more satisfied

Continuity of careContinuity of care

Two trials with 1815 women cared for by a Two trials with 1815 women cared for by a team of midwives vs traditional careteam of midwives vs traditional care

– Fewer hospital admissionsFewer hospital admissions– More likely to attend antenatal educationMore likely to attend antenatal education– Used less analgesic drugs in labourUsed less analgesic drugs in labour– Less requirement for neonatal resuscitation.Less requirement for neonatal resuscitation.– No difference for other obstetric outcomesNo difference for other obstetric outcomes

Women who carry their own Women who carry their own recordrecord

Three trials with 675 womenThree trials with 675 women

– More likely to feel in controlMore likely to feel in control– Insignificant risk of lost or left recordsInsignificant risk of lost or left records– More likely to deliver operativelyMore likely to deliver operatively– No difference for other obstetric outcomesNo difference for other obstetric outcomes

Measuring symphysis fundal Measuring symphysis fundal heightheight

1639 women recruited1639 women recruited

No difference for any obstetric outcomesNo difference for any obstetric outcomes

Psychosocial support and Psychosocial support and postpartum depressionpostpartum depression

7600 women studied:7600 women studied:

– No benefit if provided antenatallyNo benefit if provided antenatally– Postpartum support is requiredPostpartum support is required

So, in your antenatal clinic will you:So, in your antenatal clinic will you: Weigh your patients at every visit?Weigh your patients at every visit? Record their height?Record their height? Urine test every visit?Urine test every visit? Measure symphysis fundal height?Measure symphysis fundal height? Record presentation and engagement?Record presentation and engagement? Screen for depression?Screen for depression? Screen for domestic abuse?Screen for domestic abuse? Screen for thalassaemia?Screen for thalassaemia? Offer Down’s Risk testing?Offer Down’s Risk testing? Screen for diabetes?Screen for diabetes? Screen for GBS colonisation?Screen for GBS colonisation?

A New Model of Antenatal Care?A New Model of Antenatal Care? 12w12w

History for risk factorsHistory for risk factors Check weight, BP and urineCheck weight, BP and urine Scan for dates, NT (and more?)Scan for dates, NT (and more?) Blood for routine tests + aneuploidy markersBlood for routine tests + aneuploidy markers



20w20w Scan for morphology, placenta, check uterine artery Scan for morphology, placenta, check uterine artery

Dopplers and cervical lengthDopplers and cervical length




Dopplers and cervical lengthDopplers and cervical length 28w28w

Screen for gestational diabetesScreen for gestational diabetes Anti D for Rh negativeAnti D for Rh negative

34w34w Anti D for Rh negativeAnti D for Rh negative







36w36w Scan to exclude breechScan to exclude breech








38 & 40w38 & 40w Check primigravida for late onset pre eclampsiaCheck primigravida for late onset pre eclampsia








38 & 40w38 & 40w Check primigravida for late onset pre eclampsiaCheck primigravida for late onset pre eclampsia

41W41W Sweep membranes. Arrange induction of labourSweep membranes. Arrange induction of labour

is antenatal care worthwhile? max brinsmead mb bs phd may 2015

Documents

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specialist care

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routine antenatal care

antenatal care worthwhile

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