Antenatal careAntenatal care&&CounselingCounseling

DR. KHALED ALDOSSARI

SBFM , ABFM , MBBS

ASSISTANT PROFESSOR

objectives

To know definition of antenatal care.

To be familial with common symptoms during pregnancy.

to know what should be done every visit. To know ten elements of antenatal

counseling.

content

I. Definition

II. Antenatal visits

III. counseling & common problem during pregnancy

Definition

Continuous health care provided to pregnant women before labor.

diagnosis

History:

I. Menstrual period.

II. Morning sickness.

III. Abdominal pain.

antenatal visits

Every month until 28 weeks gestation .

Every 2weeks during till 36 week gestation.

Every week during the last month

& any time when medical care needed.

antenatal visits

1st visit :

History:

A. Bio data.

B. Compliant.

antenatal visits

C. Menstrual history: LNMP, EDD.

The Nãgele rule :

EDD is calculated by adding 7 days to the first day of the LMP and adding 9 months.

antenatal visits

D. Past obstetric hx: Hx of previous pregnancy. Hx of abortion. Mode of delivery. Birth weight. Mode of infant feeding.

antenatal visits

E. Current obstetric hx : Symptoms of pregnancy (nausea ,vomiting,

sleep) Symptoms of pre eclampsia

(edema ,headache( Quickening.

antenatal visits

F. Past medical hx (DM,HTN,HEART DISEASE)

G. Past surgical hx.

H. Drugs history, blood transfusion ,x ray ,RH incompatibility.

I. immunization.

Antenatal visits

Physical examination:

A. General examination (wt, hight, v/s, general appearance ,chest, abdomen ,breast ,thyroid) .

B. Local examination( inspection) Size of abdomen ,scar, sign of

pregnancy ,fetal movement ,varicose vein

Antenatal visits

Palpation: (fundal level ,fundal grip)

Auscultation of fetal heart.

Antenatal visits

1st visit investigations ; Hemoglobin & hematocrit Urine analysis Blood group

Antenatal visits

Rh type Rubella anti body titer Syphilis screen Culture for gonorrhea

Antenatal visits

Hepatitis B virus Cervical cytology HIV test ppd if there is risk of TB .

At 26-28 weeks GA : Routine screen for DM. Repeat hemoglobin and hematocrit At this time prophylactic administration of

anti- D immunoglobin .

At 32-36 weeks GA: Testing for Sexually transmitted disease Repeat hemoglobin and hematocrit if needed

Vaccination During Pregnancy

The following vaccines are considered safe to give to women who may be at risk of infection:

Hepatitis B--Pregnant women who are at high risk for this disease and have tested negative for the virus can receive this vaccine. It is used to protect the mother and baby against infection both before and after delivery.

Vaccination During Pregnancy

Influenza--This vaccine can prevent serious illness in the mother during pregnancy, but should be received after the mother has been pregnant for more than 14 weeks. If you have a serious medical condition that can lead to flu-related complications, you can receive the vaccine at any stage of pregnancy.

Vaccination During Pregnancy

Tetanus/Diphtheria--This combination of vaccines are routinely recommended for pregnant women, both those who have never been immunized and those who have not received a booster in 10 years

Consultancy tenConsultancy tenII-Nutritional supplements-Nutritional supplements

IIII- Gestational age assessment- Gestational age assessment

IIIIII-Prescribed medicines-Prescribed medicines

VIVI-Lifestyle considerations-Lifestyle considerations

VV-Management of common symptoms of -Management of common symptoms of pregnancypregnancy

VIVI-Clinical examination of pregnant women-Clinical examination of pregnant women

VIIVII-Screening for hematological conditions-Screening for hematological conditions

VIIIVIII-Screening for fetal anomalies-Screening for fetal anomalies

IXIX-Screening for infections-Screening for infections XX-Screening for clinical conditions -Screening for clinical conditions (e.g (e.g

GDM,Preclampsia,GHTN)GDM,Preclampsia,GHTN)

The following guidance is evidence based. Developed by the National Collaborating Centre for Women’s and Children’s Health

Developed at March 2008

The grading scheme used for the recommendations (A, B, C, D, good practice point [GPP] or NICE 2010)

Counseling I

Nutritional supplements

Dietary supplementation with folic acid, Dietary supplementation with folic acid, before before conception(about 3 month) and up to 12 weeks’ conception(about 3 month) and up to 12 weeks’ gestationgestation, reduces the risk of having a baby with , reduces the risk of having a baby with neural tube defects neural tube defects (anencephaly& spina (anencephaly& spina bifida). bifida).

The recommended dose is The recommended dose is 400 micrograms per 400 micrograms per dayday.(Risky women 4mg).(Risky women 4mg)

Folic acidFolic acid

A

Iron supplementation Iron supplementation should not be offered should not be offered routinelyroutinely to all pregnant women. to all pregnant women.

It does not benefit the mother’s or fetus’s It does not benefit the mother’s or fetus’s

health and may have unpleasant maternal side health and may have unpleasant maternal side effectseffects

IronIron

A

Vitamin A supplementation Vitamin A supplementation (intake greater than (intake greater than 700 micrograms)700 micrograms) might be teratogenic and might be teratogenic and therefore it should be avoided.therefore it should be avoided.

Liver and liver productsLiver and liver products may also contain high may also contain high levels of vitamin A, consumption of these levels of vitamin A, consumption of these products should also be avoided.products should also be avoided.

Vitamin AVitamin A

C

Advise women of the importance of vitamin D intake duringAdvise women of the importance of vitamin D intake duringpregnancy and breastfeeding (10mcg/day)pregnancy and breastfeeding (10mcg/day)Ensure women at risk of deficiency are following this adviceEnsure women at risk of deficiency are following this advice..

–– South Asian, African, Caribbean or Middle Eastern family originSouth Asian, African, Caribbean or Middle Eastern family origin–– women who have limited exposure to sunlight, such as women women who have limited exposure to sunlight, such as women

who are predominantly housebound, or usually remain covered who are predominantly housebound, or usually remain covered when outdoorswhen outdoors

– –women who eat a diet particularly low in vitamin D, e.g. no oily women who eat a diet particularly low in vitamin D, e.g. no oily fish, eggs, meat, vitamin D-fortified margarine or breakfast fish, eggs, meat, vitamin D-fortified margarine or breakfast cerealcereal

–– women with a pre-pregnancy body mass index above 30 kg/m2women with a pre-pregnancy body mass index above 30 kg/m2..

Vitamin DVitamin D

Counseling II

Gestational age assessment

Gestational age assessment: Gestational age assessment: LMP and ultrasoundLMP and ultrasound

Pregnant women should be offered an Pregnant women should be offered an early ultrasound scan to determine early ultrasound scan to determine gestational age and to detect multiple gestational age and to detect multiple

pregnanciespregnancies. .

A

Early ultrasound scanEarly ultrasound scan

1.1. Ensure consistency of gestational age Ensure consistency of gestational age assessments, assessments,

2.2. Improve the performance of mid-trimester Improve the performance of mid-trimester serum screening for Down’s syndrome and serum screening for Down’s syndrome and

3.3. Reduce the need for induction of labour after Reduce the need for induction of labour after 41 weeks.41 weeks.

A

Ideally, scans should be performed between Ideally, scans should be performed between 10 and 13 weeks and crown–rump length10 and 13 weeks and crown–rump length measurement used to determine gestational age. measurement used to determine gestational age.

Gestational age assessment: Gestational age assessment: LMP and ultrasound LMP and ultrasound

GPP

Pregnant women who present Pregnant women who present at or beyond 14 at or beyond 14 weeksweeks’ gestation should be offered an ultrasound ’ gestation should be offered an ultrasound scan to estimate gestational age using scan to estimate gestational age using head head circumference or bi-parietal diameter.circumference or bi-parietal diameter.

Gestational age assessment: Gestational age assessment: LMP and ultrasound LMP and ultrasound

GPP

Counseling III

Prescribed medicines

Prescribed Prescribed medicinesmedicines

Few medicines have been established as safe to Few medicines have been established as safe to use in pregnancy.use in pregnancy.

D

Prescription medicines should be used Prescription medicines should be used as little as little as possibleas possible during pregnancy and should be during pregnancy and should be limitedlimited to circumstances where the benefit to circumstances where the benefit

outweighs the riskoutweighs the risk..

Prescribed Prescribed medicinesmedicines

D

Prescribed medicinesPrescribed medicines

antiepileptic medicationantiepileptic medication؟؟؟؟؟؟؟؟؟؟؟؟

No live vaccine (3month beforNo live vaccine (3month befor

conceptionconception((

No Expose to RadationNo Expose to Radation

Counseling IV

Lifestyle considerations

Exercise in Exercise in pregnancypregnancy

Beginning or continuing a Beginning or continuing a moderate coursemoderate course of of exercise during pregnancy is not associated exercise during pregnancy is not associated with adverse outcomes.with adverse outcomes.

Pregnant women should be informed of the Pregnant women should be informed of the potential dangers of certain activities during potential dangers of certain activities during pregnancy, e.g.: contact sports, scuba pregnancy, e.g.: contact sports, scuba divingdiving

A

The majority of women can be reassured that it The majority of women can be reassured that it is safeis safe to continue working during pregnancy. to continue working during pregnancy.

A woman’s A woman’s occupation occupation during pregnancy during pregnancy should be ascertained to identify those at should be ascertained to identify those at increased risk through occupational exposure.increased risk through occupational exposure.

Working during Working during pregnancypregnancy

D

GPP

Sexual intercourse in Sexual intercourse in pregnancypregnancy

Sexual intercourse in pregnancy is not know to Sexual intercourse in pregnancy is not know to be associated with any adverse outcomesbe associated with any adverse outcomes ..

B

There are specific risks of smoking during There are specific risks of smoking during pregnancy pregnancy (such as the risk of having a baby with (such as the risk of having a baby with low birth weight and preterm).low birth weight and preterm).

The benefits of quitting at any stage should be The benefits of quitting at any stage should be emphasized.emphasized.

Women who are unable to quit smoking during Women who are unable to quit smoking during pregnancy should be encouraged to reduce pregnancy should be encouraged to reduce smoking.smoking.

Smoking in pregnancySmoking in pregnancy

A

B

Air travel during Air travel during pregnancypregnancy Pregnant women should be informed that long air Pregnant women should be informed that long air

travel is associated with an increased risk of travel is associated with an increased risk of venous thrombosis.venous thrombosis.

Wearing correctly fitted compression stockings is Wearing correctly fitted compression stockings is effective at reducing the risk.effective at reducing the risk.

B

Traveling abroad during Traveling abroad during pregnancypregnancy

If pregnant women are planning to travel abroad, If pregnant women are planning to travel abroad, they should discuss considerations such as flying, they should discuss considerations such as flying,

vaccinations and travel insurance.vaccinations and travel insurance.

GPP

Counseling VCounseling V

Management of common symptoms Management of common symptoms of pregnancyof pregnancy

Red flag

Pain during urination

Vomiting and nausea symptoms that are

extra persistent Sudden body swelling Rapid heartbeat

Red flag

Decreased fetal activity (i.e. far less than

normal to no baby movement) for more than a day

Vaginal bleeding

Red flag

Early uterus cramping (such as weeks or months before your due date)

Leaking amniotic fluid early on - which will feel a little like a constant trickling peeing sensation

Most cases of nausea and vomiting in pregnancy Most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks will resolve spontaneously within 16 to 20 weeks of gestation.of gestation.

Nausea and vomiting are not usually associated Nausea and vomiting are not usually associated with a poor pregnancy outcome. with a poor pregnancy outcome.

Nausea and vomiting in Nausea and vomiting in early pregnancyearly pregnancy

A

Nausea and vomiting in early Nausea and vomiting in early pregnancypregnancy

If a woman requests or would like to consider If a woman requests or would like to consider treatment, the following interventions appear to treatment, the following interventions appear to be effective in reducing symptoms:be effective in reducing symptoms:

non-pharmacologicalnon-pharmacological – – gingerginger

pharmacologicalpharmacological – – Antiemetic Antiemetic A

Hyperemesis GravidarumHyperemesis Gravidarum

intractable nausea and vomiting, severe intractable nausea and vomiting, severe enough to cause weight loss, dehydration, enough to cause weight loss, dehydration, ketonuria, electrolyte imbalance, acid-base ketonuria, electrolyte imbalance, acid-base disturbances anddisturbances and

if severe, hepatic and renal damageif severe, hepatic and renal damage

Pt. need referralPt. need referral

HeartburnHeartburn Women who present with symptoms of Women who present with symptoms of

heartburn in pregnancy should be offered heartburn in pregnancy should be offered information regarding lifestyle and diet information regarding lifestyle and diet modification.modification.

Antacids may be offered to women whose Antacids may be offered to women whose heartburn remains troublesomeheartburn remains troublesome

GPP

A

ConstipationConstipation

Women who present with constipation in Women who present with constipation in pregnancy should be offered information pregnancy should be offered information

regarding diet modification, such as bran or regarding diet modification, such as bran or wheat fiber supplementation.wheat fiber supplementation.

A

HemorrhoidsHemorrhoids

Women should be offered information Women should be offered information concerning diet modification. concerning diet modification.

If clinical symptoms remain troublesome, If clinical symptoms remain troublesome, standard standard hemorrhoids creamshemorrhoids creams should be should be considered.considered.

GPP

Varicose veinsVaricose veins

Varicose veins are a common symptom of Varicose veins are a common symptom of pregnancy that will not cause harm andpregnancy that will not cause harm and

Compression stockingsCompression stockings can improve the can improve the symptoms but will not prevent varicose veins symptoms but will not prevent varicose veins from emerging.from emerging.

A

Vaginal dischargeVaginal discharge

Women should be informed that an increase in Women should be informed that an increase in vaginal discharge is a vaginal discharge is a common physiological common physiological

changechange that occurs during pregnancy. that occurs during pregnancy.

GPP

If vaginal discharge is associated If vaginal discharge is associated withwith itching, itching, soreness, offensive smell or pain on passing urinesoreness, offensive smell or pain on passing urine there may be an infective cause and investigation there may be an infective cause and investigation

should be considered.should be considered.

Vaginal dischargeVaginal discharge

GPP

A A 1-week course of a topical imidazole1-week course of a topical imidazole is an is an effective treatment and should be considered effective treatment and should be considered for vaginal candidiasis infections in pregnant for vaginal candidiasis infections in pregnant

women.women.

Vaginal dischargeVaginal discharge

A

The effectiveness and safety of The effectiveness and safety of oral oral treatments for vaginal candidiasistreatments for vaginal candidiasis in in

pregnancy is uncertain and these should not pregnancy is uncertain and these should not be offered.be offered.

Vaginal dischargeVaginal discharge

GPP

BackacheBackache

Women should be informed that exercising in Women should be informed that exercising in water, massage therapy water, massage therapy might help to ease might help to ease

backachebackache during pregnancy. during pregnancy.

A

Counseling VICounseling VI

Clinical examination of pregnant Clinical examination of pregnant womenwomen

Measurement of weight Measurement of weight and body mass index and body mass index (BMI)(BMI)

Maternal weight and height should be measured at Maternal weight and height should be measured at the first antenatal appointment, and the woman’s the first antenatal appointment, and the woman’s

BMIBMI calculated calculated (weight [kg]/height[m]2).(weight [kg]/height[m]2).

A

Repeated weighingRepeated weighing during pregnancy should during pregnancy should be be confined toconfined to circumstances where clinical circumstances where clinical

management is likely to be influenced.management is likely to be influenced.

Measurement of weight Measurement of weight and body mass index and body mass index

(BMI)(BMI)

C

Breast examinationBreast examination

Routine breast examination during antenatal Routine breast examination during antenatal care care is is not recommendednot recommended for the for the promotion of postnatal breastfeeding.promotion of postnatal breastfeeding.

A

Pelvic examinationPelvic examination Routine antenatal pelvic examination Routine antenatal pelvic examination does not does not

accuratelyaccurately assess gestational age, nor does it assess gestational age, nor does it accurately predict preterm birth or accurately predict preterm birth or cephalopelvic disproportion.cephalopelvic disproportion.

So, it is So, it is not recommendednot recommended..

B

Counseling VIICounseling VII

Screening for hematological Screening for hematological conditionsconditions

AnemiaAnemia

Pregnant women should be offered screening for Pregnant women should be offered screening for anaemia. anaemia.

Screening should take place early in pregnancy Screening should take place early in pregnancy (at the first appointment) and at 28 weeks(at the first appointment) and at 28 weeks. .

This allows enough time for treatment if anaemia This allows enough time for treatment if anaemia

is detectedis detected..

B

Hemoglobin levels outside the normal range for Hemoglobin levels outside the normal range for pregnancy pregnancy (that is, 11 g/dl at first contact and (that is, 11 g/dl at first contact and 10.5 g/dl at 28 weeks)10.5 g/dl at 28 weeks) should be investigated should be investigated and and iron supplementationiron supplementation considered if considered if

indicated.indicated.

AnemiaAnemia

A

Blood grouping and Blood grouping and red cell red cell alloantibodiesalloantibodies

Women should be offered testing for Women should be offered testing for blood group blood group and RhD statusand RhD status in early pregnancy. in early pregnancy.

BB

It is recommended that routine antenatal anti-It is recommended that routine antenatal anti-D prophylaxis is offered to all non-sensitized D prophylaxis is offered to all non-sensitized

pregnant women who are RhD negative.pregnant women who are RhD negative.

Blood grouping and Blood grouping and red cell alloantibodies red cell alloantibodies

NICE 2008

Women should be screened for atypical red cell Women should be screened for atypical red cell alloantibodies in early pregnancy and again at 28 alloantibodies in early pregnancy and again at 28

weeks regardless of their RhD statusweeks regardless of their RhD status..

Blood grouping and Blood grouping and red cell alloantibodies red cell alloantibodies

D

screening for haemoglobinopathiesscreening for haemoglobinopathies

Screening for sickle cell diseases and Screening for sickle cell diseases and thalassaemias should be offered to all thalassaemias should be offered to all women as early as possible in pregnancywomen as early as possible in pregnancy

Counseling VIIICounseling VIIIScreening for fetal Screening for fetal anomaliesanomalies

Screening for Screening for structural anomalies structural anomalies

Pregnant women should be offered an Pregnant women should be offered an ultrasound ultrasound scanscan to screen for structural anomalies, to screen for structural anomalies, ideally ideally

between between 18 and 20 weeks18 and 20 weeks’ gestation’ gestation, by an , by an appropriately trained sonographer and with appropriately trained sonographer and with

equipment of an appropriate standard.equipment of an appropriate standard.

A

Screening for DownScreening for Down’’s s syndromesyndrome

Pregnant women should be offered screening Pregnant women should be offered screening for Down’s syndrome with a test which for Down’s syndrome with a test which

provides the current standard of a provides the current standard of a detection detection rate above 60% and a false-positive rate of rate above 60% and a false-positive rate of

less than 5%.less than 5%.

N.BN.B Age more than 35yr should be consider during Age more than 35yr should be consider during preconception consuling as risk of down syndrome preconception consuling as risk of down syndrome

B

The following tests meet this The following tests meet this standard:standard:

from 11 to 14 weeksfrom 11 to 14 weeks– – nuchal translucency nuchal translucency (NT)(NT)– – the combined test the combined test (NT, hCG )(NT, hCG )

from 14 to 20 weeksfrom 14 to 20 weeks– – the triple test the triple test (hCG, AFP (hCG, AFP and and unconjugated unconjugated

oestradioloestradiol))– – the quadruple test the quadruple test (hCG, AFP, (hCG, AFP, unconjugated unconjugated

oestradioloestradiol, inhibin A), inhibin A) B

Counselling Counselling IXIX

Screening for Screening for infectionsinfections

Asymptomatic Asymptomatic bacteriuriabacteriuria

Pregnant women Pregnant women should be offeredshould be offered routine routine screeningscreening for asymptomatic bacteriuria by for asymptomatic bacteriuria by midstream urine culture early in pregnancy. midstream urine culture early in pregnancy.

Identification and treatment of asymptomatic Identification and treatment of asymptomatic bacteriuria bacteriuria reduces the risk of preterm birth.reduces the risk of preterm birth.

A

Asymptomatic bacterial vaginosisAsymptomatic bacterial vaginosis

Pregnant women should Pregnant women should not be offerednot be offered routine routine screening for screening for bacterial vaginosis bacterial vaginosis because the because the evidence suggests that the identification and evidence suggests that the identification and

treatment of treatment of asymptomatic bacterial vaginosisasymptomatic bacterial vaginosis does not lower the risk for preterm birth and does not lower the risk for preterm birth and

other adverse reproductive outcomes.other adverse reproductive outcomes.

A

Chlamydia Chlamydia trachomatistrachomatis

Pregnant women should Pregnant women should not be offered routine not be offered routine screeningscreening for asymptomatic chlamydia for asymptomatic chlamydia

because there is insufficient evidence on its because there is insufficient evidence on its effectiveness and cost effectiveness. effectiveness and cost effectiveness.

C

CytomegalovirusCytomegalovirus

The available evidence does The available evidence does not support not support routine cytomegalovirus screeningroutine cytomegalovirus screening in in pregnant women and it should not be pregnant women and it should not be

offered.offered.

B

Hepatitis B virusHepatitis B virus Serological screening for hepatitis B virus Serological screening for hepatitis B virus

should be offeredshould be offered to pregnant women to pregnant women

So that effective postnatal intervention can be So that effective postnatal intervention can be offered to infected women to decrease the risk offered to infected women to decrease the risk

of mother-to-child-transmissionof mother-to-child-transmission..

A

Hepatitis C virusHepatitis C virus

Pregnant women should Pregnant women should not be offered routine not be offered routine screeningscreening for hepatitis C virus because there is for hepatitis C virus because there is insufficient evidenceinsufficient evidence on its effectiveness and on its effectiveness and

cost effectiveness.cost effectiveness.

C

HIV infectionHIV infection

Pregnant women Pregnant women should be offered screening for should be offered screening for HIV infection earlyHIV infection early in antenatal care because in antenatal care because

appropriate antenatal interventions can reduce appropriate antenatal interventions can reduce

mother-to-child transmission of HIV infectionmother-to-child transmission of HIV infection..

D

RubellaRubella

Rubella-susceptibility screening Rubella-susceptibility screening should be offered should be offered early in antenatal careearly in antenatal care to identify women at risk to identify women at risk

of contracting rubella infection and to enable of contracting rubella infection and to enable vaccination in the postnatal period for the vaccination in the postnatal period for the

protection of future pregnancies.protection of future pregnancies.

B

Streptococcus group BStreptococcus group B

Pregnant women Pregnant women should not be offered routine should not be offered routine antenatal screeningantenatal screening for group B streptococcus for group B streptococcus

(GBS) (GBS) because evidence of its clinical because evidence of its clinical effectiveness and cost effectiveness remains effectiveness and cost effectiveness remains

uncertainuncertain..

C

SyphilisSyphilis

Screening for syphilis Screening for syphilis should be offered to all should be offered to all pregnant women at an early stage in antenatal pregnant women at an early stage in antenatal

carecare because treatment of syphilis is because treatment of syphilis is beneficial to the mother and fetus.beneficial to the mother and fetus.

B

ToxoplasmosisToxoplasmosis

RoutineRoutine antenatal serological screening for antenatal serological screening for toxoplasmosis toxoplasmosis should not be offeredshould not be offered because the because the harms of screening may outweigh the potential harms of screening may outweigh the potential

benefits.benefits.

B

Counseling X Counseling X

Screening for clinical Screening for clinical conditionsconditions

Gestational diabetes Gestational diabetes mellitusmellitusScreening for gestational diabetes at 24-28 Screening for gestational diabetes at 24-28

weeks GA using risk factors isweeks GA using risk factors is .… .…

• •body mass index above 30 kg/m²body mass index above 30 kg/m²

• •previous macrosomic baby weighing 4.5 kg or aboveprevious macrosomic baby weighing 4.5 kg or above

• •previous gestational diabetes (refer to Diabetes in pregnancy’)previous gestational diabetes (refer to Diabetes in pregnancy’)

• •family history of diabetesfamily history of diabetes

B

I-hour, 50 g Oral Glucose Challenge Test I-hour, 50 g Oral Glucose Challenge Test (OGCT)(OGCT)

• •plasma glucose (PG) <7.8 mmol/L --> no plasma glucose (PG) <7.8 mmol/L --> no GDMGDM

• •PG ~7.8 and <10.3 mmol/L --> do 2-hour 75 g PG ~7.8 and <10.3 mmol/L --> do 2-hour 75 g oral glucose tolerance test (OGTT)oral glucose tolerance test (OGTT)

for diagnosisfor diagnosis

• •PG ~1O.3 mmol/L --> GDM establishedPG ~1O.3 mmol/L --> GDM established

Issues with diabetesIssues with diabetes

• •In most women, gestational diabetes willIn most women, gestational diabetes will

respond to changes in diet and exerciserespond to changes in diet and exercise

• •Birth complications such as Birth complications such as shoulder dystociashoulder dystocia

• •Increased monitoring and interventions duringIncreased monitoring and interventions during

both pregnancy and labourboth pregnancy and labour..

• •ScreeningScreening

Gestational hypertensionGestational hypertension

Risk FactorsRisk Factors

• •maternal factorsmaternal factors

• •primigravida (80-90% of gestational HTN)primigravida (80-90% of gestational HTN)

• •first conception with a new partnerfirst conception with a new partner

• •PMHx or FHx of gestational HTNPMHx or FHx of gestational HTN

• •DM, chronic HTN, or renal insufficiencyDM, chronic HTN, or renal insufficiency

• •antiphospholipid antibody syndrome (APLA)antiphospholipid antibody syndrome (APLA)

• •extremes of maternal age «18 or >35extremes of maternal age «18 or >35((

• •fetal factorsfetal factors

• •IUGR or oligohydramnios, GTN, multiple IUGR or oligohydramnios, GTN, multiple gestation, fetal gestation, fetal hydropshydrops

Pre-eclampsiaPre-eclampsia

At first contact a woman’s At first contact a woman’s level of risk for pre-level of risk for pre-eclampsiaeclampsia should be evaluated so that a plan for should be evaluated so that a plan for

her subsequent schedule of antenatal her subsequent schedule of antenatal appointments can be formulated. appointments can be formulated.

C

Developing pre-eclampsia during a pregnancy is Developing pre-eclampsia during a pregnancy is increased in women whoincreased in women who::

1.1. are nulliparousare nulliparous

2.2. are aged are aged 4040 or older or older

3.3. have a family history of pre-eclampsia have a family history of pre-eclampsia

4.4. have a prior history of pre-eclampsiahave a prior history of pre-eclampsia

5.5. have a body mass index have a body mass index (BMI)(BMI) at or above at or above 3535 at first at first contactcontact

6.6. have a multiple pregnancy or pre-existing vascular have a multiple pregnancy or pre-existing vascular disease disease (for example, hypertension or diabetes).(for example, hypertension or diabetes).

C

Whenever blood pressure is measured in pregnancy Whenever blood pressure is measured in pregnancy a a urine sample should be tested at the same time urine sample should be tested at the same time

for proteinuria.for proteinuria.

Pre-eclampsiaPre-eclampsia

C

Pregnant women should be informed of the Pregnant women should be informed of the symptoms of advanced pre-eclampsia because symptoms of advanced pre-eclampsia because these may be associated with poorer pregnancy these may be associated with poorer pregnancy outcomes for the mother or baby.outcomes for the mother or baby.

Symptoms include Symptoms include headache;headache;

problems with vision, such as blurring or flashing before the eyes;problems with vision, such as blurring or flashing before the eyes;

bad pain just below the ribs; bad pain just below the ribs;

vomiting andvomiting and

sudden swelling of face, hands or feet.sudden swelling of face, hands or feet.

Pre-eclampsiaPre-eclampsia

D

references

-Swanson

-Family medicine practice

-Emedicine

-NICE clinical guideline 6 (Routine care for the healthy

-pregnant woman )June 2010 -SPECIAL THANKS FOR DR. ALI AL MOUSA