ANTENATAL CARE AND HIGH RISK PREGNANCY

Although pregnancy is considered a normal physiologic event, yet it can be complicated by pathologic processes dangerous to the mother and foetus in about 5-20% of cases. Some of these complications are preventable; others are predictable, allowing early diagnosis and management.

PRE-PREGNANCY COUNSELING

The preconception visit:

The ideal first visit should be at a preconception clinic where health education and risk assessment can be directed towards the planned pregnancy. Advice can be given regarding the avoidance of harmful and teratogenic factors (drugs, cigarette smoking and alcohol intake), ensuring an optimal dietary intake, and absence or control of chronic medical disorders (as diabetes, hypertension), in order to allow pregnancy to be started in the optimum conditions.
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Objectives: 1. Being able to council females before

pregnycy.
2. Identification of Risk factors in female before

pregnancy.
3. Being able to select high risk cases for

further screening lest.

The aim of pre-pregnancy care is to give a woman enough information for her pregnancy to occur under the optimal possible

circumstances. Areas to cover are:

Diet:
Folate rich foods prior to pregnancy and in the first
l2wk. of pregnancy (see below). Avoidance of unpasteurized dairy products, uncooked eggs, pre-

prepared salads to prevent infection (e.g. Listeriosis,

salmonella) during pregnancy. When preparing food keep cooked and raw meats separately. Wash all soil

off fruit and vegetables before eating. Wash hands

before and after preparation. Only eat well-cooked meat.
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Folate supplementation:
If no previous neural tube defects, folic acid 400
microgram supplementation prior to conception

when pregnancy is being planned and for l3wk

after conception decreases risk of neural tube

defect by 72%.

Chronic disease
Review of pre-existing medical conditions with referral for expert advice where necessary. Refer women who are diabetic for specialist diabetic review and change women taking oral hypo-glycemics to insulin. Women with

epilepsyreview

medication.

Heart

diseaserefer

for

specialist advice if situation not clear. GU disease (e.g. HIV, HSV, genital warts, bacterial vaginosis)refer for treatment advice on mode of delivery if necessary. Discontinue all known possible teratogens prior to conception
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Problems in previous pregnancies

Recurrent miscarriage; cervical incompetence;
congenital abnormalities/inherited disorders

pre-pregnancy counseling and detailed advice on

genetic screening for high-risk pregnancies is

available via regional genetics services.

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Rubella status
If rubella status is unknown suggest it is checked. Rubella infection in early pregnancy carries a high chance (4070%) of deafness, blindness, cardiac abnormalities or multiple fetal

abnormalities. If the woman is not rubella

immune, suggest immunization with avoidance of

pregnancy for 3 months afterwards (live vaccine).
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Contraception
Women contemplating pregnancy are usually still
using contraception. Discussion about how to

stop/what

to

expect

may

be

helpful

(e.g.

injectables, IUCD).

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Smoking
Smoking decreases ovulation, sperm count & sperm motility. Once the woman is pregnant, smoking increases miscarriage rate (x2), risk of pre-ternm delivery and low birth weight (by an average of200g). Explain risks and advise on ways to stop (this includes passive smoking).
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Discussion of antenatal care and screening available

Brief discussion of antenatal screening and antenatal care procedures allows women to investigate their choices in pregnancy at their leisure. Brief

discussion about miscarriage and possibility of infertility allows women to be more confident about

asking for help if problems with conception/early

pregnancy occur.
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SCREENING IN PREGNANCY
Most women undergo some form of screening before or during pregnancy. It aims to identify, prevent and treat actual or potential problems. Women and their partners regarding must be given and unbiased diagnostic information tests, the

screening

meaning and consequences of both, what to expect

in

terms

of

results,

and

further

options

for

management.
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GPs need to be aware of the techniques of prenatal

diagnosis in order to:

Identify all women who might benefit from

genetic counseling and/or early assessment by the obstetrician;

Counsel patients about the accuracy and risk

of prenatal diagnosis;

Make sure that the opportunity for prenatal

diagnosis is not overlooked as certain tests are done at certain times.
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Pre-pregnancy genetic screening

There are many inherited diseases and more are

being discovered all the time. Refer before pregnancy

couples who request referral or those with factors, which put them at high risk of having a baby with a genetic disorder to a trained obstetrician or genetic counselor. Risk factors that warrant pre-pregnancy genetic screening:
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Personal or past history of genetic abnormality: e.g. Downs syndrome; sickle cell; other muscular

dystrophies; Huntingtons chorea; polycystic kidneys.

Diabetic mothers: have an increased risk of feti with congenital anomalies. Older women: Risk of Downs syndrome increases with maternal age.

Consanguineous couples: 1st degree cousins who have

a baby together have an increased risk of congenital malformations in their offspring.
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Tools of antenatal screening

After referral to the specialist, certain tools may be used for optimal counseling. Basic screening tests: Blood and urine tests e.g. Hb estimation; blood group; dipstick screening of urine for

proteinuria and glycosuria; rubella immune status

screening; hepatitis B screening; syphilis screening. Ensure women are given information about the reasons for, significance of and results of routine tests.

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Ultrasound scan: High resolution anomaly scan is routinely offered to pregnant women at 18 weeks of gestation. Its purpose e.g. is to detect GIT, structural skeletal

abnormalities

cardiac,

abnormalities, etc.

a-fetoprotein (AFP): measured in the maternal blood

and amniotic fluid. Its level increases with twins or

fetal malformation: neural tube defect, posterior

urethral valves, nephrosis, or Turners syndrome
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Decreased

levels

are

associated

with

diabetic

mothers and chromosomal abnormality e.g. Downs syndrome. Routinely offered in many centers. AFP alone is a non-specific test requiring those with abnormal values to undergo further investigation.

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Chorionic

villus

sampling

(CVS):

At

10-12wk

gestation the developing placenta is sampled per

abdomen or trans-cervically with US guidance. Used to detect genetic or metabolic abnormality in high risk pregnancies. Advantages. Undertaken earlier than amniocentesis to allow termination of affected pregnancies at an earlier stage. Risks. 4% abortion; limb defects (rare).
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At Amniocentesis: Sampling of amniotic fluid via a transabominal needle under ultrasound guidance. When undertaken for screening purposes, it takes place from 16l9wk gestation. May be routinely offered to women at high risk of fetal abnormality (e.g. women >35 years of age to

exclude Downs syndrome) or to clarify abnormalities

found with other screening tests e.g. abnormal AFP. Fetoscopy: Fibreoptic visualization of the fetus. Carried out from l5wk. Enables external abnormalities to be detected, fetal blood sampled and organs biopsied. Fetal loss rate 4%.
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For certain disorders, some standard tests are offered:

Spina bifida
U/S at 1719 wk gestation detects 9095% spina bifida and 100% anencephaly. AFP detects 80% of open defects and 90% of those with anencephaly. Confirmation with U/S is required.
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Downs syndrome
The commonest single cause of mental handicap in children of school age. incidence: 3/2000 births. Numerous methods of antenatal screening have been tried but it is unclear which is best.

Clarification is awaited. Options are: Age: Incidence with age1:365 at age 35, rising to

1:110 at age 40 and 1:30 at age 45. Offering

amniocentesis

to

all

pregnant

women

>35

combined with routine anomaly scanning identifies 70% of all cases of Downs syndrome.
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AFP alonenon-specific test. Necessitates further evaluation in all cases.

Double/triple test: Blood test which measures AFP and

hCG + estriol. Blood is taken at l6wk. gestation and a risk value calculated for the individual woman taking into account age, and exact gestation. The result is expressed as a risk assessment (e.g. 1:300) or as a +ve or -ve result. A +ve result usually means the risk of having a Downs syndrome baby is >1:250 and amniocentesis is recommended. A +ve test does not

indicate the presence of Downs syndrome but just an

increased risk.
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Nuchal translucency test: U/S measurement of the translucency of the nuchal fold in the neck of the fetus

at 10-l4wk. gestation. Detection rate =80%, false +ve

rate 8%. integrated test Combines blood tests and U/S to produce a single estimate of the womans risk of having a child with Downs syndrome. Uses: Womans age; measurement at 10l3wk. gestation of nuchal

translucency and maternal serum level of AFP, unconjugated estriol, hCG. Detection rate: 85%. Only 1%

of women require unnecessary amniocentesis.

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Hemoglobinopathies
Antenatal screening is routinely offered to all women in areas where >15% of the population are in high risk ethnic groups (Black ethnic groups for Sickle cell disease and Mediterranean for Thalassaemia). In other areas hemoglobinopathy screening should be offered to people

whose

racial

background

of

hemoglobinopathies

predominately occur. Ideally screening should be carried out preconceptionly. Otherwise perform as early as

possible into pregnancy. All women identified as having a

trait, or the disorder, should be referred for specialist counseling and their partners offered screening.
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Antenatal care (ANC)

Antenatal care (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.

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The objectives of ANC are carried out via:

1. Early detection and, possibly prevention, of complications specific to pregnancy, as preeclampsia, eclampsia, and obstetric haemorrhage. 2. Detection and management, or at least amelioration, of any medical disorder complicating pregnancy as anaemia, diabetes mellitus, cardiac, renal, or endocrine disorders.

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3. Detection of complications which may affect labour as disproportion and malpresentations. 4. Education of the patient and her family about pregnancy, labour and delivery, the hygiene and diet in pregnancy, and the warning or alarming symptoms that necessitate consultation. 5. Laboratory investigations that may assure the general health and detect medical problems. 6. Finally patients are classified into normal or high risk throughout pregnancy and managed accordingly.
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The First ANC Visit:

Aim: Thorough history taking and clinical examination to identify important risk factors: History: Menstrual H.: To identify LMP, calculate gestational age, and the EDD (Naegles formula). Obstetric H.: Previous pregnancies provide important clues to potential problems in the current one. Medical H.: Medical disorders exacerbated by pregnancy e.g. hypertension, diabetes, heart diseaseetc. Surgical H.: e.g. uterine surgery as myomectomy, previous CS. Family H.: e.g. diabetes, twins, familial disorders.
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General examination: Pulse, temperature and B.P., palloretc. Abdominal Examination: abdominal masses, enlarged liver or spleen, hernias,etc Vaginal examination: done only if necessary, e.g.: for suspected pelvic masses, ectopic pregnancy etc.

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Routine laboratory tests:

Blood group and Rh typing, to identify RH negative patients. Complete blood picture: for Hb%, WBCs, and platelets. Blood sugar level: random blood glucose, or fasting and 2 hrs postprandial levels. Complete urine analysis: for pus cells, RBCs, albumin and sugaretc, Other tests as: TORCH antibodies IgG and IgM, VDRL, hepatitis B & C if necessary, especially in the first pregnancy.
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RETURN VISITS:
Monthly visits are required in the first 6 months, twice weekly visits in 7th and 8th months, then weekly visits in the 9th month until delivery.

In each visit important data include;

Warning symptoms, e.g. Bleeding or regular menstrual like colicky pains, persistant vomiting, sudden escape of liquor amnii, severe persistant headache, blurring of vision, marked swelling of the lower limbs. Daily fetal movement count (DFMC). Weight gain: the average weight gain during pregnancy is 11-16 Kg. (normal = 0.5 kg/wk > 20 wks). Excessive weight gain many denote occult oedema (developing preeclampsia) while inadequate weight gain may reflect nutritional deficit or fetal growth retardation).

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Examination for L.L. Oedema: ankle oedema is acceptable in late 2nd and 3rd trimesters.
Blood pressure measurements: to detect early gestational hypertension or preeclampsia. Fundal level: Should be measured and recorded at each visit after 20 weeks. Fetal heart sounds, heard by the Sonicaid Duplex instrument, or by Pinnard stethoscope. Ultrasonography whenever needed to ensure gestational age, to assure normal fetal growth, to assess fetal well being, to exclude major fetal anomalies, to evaluate placental location and amniotic fluid volume at various pregnancy trimesters.
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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.
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Breasts: Daily washes as a part of body hygiene. In the last few weeks, massage of the nipples using lubricant creams might reduce the incidence of cracking. Retracted nipple is withdrawn by the thumb and finger using a lubricant. Sexual intercourse: Is better minimized in the first trimester to avoid bleeding then gradually allowed. It is completely restricted only if there is recurrent bleeding, tendency to abortion, preterm labour, or suspected rupture of the membranes.
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Smoking: Should be strictly avoided as it may result in placental insufficiency, delivery of small babies, or may be a cause of premature labour.

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.
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Nutrition in pregnancy:
Nutritional Requirements of the pregnant mother should include:

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. 43

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.
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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.
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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, rabies, influenza, cholera and typhoid. Passive immunization against hepatitis A and B may be given.
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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 the benefits may outweigh the risks. Group: X Contraindicated in pregnancy, may cause adverse fetal effects.
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COMMON COMPLAINTS DURING PREGNANCY

Morning sickness: A sensation of nausea, with or without vomiting, which may be more evident in the morning, is common especially in primigravidas. Management by reassurance, frequent small light meals, vitamin B6, and if severe certain antiemetic drugs may be given for a short period of time.
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Heart Burn: Dilatation of the cardiac opening of the stomach and oesophageal regurgitation, commonly lead to a sensation of heart burn. Less commonly the cause is some degree of a hiatus hernia. Management: Frequent light diet, antacids, and allowing 2 hours between meals and sleep.

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Constipation: It is due to reduced intestinal motility due to steroid hormones, with continued fluid absorption and pressure by the gravid uterus. Management includes increased fluid intake, regulation of bowel habits, diet should be rich in fresh vegetables. Mild laxatives may be required.
Haemorrhoids (Piles): Haemorrhoids are predisposed to by congenital weakness of the walls of the veins, constipation, straining, and prolonged standing. Management is by avoiding constipation and local anaesthetic ointment as lignocaine when necessary.
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Headache: One of the commonest complaints, especially those with history of migraine headache attacks. The condition is aggravated by vasodilatation accompanying pregnancy. It may also be due to nasal congestion or chronic sinusitis, errors of refraction or emotional tension. In most cases symptomatic treatment is achieved by use of Paracetamol derivatives. Severe and persistent headache in the 3rd trimester may be suggestive of preeclampsia.
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Breast tenderness: Caused by breast engorgement and managed by avoiding tight clothes.
Breathlessness: Common, can be noticed as early as the first 12th week of pregnancy, due to hyperventilation caused by progesterone. In late weeks, the enlarging uterus can cause mechanical pressure.
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Abdominal pain: Pelvic heaviness or sensation of dragging caused by the weight of the uterus on the pelvic support and the abdominal wall. Management: Rest especially in the lateral position. Traction on the round ligament with slight rotation of the uterus can cause abdominal discomfort along the course of the ligament. Management: Reassurance, change of position.
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Braxton-Hicks contractions: infrequent, irregular and not increasing in frequency or strength. Management: Reassurance, and if recurrent or severe, mild sedatives or antispasmodics. Flatulence and distension: may be caused by

large, fatty meals or intestinal hypotonia, constipation and pressure by the enlarging gravid uterus.

Management:

Avoiding large, fatty meals. Regular evacuation of bowel. Treatment of constipation. Antiflatulent drugs as charcoal tablets.
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Urinary symptoms: Frequency, urgency and stress incontinence are quite common in late pregnancy which may be explained by increased intra-abdominal pressure together with pressure on the bladder by enlarging uterus. The most important management is to exclude urinary tract infection.

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Lower limb and Ankle oedema: Is common in late pregnancy. Physiological: due to salt and water retention caused by ovarian, adrenal and placental steroid hormones, pressure of the uterus on the pelvic veins and prolonged sitting or standing.
Pathological: (differential diagnosis of preeclampsia).

Management: (after exclusion of pathological

causes) is by minimizing long sitting and standing, elevation of legs whenever possible, and mild exercise. Reduction of salt intake, does not usually affect the condition.

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Leg Cramps: Transient nocturnal painful cramps, mostly due to accumulation of lactic acid with poor venous drainage due to pressure of gravid uterus and LL oedema. Less commonly it may be attributed to reduced serum calcium or magnesium or elevated serum phosphorus. Management includes massage to leg muscles, calcium and magnesium supplementation. Aluminium hydroxide may be given to reduce phosphorus absorption.
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Varicose veins (V.V.): V.V. is predisposed to by congenital weakness of the wall of the veins (main cause), poor muscle activity, increased venous pressure, obesity and pregnancy induced vasodilatation. Management includes: avoiding long standing and sitting, active muscle exercise, elevation of the leg, control of weight gain, and elastic cotton stockings used while lying down and the veins are empty. Surgical or injection treatment is avoided during pregnancy.
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Backache: Backache is one of the commonest complaints during pregnancy. It may be explained by increased lumbar lordosis, and relaxation of the back muscles and pelvic joints caused by steroids. Management is by frequent bed rest to minimize lordosis, exercise, e.g., walking to maintain muscle strength, light massage to relax tense back muscle and avoiding high-heels. Fatigue: Fatigue may be explained by anaemia, extraweight gain, breathlessness, or other systemic diseases. Early in pregnancy, there may be fatigue and desire for excessive periods of sleep.
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Vaginal discharge (leucorrhoea): Due to excess oestrogen production. No treatment is required except if it is associated with infection by trichomonas, or Candida albicans.
Sweating and "feeling of heat". Hot flashes are common probably due to increased peripheral circulation and vasodilatation. Management includes frequent rest periods and cold showers and increased fluid intake.
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High Risk Pregnancy

High Risk Pregnancy is a pregnancy complicated by a disease or a disorder that may endanger the life or affect the health of the mother, the fetus or the newborn. Taking a thorough history and performing a physical examination are the best way to identify the high-risk pregnant women. Once identified, they should be referred to a center specialized in maternal and fetal medicine.
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High risk pregnancy may be associated with:

Severe medical conditions affecting the mother such as:

Diabetes Mellitus, cardiac disease grades III and IV, artificial heart valves, systemic lupus erythematosis, and sickle cell disease.

Recurrent poor obstetrical outcomes such as:

Habitual abortion, recurrent still birth (SB), recurrent early rupture of membranes (ROM), and recurrent pre term labor (PTL).

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Obstetrical complications that require specialized care such as:

Severe pre-eclampsia (PE) or eclampsia, HELLP syndrome, severe intrauterine fetal growth restriction (IUGR), and multiple high risk factors.

Conditions that may require invasive procedures for fetal diagnosis or therapy as:
Immune and non immune hydrops fetalis, and congenital anomalies or genetic disorders.
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Preconception counseling:
The obstetrician discusses and explains the following items:

The high risk factor(s) and its possible effects on the mother, fetus, and the newborn.

The importance of proper monitoring during pregnancy and labor.

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The possibility of early intervention and the sequelae of pre term labor. Antenatal care in a well equipped antenatal clinic. The need to deliver in a well equipped hospital, with warning against home delivery.
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Classification according to a risk scoring system:

For each country or location, a specific risk score is developed to identify high risk cases and to evaluate the magnitude of risk. The scoring system determines the prevalence of risk factors together with the associated peri-natal mortality.

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Conditions detected during history taking:

Identification of high risk pregnancy during antenatal care

Age; whether young (> 18) or elderly (< 35) Primigravida. Parity; whether nullipara (primigravida), or grand multipara (< 4) Previous obstetric difficulties, fetal loss or abnormalities Medical disorders as; Diabetes mellitus, cardiac or renal disease
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Conditions observed during general examination:

Extreme obesity (maternal weight > 120 kg). Short stature (less than 150 cm) Hypertension (>140/90) Severe anemia (Hb <8.0 gm %) Cardiac or renal disease. Poor weight gain during pregnancy
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Conditions diagnosed during obstetric examination

Pre- eclampsia (PE) Ante partum hemorrhage (APH) Multiple pregnancy

Malpresentations, and Feto-pelvic disproportion

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Conditions detected during routine investigations

Severe anemia, thrombocytopenia, and hyperglycemia,

Glycosuria and Albuminuria.

Rh negative blood typing

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Screening for fetal anomalies:

Congenital anomalies: Ultrasonography for fetal anatomy survey for detection of (e.g. anencephay, NTDs, Limb and skeletal deformities, cardiac and renal anomaliesetc).
Chromosomal abnormalities, as Down's syndrome (by 1st trimester US, chorionic villus sampling, and 2nd trimester amniocentesis).

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Screening for infections:

TORCH, toxoplasmosis, rubella, cytomegalovirus, herpes simplex.

Hepatitis B & C and Human Immunity Virus (HIV).

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Fetal surveillance in high risk cases

Correlation between fetal growth and gestational age. (Clinical & US). Daily Fetal Movement Count (DFMC). Non stress test (NST). Contraction stress test (CST). Biophysical profile score (BPPS).

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Delivery of High Risk Patients

Attention to the risks that may develop during labor and may affect maternal or fetal conditions. The place of delivery should be fully equipped for maternal & fetal resuscitation (maternal & neonatal intensive care units - ICU). Efficient well-trained personnel, specialists & consultants should be available 24 hours a day. Monitoring of fetal well being during labor, maternal condition and progress of labor (partogram) is essential.
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Postnatal care
The mother is still at risk for complications during the immediate & late postpartum period. The new born must be assessed and managed by a neonatologist.

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THANK YOU

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