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Transcript of 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
Diagnosis Of Pregnancy
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.
Diagnosis Of Pregnancy
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
Identification of HRP during ANC
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
Identification of HRP during ANC
C-Conditions observed during obstetric examination
Pre- eclampsia (PE)
Antepartum hemorrhage (APH)
Multiple pregnancy
Malpresentations, and malpositions
Feto-pelvic disproportion
Identification of HRP during ANC
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
Ultrasonography in pregnancy
1st Trimester Ultrasound
Number
Site
Viablity
Nuchal translucency –congenetal anomalies
Dating
Ultrasonography in pregnancy
1st Trimester Ultrasound
Number
Site
Viablity
Nuchal translucency –congenetal anomalies
Dating
Ultrasonography in pregnancy
1st Trimester Ultrasound
Number
Site
Viablity
Nuchal translucency –congenetal anomalies
Dating
Ultrasonography in pregnancy
1st Trimester Ultrasound
Number
Site
Viablity
Nuchal translucency –congenetal anomalies
Dating
Ultrasonography in pregnancy
2nd Trimester Ultrasound
Fetal anomaly scan± 3D US
Dating
Ultrasonography in pregnancy
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.
What to write in prescription ??
1st Trimester:
Folic acid 500 microgram
Folic acid 500 tab
Folicap 0.5 mg cap
Cobal F tab
What to write in prescription ??
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]