In the name of God

Obstetrician & Gynecologist Prenatalogist from KCL,England Dr Solmaz Piri Obstetrician & Gynecologist Prenatalogist from KCL,England

Prenatal Care  The major goal of prenatal care is to ensure the birth of a healthy baby with minimal risk for the mother.

Main Components Patient education and communication Early, accurate estimation of gestational age Identification of the patient at risk for complications Ongoing evaluation of the health status of both mother and fetus Anticipation of problems and intervention, if possible, to prevent or minimize morbidity Patient education and communication

Woman-centred care

care and that of her baby should be sought and respected at all times Women, their partners and their families should always be treated with kindness, respect dignity The views, beliefs and values of the woman, and her family in relation to her care and that of her baby should be sought and respected at all times

booking (ideally by 10 weeks)

Documentation of care

Gestational age Crown–rump length measurement should be used to determinegestational age. If the crown–rump length is above 84mm, the gestational age should be estimated using head circumference.

Immunization

Tetanus and diphtheria toxoid vaccine (Td) Available vaccines Tetanus and diphtheria toxoid vaccine (Td) Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap).

In 2013, The ACIP recommendations supported by the American College of Obstetricians and Gynecologists All pregnant women receive vaccination against pertussis with Tdap during each pregnancy, optimally between 27 and 36 weeks of gestation, regardless of prior vaccination status, to better protect their infant

tetanus booster If Tdap is given earlier than 27 to 36 weeks and at any stage of pregnancy if the woman lives in an area with a pertussis epidemic or required as part of wound management

Varicella vaccination Varicella vaccination is recommended for women without evidence of immunity preconceptionally or postpartum: Postpartum:The first dose is given while the patient is in the hospital and the second dose is given four to eight weeks later, which typically coincides with the routine postpartum visit. Breastfeeding is not a contraindication

History The elements of the patient history include: Personal and demographic information Past obstetrical history Personal and family medical history Past surgical history Genetic history Menstrual and gynecological history Current pregnancy history Psychosocial information

Physical examination Classic and complete approach Everything is important Every mild derangement should be carefully adressed Keep in mind : Pregnant women is using her body reserve and may not be able to make further compensation

Rhesus type and antibody screen — This test will detect antibodies potentially causing hemolytic disease of the newborn.

Folic acid

The recommended dose is 400 micrograms per day Dietary supplementation with folic acid, before conception and throughout the first 12 weeks, reduces the risk of having a baby with a neural tube defect The recommended dose is 400 micrograms per day

Vitamin A, be carefull ! Pregnant women should be informed that vitamin A supplementation (intake above 700 micrograms) might be teratogenic and should therefore be avoided. Pregnant women should be informed that liver and liver products may also contain high levels of vitamin A, and therefore Consumption of these products should also be avoided.

vitamin D

haematological conditions

gestational diabetes

fetal anomalies and aneuploidies

Air travel

Hepatitis B Testing for HBsAg should be performed on all women at the first prenatal visit and repeated late in pregnancy in those at high risk for HBV infection. The current recommendation is to provide passive-active immunization to newborns of carrier mothers.

Antivirals A meta-analysis of 10 studies concluded that the administration of lamivudine to the mother in late pregnancy in addition to hepatitis B vaccination and hepatitis B immunoglobulin prophylaxis for the infant significantly reduced mother-to-child transmission

More data are needed to clarify the HBV DNA cutoff for recommending antiviral therapy to pregnant HBV carriers At present, we tend to offer antiviral prophylaxis in women who have a high viral load (more than 8 log(10) int. unit/mL). Treatment should be started preferably six to eight weeks before delivery to allow enough time for HBV DNA levels to decline. Of the available oral agents, telbivudine and tenofovir are pregnancy class B drugs

With appropriate immunoprophylaxis, breastfeeding of infants of HBV carriers poses no additional risk for the transmission of HBV Infants who received HBIG and the first dose of vaccine at birth may be breastfed as long as they complete the course of vaccination but carrier mothers should not participate in donating breast milk. Mothers with chronic hepatitis B who are breastfeeding should also exercise care to prevent bleeding from cracked nipples

Further tests VDRL Asymptomatic bactriuria HIV Thyroid function tests

Not recommended CMV Toxoplasmosis HSV Bacterial Vaginosis

Thank you very much for your attention