ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD. ANTENATAL CARE

Objectives of Prenatal Care 1) - the diagnosis of pregnancy, calculation of the gestational age and the estimated date of confinement (EDC); 2) - the prognosis for the present pregnancy; 3) - the prognosis for delivery; 4) - the prognosis for the puerperium, the newborn and lactation; 5) - the prognosis for the future pregnancies.

The providers of antenatal care family doctors obstetric specialists trained nurse-midwives It is very important to establish a good relationship between the patient and her medical advisers: doctor and midwife.

The technique of antenatal care The first antenatal visit Each pregnant woman should be seen first before the 10 th week of pregnancy. At this first visit – a medical file: A.- Comprehensive history; B.- Physical examination; C.- Routine laboratory tests.

The technique of antenatal care VISITS UP TO THE TERM First visit in early pregnancy. Then every 4 weeks until 28 weeks. Then every 2 weeks until 36 weeks. Then weekly until delivery. For high risk patients, individualized and more visits.

The technique of antenatal care VISITS UP TO THE TERM general assessment; weight gain (4-5 kg before the 20th week, then 0,5 kg weekly); blood pressure. Normally under 140/90 mmHg obstetrical examination: the height of the uterine fundus, the time of "quickening" and the fetal movements; after the 28th week, checking the lie, the presentation and the position of the baby and the auscultation of the fetal heart; at about the 37 weeks the pelvic assessment made by the obstetrician; repeated certain laboratory tests.

The technique of antenatal care FIRST VISIT History Gestational age (by adding 9 months plus seven days at LMP) = Naegele rule Accurate estimation average duration = 266 days from the conception and 280 days from the first day of the LMP First day of the last normal menstrual period. »» Regular and normal periods? »» Oral contraceptive pills? »» Lactation?

The technique of antenatal care Ultrasound estimation of GA, EDC 1 st trimester: - The best & most accurate. - Measure crown-rump length (CRL ± 5 days).

The technique of antenatal care

2 nd trimester: - (BPD, HC, AC, FL ± 10 days) 3 rd trimester: - Much less accurate.. BPDHC AC FL

The technique of antenatal care History Nutrition The pregnant woman of average weight requires about 2400 Kcal daily and her diet must include: - animal and vegetable protein (100g) - carbohydrates (500g) - lipids (100g) - minerals - water-soluble and fat-soluble vitamins (vitamin D- 400 u, daily)

The technique of antenatal care Supplements required are iron, vitamin D and folic acid. maternal folate deficiencies: - abruptio placentae, - pregnancy-induced hypertension - neural cord defects underweight mothers risk: - perinatal morbidity and mortality, - low birthweight infants, - preterm delivery. obesity ► hypertension, diabetes, wound complications, thromboembolism.

The technique of antenatal care Environmental and ocupational factors  Low socio-economic status  Employment  Addiction to tobacco, drugs and alcohol ► increased risk for: spontaneous abortion, prematurity, fetal death, low birthweight, etc. the fetal alcohol syndrome including cranio-facial defects, limb and cardio-vascular defects, growth and mental retardation smoking ► smaller infants (average of 2550 g).

Fetal alcohol syndrome IUGR Behavior disturbance Brain defects Cardiac defects Spinal defects Craniofacial anomalies

The technique of antenatal care Medication Any administrated drug reaches the fetus, therefore its advantages must outweight the risks.

The technique of antenatal care General history 1). Family history 2). Age 3). Medical history 4). Obstetric history

The technique of antenatal care 1). Family history. a familial tendency for multiple pregnancies, congenital abnormalities, diabetes, etc 2). Maternal age less than 20 years ► ↑ risk for premature birth, fetal deaths, preeclampsia; over 35 years ► ↑ risk for first trimester miscarriage, genetic abnormalities, antepartum bleeding, preterm labor maternal and fetal death.

The technique of antenatal care

3). Medical history chronic hypertension, cardiac diseases, renal diseases, diabetes, venous thromboembolic disorders, infectious diseases (rubella, syphilis, hepatitis B, gonorrhea, cytomegalovirus, Herpes, Toxoplasmosis, HIV). 4). Obstetric history abortions full term and premature deliveries (route of each delivery included), high parity (puerperal hemorrhage, multiple gestation, placenta praevia). Complications of previous pregnancies, deliveries and postpartum of previous confinements and breast-feeding.

The technique of antenatal care Physical examination General examination (height, weight, blood pressure, eye fundus, breasts, heart, lungs, abdomen, extremities and current nutritional status). Abdominal examination. Obstetric examination – speculum and bimanual palpation.

The technique of antenatal care Routine laboratory tests Blood hemoglobin (N= 10,5-15 g); hematocrit (N > 35%); MCV and MCH (southern European, African or Asian country); ABO and Rh group; Rh antibodies (Rh negative); irregular antibodies; VDRL; hepatitis (HBs Ag); anti-rubella antibodies; HIV antibody; glycemia; Urine ► urinalysis (specific gravity, protein, sugar, cells); ► culture for bacteriuria; Cervical cytology and culture from the vaginal discharge.

The technique of antenatal care Routine laboratory tests Further tests in pregnancy urinalysis - repeated monthly; hemoglobin concentration and hematocrit - at weeks; glycemia - repeated at about 28 weeks; for Rh-negative women - Rh antibodies at 20, 24, 28, 32, 36 weeks; irregular antibody test - repeated at 36 weeks.

Antenatal screening 1. Routine ultrasound examination 1 st trimester: »» Diagnose pregnancy. »» Assure accurate dating. »» Fetal number. »» Fetal viability. »» Adnexial mass. »» Screen for chromosomal anomalies; Nuchal translucency & nasal bone.

Antenatal screening 2 nd trimester: »» Detailed anomaly scan (18-20 weeks). »» Placental localization.

Antenatal screening

3 rd trimester: »» When indicated (high risk pregnancy), »» Growth & fetal welfare parameters. Regular/ serial US: »» High risk pregnancy. »» Poor obstetric history. »» New problem during antenatal care (IUGR, PE, Gestational Diabetes, etc).

Antenatal screening 2. Screening for prenatal defects chorion villus sampling amniocentesis Amniocentesis – early / late. A needle is thrust through the abdominal wall into the amniotic sac, guided by ultrasound in order to avoid the placenta. multiple-marker screening

Antenatal screening Chorionic villus sampling Performed between the 9 th and the 11 th week of pregnancy. Chorionic tissue from the placental edge (by sucking it through a narrow cannula, introduced under ultrasonic guidance). The kariotype of the sample can be determined within 24 h. Fetal loss is of 3%.

Antenatal screening Multiple-marker screening tests Prenatal screening for open neural tube defects (spina bifida, anencephaly), Down syndrome, Edwards syndrome,etc duble test (PAPP-A; βHCG) + nuchal translucency at weeks (12 weeks) triple test (AFP; βHCG; E3) (16-18) weeks the acetylcolinesterase level in the amniotic fluid alpha-fetoprotein.

Antenatal screening 3. Biochemical tests estriol excretion / plasma serial values - less than 12 mg/24 hours → fetal jeopardy. 4. Biophysical tests A. The nonstress test (NST) or fetal activity test (FAT) B. The contraction stress test (CST) : test of fetal reactivity in response to oxytocin administered i.v. C. The biophysical profile → a combination of nonstress testing and real-time ultrasound examination

Antenatal screening The biophysical profile or Manning score = 5 variables that are scored by 0, 1 or 2.  fetal breathing movements  fetal movements or NST  fetal tone  fetal reactivity  the amniotic fluid volume

ANTENATAL ASSESSMENT Pregnancy is classified to be: uncomplicated or low risk high risk * high-risk pregnancies, presenting medical or obstetric problems that require close and complexe surveillance by a medical team, at intervals determined by the nature and severity of the problems.

INTRAPARTUM ASSESSMENT The prognosis for delivery ► assessed after the 28 th week of pregnancy or at the onset of labor. ♦ maternal factors age and parity medical history the size and shape of the bony pelvis the soft tissues of the pelvis the powers

INTRAPARTUM ASSESSMENT ♦ fetal factors the fetus - the number, the size, the lie, the presentation, the position of the presenting part, fetal wellbeing / distress, gross congenital malformations the placenta the membranes the amniotic fluid the umbilical cord.