1. Is Antenatal Care Worthwhile? Max Brinsmead MB BS PhD May 2015

2. I will not directly answer this because: n There are no trials of AN care vs no AN care n Instead I will… n Look at what we are we doing in AN care n This requires a diversion into epidemiology n Review those parts of AN care that has been tested by rigorous RCT? n What will AN care look like in the future?

3. Why do we: n Take a history? n Perform blood tests? n Measure BP? n Perform ultrasound? n Palpate the abdomen? n Weigh patients? n Test urine?

4. Antenatal care is designed to: n Single out pregnancies that are abnormal, disordered or high risk… n In order to provide interventions that will optimise an outcome n Provide preparation for childbirth and parenting

5. Screening is: n The application of a TEST to an ASYMPTOMATIC population in order to FIND cases of DISEASE or ABNORMALITY.

6. The objective of screening:

8. A good screening test

9. A typical screening scenario:

10. Characteristics of a Test n Sensitivity = the chance that the disease will be detected n Positive predictive value = the chance that a screen positive individual will have the disease

11. Down syndrome detection: n Sensitivity based on age = 30% n Based on 2 nd trimester triple test = 60% n Based on 1 st trimester combined test = 88% and n Positive predictive value = 1:10

12. Antenatal Care as Screening n Urinalysis

13. Antenatal Care as Screening n Urinalysis n Pre eclampsia

14. Antenatal Care as Screening n Urinalysis n BP measures n Pre eclampsia

15. Antenatal Care as Screening n Urinalysis n BP measures n Pre eclampsia

16. Antenatal Care as Screening n Urinalysis n BP measures n Detection of oedema n Pre eclampsia

17. Antenatal Care as Screening n Urinalysis n BP measures n Detection of oedema n Pre eclampsia

18. Antenatal Care as Screening n Urinalysis n BP measures n Detection of oedema n Maternal weight gain n Pre eclampsia

19. Antenatal Care as Screening n Urinalysis n BP measures n Detection of oedema n Maternal weight gain n Pre eclampsia n Fetal growth

20. Antenatal Care as Screening n Haemaglobin n Red cell indices n RBC antibodies n Reagin tests n Anaemia n Thalassaemia n Fetal isoimmunisation n Syphilis

21. Antenatal Care as Screening n Glucose challenge test n Vaginal swab n Hep C testing n Gestational diabetes n Group B Streptococci n Hep C infection

22. 7 Criteria to test a screening program n Is there a good screening test available? n Is there an intervention available? n Is the disease worth detecting? n Will screen positive patients comply? n Will the test reach those applicable? n Has the program been tested by RCT? n Can the health system cope with the program?

23. Problems with Screening: n FALSE POSITIVES – And the resources required to deal with them n UNREALISTIC EXPECATATIONS –ie misunderstanding about the sensitivity of the test

24. An Evidence Base for Antenatal Care The Cochrane Library

25. The Cochrane Library on Antenatal Care n 64 Analyses of which: –7 evaluate routine antenatal care – 15 evaluate routine advice during pregnancy – 16 evaluate management of common minor problems – 26 evaluate management of high risk pregnancies

26. Trials of care for low risk women n Ten trials with >60,000 women –Fewer visits not associated with adverse outcome – But women less satisfied – Midwife or GP care as good as Specialist care – And women more satisfied

27. Continuity of care n Two trials with 1815 women cared for by a team of midwives vs traditional care –Fewer hospital admissions –More likely to attend antenatal education – Used less analgesic drugs in labour – Less requirement for neonatal resuscitation. – No difference for other obstetric outcomes

28. Women who carry their own record n Three trials with 675 women –More likely to feel in control –Insignificant risk of lost or left records – More likely to deliver operatively – No difference for other obstetric outcomes

29. Measuring symphysis fundal height n 1639 women recruited No difference for any obstetric outcomes

30. Psychosocial support and postpartum depression n 7600 women studied: –No benefit if provided antenatally –Postpartum support is required

31. So, in your antenatal clinic will you: n Weigh your patients at every visit? n Record their height? n Urine test every visit? n Measure symphysis fundal height? n Record presentation and engagement? n Screen for depression? n Screen for domestic abuse? n Screen for thalassaemia? n Offer Down’s Risk testing? n Screen for diabetes? n Screen for GBS colonisation?

32. A New Model of Antenatal Care? n 12w n History for risk factors n Check weight, BP and urine n Scan for dates, NT (and more?) n Blood for routine tests + aneuploidy markers

33. A New Model of Antenatal Care? n 12w n History for risk factors n Check weight, BP and urine n Scan for dates, NT (and more?) n Blood for routine tests + aneuploidy markers n 20w n Scan for morphology, placenta, check uterine artery Dopplers and cervical length

34. A New Model of Antenatal Care? n 12w n History for risk factors n Check weight, BP and urine n Scan for dates, NT (and more?) n Blood for routine tests + aneuploidy markers n 20w n Scan for morphology, placenta, check uterine artery Dopplers and cervical length n 28w n Screen for gestational diabetes n Anti D for Rh negative n 34w n Anti D for Rh negative

35. A New Model of Antenatal Care? n 12w n History for risk factors n Check weight, BP and urine n Scan for dates, NT (and more?) n Blood for routine tests + aneuploidy markers n 20w n Scan for morphology, placenta, check uterine artery Dopplers and cervical length n 28w n Screen for gestational diabetes n Anti D for Rh negative n 34w n Anti D for Rh negative n 36w n Scan to exclude breech

36. A New Model of Antenatal Care? n 12w n History for risk factors n Check weight, BP and urine n Scan for dates, NT (and more?) n Blood for routine tests + aneuploidy markers n 20w n Scan for morphology, placenta, check uterine artery Dopplers and cervical length n 28w n Screen for gestational diabetes n Anti D for Rh negative n 34w n Anti D for Rh negative n 36w n Scan to exclude breech n 38 & 40w n Check primigravida for late onset pre eclampsia

37. A New Model of Antenatal Care? n 12w n History for risk factors n Check weight, BP and urine n Scan for dates, NT (and more?) n Blood for routine tests + aneuploidy markers n 20w n Scan for morphology, placenta, check uterine artery Dopplers and cervical length n 28w n Screen for gestational diabetes n Anti D for Rh negative n 34w n Anti D for Rh negative n 36w n Scan to exclude breech n 38 & 40w n Check primigravida for late onset pre eclampsia n 41W n Sweep membranes. Arrange induction of labour