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Antenatal Care . DR. Yasir Katib MBBS, FRCSC Perinatologest. Antenatal care (ANC) goals and strategy. Explain the components and objectives of prenatal goals Describe the frequency and aim of each prenatal visit Genetic counseling and its available tools

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antenatal care

Antenatal Care

DR. Yasir Katib

MBBS, FRCSC

Perinatologest

antenatal care anc goals and strategy
Antenatal care (ANC) goals and strategy
  • Explain the components and objectives of prenatal goals
  • Describe the frequency and aim of each prenatal visit
  • Genetic counseling and its available tools
  • Risks and benefits of the genetic tests
anc objectives
ANC Objectives

To ensure the birth of a healthy baby with minimal risk for the mother by

  • Early, accurate estimation of GA
  • 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
slide4
ANC
  • Prenatal care is not a single intervention
  • “Quantity" Vs. “Quality" of ANC
  • A systematic review of observational studies and randomized trials concluded that there was no conclusive evidence that prenatal care improved birth outcomes
  • Randomized trials have also shown that enhanced prenatal care did not result in improved outcomes compared to routine prenatal care
anc components
ANC Components
  • HISTORY
  • PHYSICAL EXAMINATION
  • LABORATORY TESTS
  • DIAGNOSTIC IMIGING
  • PATIENT EDUCATION
  • MEDICATIONS
history
HISTORY
  • Personal and demographic information
  • Current pregnancy history (dating)
  • Past obstetrical history (time, place, GA, complications, sex, weight& currant status)
  • Personal and family medical history
  • Past surgical history
  • Genetic history
  • Menstrual and gynecological history
  • Psychosocial information
physical examination
Physical examination

A complete physical examination

Specially…

  • Uterine size and shape
  • Evaluation of the adenexea
  • Baseline blood pressure, weight, and height
laboratory tests 1 st visit
LABORATORY TESTS1st visit
  • A standard panel of laboratory tests (Routine)
  • CBC
  • Blood gp & antibodies screen
  • HbS Ag
  • Rubella
  • VDRL
  • Urine C&S
  • Cervical PAP smear
laboratory tests 1 st visit1
LABORATORY TESTS1st visit
  • In high risk population
  • Chlamydia swab
  • HIV
  • TFT
laboratory tests others
LABORATORY TESTSothers
  • N. gonorrhea
  • TB
  • Toxoplasmosis
  • HCV
  • BV
  • Others HB electrophoresis, cystic fibrosis, phenylalanine level …etc
follow up visits
Follow-up visits
  • Major goals (PET, malpresentation)

Components

  • Wt, B/P, SPH, FH auscultation, FM, lie, presentation
  • Patient’s concerns
  • Education
  • Risk identifications
follow up visits1
Follow-up visits

Uncomplicated pregnancies

  • Every 4 weeks until 28 wks
  • Every 2 to 3 weeks from 28 to 36 wks
  • Weekly until delivery
follow up visits2
Follow-up visits

Laboratory follow-up

  • GDM screening at 24-28 wks
  • CBC & antibodies screen
  • GBS screening (recto-vaginal swab) at 35-37 wks
diagnostic imiging
DIAGNOSTIC IMIGING

Ultrasound

  • Minimum requirement
  • Usefulness
  • Limitations

Others

  • MRI
1 st trimester u s
1st Trimester U/S
  • Confirm pregnancy
  • Viability
  • Assess GA (Dating)
  • Multiple gestations (chorionicity / amnionicity)
  • Maternal pelvic anomalies

AIUM Standards and Guidelines

2 nd trimester u s
2nd Trimester U/S

Fetal normality:

  • • Head shape and size and internal structures (cavum pellucidum, cerebellum, ventricular size at atrium < 10 mm)
  • • Spine: longitudinal and transverse
  • • Abdominal shape and content at level of stomach
  • • Abdominal shape and content at level of kidneys and umbilicus
  • • Renal pelvis < 5 mm anterior–posterior measurement
  • • Longitudinal axis abdominal–thoracic appearance (diaphragm and bladder)
  • • Thorax at level of a four-chamber cardiac view
  • • Arms: three bones and hand (not counting fingers)
  • • Legs: three bones and foot (not counting toes)
value of prenatal genetic diagnosis why do we do it
VALUE OF PRENATAL GENETIC DIAGNOSIS:Why do we do it?
  • Reassurance
  • Increases options
  • Antenatal fetal treatment
  • Preparation for outcome
  • Avoidance of obstetric complications
  • Selective termination
slide21

Maternal age-based screening

Rationale

70%

30%

1/200 risk of miscarriage

1/200 chance of abnormality

=

=

slide22

10

1

0.1

0.01

0.001

0.0001

20

25

30

35

40

44

Years

Assessment of Background Risk

Maternal Age

  • Trisomy 21

47xxx/xxy/xyy

Risk %

  • Trisomy 18
  • Trisomy 13

45x

Triploidy

Courtesy Dr J Johnson and the Fetal Medicine Foundation

slide23

100

47xxx/xxy/xyy

80

60

Trisomy 21

40

45x

20

Trisomy 18

Trisomy 13

0

Triploidy

10

14

18

25

30

35

40

Weeks

Assessment of Backround Risk

Gestational Age

%

Courtesy Dr J Johnson and the

Fetal Medicine Foundation

Snijders et al 1999

slide25

Screening at 11-20 wks

10 12 14 16 18 20 wks

  • Allows adjustment of age-related risk
  • Improved detection rate

Courtesy Dr J Johnson and the Fetal Medicine Foundation

a non invasive prenatal diagnostic tests
A-Non-invasive prenatal diagnostic tests
  • Nuchal Screen
  • Nuchal plus biochemistry
  • Maternal Serum Screen
  • Ultrasound
slide27

Nuchal Translucency

1-

“the skin is deficient in elasticity. . . . . . too large for the body”

Langdon Down

Observations on an ethnic classification of idiots.

Clinical Lecture Reports, London Hospital 1866;3:259.

Courtesy Dr J Johnson and the Fetal Medicine Foundation

slide28

Nuchal Translucency

  • Gestation 11-14 wks
  • CRL 45-84 mm
  • Mid-sagittal view
  • Image size >75%
  • Neutral position
  • Away from amnion
  • Maximum lucency
  • Calipers on-to-on

Courtesy Dr J Johnson and the Fetal Medicine Foundation

slide29

Significance of increased nuchal fluid

  • Chromosome abnormalities
  • Birth defects (cardiac, d.hernia)
  • Genetic syndromes
  • Increased mortality (> 3.5 mm)

Courtesy Dr J Johnson and the Fetal Medicine Foundation

slide30

Pathophysiology of increased

nuchal translucency

  • Abnormal or delayed lymphatic development
  • Venous congestion
  • Cardiac failure
  • Altered composition of extracellular matrix
  • Failure of lymphatic drainage due to fetal hypokinesia
  • Fetal anemia or hypoproteinemia
  • Congenital infection
          • Courtesy Dr J Johnson and the Fetal Medicine Foundation
slide31

First Trimester Biochemical Markers

2-

  • PAPP-A: Pregnancy associated plasma protein A
  • Produced by placental trophoblast
  • Increases in 10-14 week period
  • Lower in DS pregnancies (0.43 MOM)
  • Associated with 42 % DR at 5% FPR.
  • Free - hCg: Free  subunit of human chorionic gonadotrophin.
  • Placental protein
  • Decreases in T1 like total hGC
  • Higher in DS pregnancies (1.79 MOM)
  • Associated with 23% DR at 5% FPR
  • Courtesy Dr J Johnson and the Fetal Medicine Foundation
slide32

Detection Rate

89%

100

72%

80

60%

%

60

30%

40

20

0

Age

ßhCG

PAPP-A

Age

Age

NT

All

ßhCG

PAPP-A

Screening at 11-14 wks

Fetal NT + Maternal age + ßhCG + PAPP-A at 11-14 wks

Invasive

Testing

5%

  • Courtesy Dr J Johnson and the Fetal Medicine Foundation
3 maternal serum screen
3- Maternal Serum Screen
  • Three biochemical markers
    • BHCG
    • AFP
    • Estriol
  • Gives age adjusted risk
  • Screens for Down’s and NTD
  • 15-20 wks
slide34
MSS

0

1/1

1/378

Risk = age X OR BHCG X OR uE3 X OR AFP

mss limitations
MSS Limitations
  • Sensitivity 70 %
  • Specificity 95% ( False positive 5%)

Two reasons for a false positive:

  • Wrong dates
  • Twins
4 ultrasound
4- Ultrasound
  • Ultrasound screening(detailed scan)
  • 18-20 weeks
b invasive techniques for early prenatal testing
B- INVASIVE TECHNIQUES FOR EARLY PRENATAL TESTING
  • Chorionic Villus Sampling
  • Amniocentesis
amniocentisis
Amniocentisis

http://wchs.health.wa.gov.au/health/a/amnio.htm

amniocentisis1
Amniocentisis
  • Performed at or more 15 weeks
  • Takes 2-3 weeks for Karyotype
  • Pregnancy loss risk 1/200
  • Can get result of trisomies 13,18,21 and Turners Syndrome X0 in 48 hours with FISH (Florescent Insitu Hybridization)
chorionic villus sampling
Chorionic Villus Sampling
  • Performed at 10-14 weeks
  • Takes 2-3 weeks for the result
  • Pregnancy loss rate 1/100
  • Operator experience important
  • Link to limb abnormalities (still controversial)
  • Placental mosaicism up to 3%, but little effect on outcome
post test
Post Test
  • A standard panel of laboratory tests (Routine) dose not include
  • Rubella
  • TFT
  • VDRL
  • Urine C&S
  • Cervical PAP smear
post test1
Post Test

First trimister scan does not include

  • Fetal morphology
  • Viability
  • Assess GA (Dating)
  • Multiple gestations (chorionicity / amnionicity)
  • Maternal pelvic anomalies
post test2
Post Test

Which of the following is not a cause for an abnormal MSS

  • Down’s syndrome
  • IUFD
  • Twins
  • Wrong dates
  • Congenital heart disease
post test3
Post Test

A false positive on the MSS occurs in 1/20 tests

  • True
  • False
post test4
Post Test

List Two advantages of Amniocentesis over CVS

  • Decreased miscarriage rate
  • Lower risk of mosaicism
  • No association with limb reductions
post test5
Post test

Which of the following tests is the best at detecting Down’s Syndrome

  • MSS
  • Nuchal
  • Nuchal plus PAPP A and Free BHCG
post test6
Post Test

What is the miscarriage rate with amniocentesis?

  • 0.5%
  • 3%
  • 5%
  • 10%
post test7
Post Test

List one advantage of CVS over amniocentesis

  • Early results