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  1. Antenatal Care Continuing Medical Education Activities for Non-specialists Dr TC Pun 27/2/2002

  2. Antenatal Care • Introduction • The first visit • Subsequent visits • Screening tests • Prenatal diagnosis and ultrasonogram • General advice • Summary

  3. Introduction Objectives • education and information • screening • early identification of complications • treatment of complications

  4. Introduction Patterns of routine antenatal care for low-risk pregnancy • assess the effects of antenatal care programmes for low-risk women • three trials, all conducted in developed countries, evaluating the type of care provider Cochrane Database Syst Rev 2001;4:CD000934

  5. Introduction • Giles 1992 – midwives versus obstetricians, 89 women, cost savings • Tucker 1996 – general practitioners and midwives versus shared care, 1765 women, clinical effectiveness and satisfaction • Turnbull 1996 – midwives versus shared care, 1299 women, clinical effectiveness and satisfaction

  6. Introduction • no difference for several outcome variables including caesarean section, anaemia, urinary tract infections and postpartum haemorrhage • there is a trend to lower rate of preterm delivery, antepartum haemorrhage, lower perinatal mortality • lack of recognition of fetal malpresentations tended to be higher in this group Cochrane Database Syst Rev 2001;4:CD000934

  7. Introduction • the midwife/general practitioner managed care group had a statistically significant lower rate of pregnancy induced hypertension and pre-eclampsia • overall, it appears that satisfaction with midwife/general practitioner managed care was similar or higher (in some variables) Cochrane Database Syst Rev 2001;4:CD000934

  8. Introduction • the midwife/general practitioner managed care group had a statistically significant lower rate of pregnancy induced hypertension and pre-eclampsia • overall, it appears that satisfaction with midwife/general practitioner managed care was similar or higher (in some variables) Cochrane Database Syst Rev 2001;4:CD000934

  9. Introduction Shared antenatal care between Family Health Services and Hospital(Consultant) Services for Low Risk Women • decrease in workload to hospital clinics • diagnosis of IUGR, malpresentation, pregnancy induced hypertension improved • number of NST, hospital admission, duration of stay reduced Chan FY et al 1993 Asia-Oceania J Obstet Gynaecol 19(3):291-298

  10. Antenatal Care • Introduction • The first visit • Subsequent visits • Screening tests • Prenatal diagnosis and ultrasonogram • General advice • Summary

  11. The first visit • timing • history • physical examination • risk determination

  12. The first visit Timing • pregnancy test positive within a few days after missed period • early pregnancy complications like miscarriages, ectopic pregnancy may be first diagnosed in the clinic

  13. Guidance on Ultrasound Procedures in Early Pregnancy Royal College of Radiologists, Royal College of Obstetricians and Gynaecologists 1995

  14. What should be reported • number of sacs and mean gestation sac diameter • regularity and outline of the sac • presence of any haematoma • presence of a yolk sac • presence of a fetal pole • CRL • presence/absence of fetal heart movement • extrauterine observations should include the appearance of the ovaries, the presence of any ovarian cyst or any findings suggestive of an ectopic pregnancy

  15. Miscarriage Silent miscarriage • sac diameter >20 mm with no evidence of embryo or yolk sac • CRL >6 mm with no evidence of cardiac pulsation • if sac diameter <20 mm or CRL < 6 mm, repeat at least 1 week later

  16. Miscarriage Incomplete miscarriage • thick irregular echoes in the midline of the uterine cavity • differential diagnosis: blood clots

  17. Miscarriage Complete miscarriage • well defined regular endometrial line • reliability: 98%

  18. Ectopic pregnancy • live embryo within a gestational sac in the adnexa - gold standard • poorly defined tubal ring • presence of varying amount of fluid in the Pouch of Douglas

  19. Ectopic pregnancy • may be normal in up to a quarter of patients • enlarged but empty uterus with or without an adnexal mass and/or fluid in the Pouch of Douglas • early diagnosis of normal intrauterine pregnancy in transvaginal scan • complex adnexal mass seen in 7% of patients with normal intrauterine pregnancies

  20. The first visit Early Pregnancy Assessment Unit • Streamline the management of women with early pregnancy bleeding or pain • Reduce the admission time

  21. The first visit • timing • history • physical examination • risk determination

  22. The first visit Is routine antenatal booking vaginal examination necessary for reasons other than cervical cytology if ultrasound examination is planned? • 11622 consecutive case records abstracted retrospectively • If ultrasound is planned has few advantages beyond the taking of a cervical smear O’Donovan et al 1988 Br J Obstet Gynaecol 95:556-9

  23. The first visit Routine vaginal examination at antenatal booking • reasonable to reserve VE at the booking antenatal clinic for women • with a clinical indication, such as pain, bleeding or vaginitis • who have not had a satisfactory smear within the past 3 years Lancet 1988:432-3

  24. The first visit Pitfalls associated with cervical screening during pregnancy • sampling difficulty because of enlargement of cervix, increased mucous secretion and increased difficulty in viewing the cervix(Cronje et al 2000 Int J Gynecol Obstet 68:19-23) • cytological diagnostic pitfalls unique to this population(Michael & Esfahani 1997 Diagn Cytopatho 17:99-107)

  25. The first visit • timing • history • physical examination • risk determination

  26. The first visit Risk scoring system • difficult to make quantitative estimates of the exact risk associated with a given factor • validity of adding weighed scores • difficulty in definition of risk factors • more predictive of outcome in second or late pregnancies

  27. The first visit Risk scoring system • both the positive(10-30%) and negative predictive values of all scoring systems are poor • risk of increase in intervention • may help to provide a minimum level of care and attention in settings where these are inadequate

  28. The first visit Modified McGill’s score • with score 2 and above will be seen at TYH • Demographic • Obstetrical history • Habits • Growth • Medical problems • Current pregnancy

  29. Modified McGill Score(1) Demographic • age <16(1) • parity >5(1) • weight <38 kg(1) • weight >70 kg(1) • unstable family(2)

  30. Modified McGill Score(2) Obstetric History • perinatal death(2) • SGA/LBW baby(2) • gestational proteinuric hypertension(2) • abruptio placentae(2) • previous caesarean section(1) • infertility(1) • IGT/GDM(1)

  31. Modified McGill Score(3) Habits • smoking(1) • alcohol(1) • drug addiction(2) Growth • discrepancy >2 weeks(2)

  32. Modified McGill Score(4) Medical problems • recurrent UTI(2) • impaired renal function(2) • heart disease(2) • essential hypertension(2) • severe respiratory disease(2) • diabetes mellitus(2) • hyperthyroidism(2) • jaundice(2) • other major disease(2)

  33. Modified McGill Score(5) Current pregnancy • recurrent vaginal bleeding > 12 weeks(2) • anaemia <10 g(1), <9 g(2) • hypertension(2) • hydramnios(2) • oligohydramnios(2) • multiple pregnancy(2) • Rh negative mother(2)

  34. Antenatal Care • Introduction • The first visit • Subsequent visits • Screening tests • Prenatal diagnosis and ultrasonogram • General advice • Summary

  35. Subsequent visits Patterns of routine antenatal care for low-risk pregnancy • in developed countries with well established obstetrics services, small reductions in the number of prenatal visits (equal or less than two visits) are compatible with similar good perinatal outcomes • women may be somehow disappointed with fewer visits Cochrane Database Syst Rev 2001;4:CD000934

  36. Subsequent visits Patterns of routine antenatal care for low-risk pregnancy • in developing countries, in which a proportionally major reduction in the number of visits was achieved, also supports this conclusion • in the light of the available evidence, the four antenatal care visits schedule tested in the largest trials appears to be the minimum that should be offered to low risk pregnant women. Cochrane Database Syst Rev 2001;4:CD000934

  37. Subsequent visits • every 4 week till 28 weeks • every 2 week till 36 weeks • every week till delivery

  38. Subsequent visits Fundal height for IUGR • high specificity • moderate sensitivity • high negative predictive value • only one randomized trial – ‘unwise to abandon’(Cochrane Database Syst Rev. 2000;(2):CD000944)

  39. Antenatal Care • Introduction • The first visit • Subsequent visits • Screening tests • Prenatal diagnosis and ultrasonogram • General advice • Summary

  40. Screening tests • Hb – at booking and at 30-32 weeks • Rh – for isoimmunisation • rubella immune status • VDRL • HbsAg status • cervical smear • MCV

  41. Screening tests HIV • opt-out screening since 1/9/2001 • information to be given • HIV is the virus causing AIDS but HIV infection may not lead to AIDS till years later • positive result means infection; although there is no cure but treatment can delay the onset of AIDS

  42. Screening tests HIV • information to be given • mother to baby transmission occurs in 15-40% and treatment can reduce the chance • window period • confidentiality

  43. Screening tests Results of the first 3 months • 10238 tests were performed • 4% chose not to be tested • 6 positive results

  44. Screening tests Biochemical screening for Down’s Syndrome • 97% of Down syndrome pregnancies are sporadic • age as screening test is not sensitive • AFP and HCG for screening between 15-20 weeks improves the sensitivity(screen positive rate of 5% or less, sensitivity of 60-70%)

  45. Screening tests Biochemical screening for Down’s Syndrome • value of addition of oestriol controversial • role of nuchal lucency measurement

  46. Screening tests Gestational diabetes • increase in perinatal mortality associated with abnormal glucose tolerance appears to be predicted as much by the indication for glucose tolerance testing • no convincing evidence that treatment of women with an abnormal glucose tolerance test will reduce perinatal mortality or morbidity • no benefit has been established for glucose screening

  47. Screening tests Gestational glucose tolerance screening at TYH • 75 g OGTT for those with risk factors • spot glucose screening using cut off of more than 5 mmol/l(more than) or 5.8 mmol/l(less than 2 hours after meal) for those without risk factors