Antenatal care

Definition
An antenatal visit is defined as an
intentional encounter between a
pregnant woman and a health care
provider to assess and improve
maternal and fetal well-being
throughout pregnancy and prior to
labor
 Antenatal Care (ANC) means care
before birth, and includes
education, counseling, screening and
treatment to monitor and to promote
the well-being of the mother and
fetus.
 Traditional schedule
The 'traditional' number of antenatal visits is
approximately 14
based on early presentation and a schedule
of four weekly visits until 28 weeks gestation
then fortnightly visits until 36 weeks
gestation
followed by weekly visits until birth.
 Objectives of ANC
Promote and maintain the health of mother and
baby by providing education on nutrition, personal
hygiene and birthing process

Detect and manage complications during

pregnancy, whether medical, surgical or obstetrical

Help prepare mother to breastfeed successfully,

experience normal puerperium, and take good care
of the child physically, psychologically and socially
National status: the whole
picture
 National status: the good news
Coverage with primary health care services indicators
(WHO Stats)
Population with access to local health services, total 100%
2008

Population with access to local health services, urban 100%

2008

Population with access to local health services, rural 100%

2008

Contraceptive prevalence 60% 2008

Antenatal care coverage 60% 2008

Births attended by skilled health personnel 81 % 2008

National status: More good news

National maternal mortality ratio

in Egypt halved between 1992
93 and 2000

MMR in Egypt has dropped from

184/100,000 live births in1993
to 52 in 2013
{WHO
 National Objectives
Reduce maternal & perinatal
mortality and morbidity
Screen for endemic and common
clinical conditions
Teaching mothers healthy practices
about pregnancy and child birth
Establish a nationwide system of
referrals to ensure best management
for at risk patients
 Reduced number of visits:
Prioritizing risk
Lowering the number of routine prenatal visits
does not jeopardize health outcomes for
pregnancy women or their babies, but may
reduce women's satisfaction with care.

A model with a reduced number of antenatal

visits, with or without goal-oriented components,
could be introduced into clinical practice without
risk to mother or baby, but some degree of
dissatisfaction by the mother could be expected.
Lower costs can be achieved.

WHO systematic review of randomised controlled trials of

routine antenatal care.
Structured antenatal care:
suggested schedule
for improving quality
 Booking visit
Timing
2-3 weeks following +ve
pregnancy test
Objectives
Confirm IUGS
Confirm fetal viability & twining
Order investigations
Plan NIPS for at risk patients
Tools
 Objectives of investigations requested :
Screening and detection of common and
endemic conditions:

Anemia

Blood group& Rh

Rubella status

Antitoxoplasmosis Ig

HBV &HCV

Bacteriuria
 Supplements
Folic acid: 400-4000 g/day
Progesterone ?
Antiemetics?
Vasopressors: contraindicated
 Second visit
Timing 12-14 w
Objectives
Pregnancy dating
Revise investigations
First trimester Anomaly scan
Genetic ultrasound performed
Risk for pre-eclampsia

Classify case as High or Low risk

Screening for chromosomal defects.

I-Nuchal translucency.
II-Fetal heart rate.
III-Biochemical
markers.
IV- Ultrasonographic
markers:
A] Nasal bones.
B] Facial angle.
C] Ductus venosus .
D] Tricuspid flow.
ASSESSMENT OF
NUCHAL
TRANSLUCENCY
 Nuchal translucency
It is the sonographic
appearance of a collection
of fluid under the skin
behind the fetal neck in
the first trimester.
In the second trimester
this translucency resolves.
In few cases it progresses
to cystic hygroma or
generalized oedema with
or without fetal hydrops.
Measurement
CRL equal to 45-
84 mm

After 13 weeks and 6

days the fetus is
commonly vertical,
causing difficulty in
obtaining
appropriate image.
Evaluation of Nasal
bone
The Magical Plane
 It is examined in exact
mid-sagittal plane. The
following must be seen:
1. Echogenic tip of the
nose.
2. Rectangular palate.
3. Translucent
diencephalon
4. Nuchal membrane.
Only 10 degrees tilt of the
probe can cause non-
visualization.
 Absence of nasal bone
It occurs in:
3% of euploid fetuses.
60% in cases of trisomy
21
50% in cases of trisomy
18
40% in cases of trisomy
13
 1ST TRIMESTER : Combined test

When :
Scan and blood test at
1113

How
1. Ultrasound (nuchal)
scan measurement of the
subcutaneous (SC)

2. A blood test measuring:

PAPP-A
-hCG
Serum analyte :
overview
 Supplements
Iron
Calcium+ vit D
Omega-3 ?
Aspirin when indicated
 Third visit
Timing 18-22w
Objectives
Baseline Fetal growth
Full anomaly scan performed
Screening for clinical conditions
Preterm birth cervical
assessment
 Fourth visit
Timing 26-30w
Objectives
Monitor fetal growth
and umbilical artery
blood flow resistance.
Detection of placenta
previa & accreta
Maternal well-being
Screen for GDM,
anemia and
Asymptomatic
bacteriuria
 Screening for diabetes
1. Two step test
2. One-step test.
 Complete blood picture
and supplements
Hemoglobin
MCV
Platelet count.
White cell count.
 Recurrent visits

Timing 34w then biweekly

Objectives
Monitor fetal growth and well-being
Confirm placentation and identify
presentation
Detection of complications &offer
intervention
Prepare woman for admission including
 Take Home Message
Define national objectives
Set National priorities
Reducing No. of visits will not affect
outcome
Improving Quality per visit will
improve outcome
Screening versus early detection of
complications is still debatabale
THANK YOU