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Preconceptual and Antenatal Care - Coggle Diagram
Preconceptual and Antenatal Care
Physiological changes in pregancy
Result of hormonal changes
Blood chemistry
↑ Blood cells no.
↑ Clotting factors
↑ Fibrinolytic activity
Iron deficiency and anaemia
Cardiovascular
↑ HR
↑ SV
↓ Peripheral vascular resitance
Respiratory system
Displacement of diaphragm superiorly
↓ Functional reserve
↑ Risk of apnoea and dypsnoea
Hyperventilation
Gastrointestinal
Nausea and vomiting
Reflux and acidity
General
Mood and behaviour changes
↑ Nutritional demand
Preconceptual care
Goal
Improve health outcomes for women and their children
Importance
Allows physical and mental halth conditions and social need to be addess and managed prior to pregnancy
Allows women to be aware fo potential risks and make an informed decision about their pregnancy
Many potentially modificable risk factors whcih influence pregnancy outcomes are present before conception - prenatal care is often given too late
When
Ideally 3-12 months prior to conception
Where
Primary care
Other health settings - if attending secondary care
Responsibility of all clinicans
Who
Everyone
High risk pt with comorbidities or hx of poor pregnancy outcomes
Well-educated and motivated couples seek preconceptual care
Consultation
Assess
History
Pt details
Have they tried to concieve
3x per week is optimal
Understanding fertile window
PMHx
Diabetes
Asthma
Epilespy
Thyroid dysfunction
Mental health problems
Obs hx
Gravidity
Parity
Details of previous preg / deliveries
Genetic conditions
Gynae hx
Menstual hx
Contraception
Hx STIs
Hx of ectopic pregnancy
FHx
Genetic conditions
DM
VTE
Sx
Ocupational hazards - radiation
Smoking
Alcohol
Illicit substances
Revent ravel to Zika are
Medication
May need to be stopped / optimised
In consultation with secondary acare
OTC meds
Examination
BMI
BP
Cervical screen if due (can't be done during pregnancy)
Investigations
Rubella immunity status
Varicella immunity status if no clear hx
HbA1c
Target is <48 mmol/L
TSH in hx of hypothyroidism
<2.5 before conception
Increase 30-50% when pregnancy confirmed
1st trimester <2.5
2/3 rd trimester <3
Manage
Advise and refer as needed
Weight
BMI 18.5-24.9
Diet
Iron rich
Well balanced
Exercise
150 min per week
Supplements
0.4 folic acid at least 3 months prior to conception
10μg (400units) Vit D per day
Contraception
Stop at appropriate time
Education
Planning a pregnancy leaflet
Medical
Manage comobidities
Immunisation for rubella + varicella
Done > 1 month before conception
Folic Acid
Doses
RF for neural tube defects
5mg
0.4mg
Risk Factors for Neural Tube defects
BMI => 30
Diabetes
Patients on anti-epileptic drugs
Sickle cell disease or Thalassaemia
Previous infant with neural tube defects / Fhx of neural tube defects
Patient on ART for HIV tx
Coeliac diseasse
Regimen
Begin 3 months prior to conception
Stopped at 12 weeks - neural tube formed
Exception : Sickle cell, thalassaemia, thalassaemia trait continue throughout pregnancy
Smoking, Alcohol, Drugs
Smoking
Affects fertility
Affects pregnancy outcomes
Risks
Miscarriage
Preterm delivery
Low birth weight
Placental abruption
Dose dependant reduction in intra-uterine growth
Still birth
SIDS
Management
Reduction is beneficial even if cessation is not achieved
Nicotine replacement therapy ( NRT)
Refer to smoking cessation programme opt out rather then opt in
Alcohol
Teratogen
Risks
Fetal alcohol syndrome
Dose response
IUGR
Managment
Give up all alcohol whilst trying to concieve and when pregnancy
Especially first 12 weeks
Support : drugs.ie
Epidemiology
50% drink no alcohol in pregnancy
10% admit to drinking more than 3 units per week
Substance Misuse - What to offer
Information
about effects on unborn baby
What to
expect
- medical care / social services
Help with
transportation
to support attendance - benefits and travel cards - call, text, post
Referral
to approapriate substance misuse programme and specialised clinic the
first time she discloses
5mg Folic acid
for duration of pregnancy - alcohol delays absorption of vitamins
Repeat screening
for infecious disease screen at
28 weeks
for those in sex trade industry or IVDU - include hep C
Screening for
chlamydia / Gonorrhoea C
by low vaginal swab in pregnancy
Recereational Drug Use
Always ask
Advise
Stop if able
If unable - refer to specialist service
Contraceptive advice to women using illicit drugs who may become pregnant before drug use has stopped
Offer testing for Hep B / C / HIV for women injecting drugs
Potential harms
Marijuana
Childhood neurodevelopmental effects
Cocaine
Low birth weight
Small head circumference
Premature birth
Perinatal death
Heroin / other opiates
Spontaneous abortion
Intrauterine death
Low birth weight
Premature birth
Infant distress dur to acute drug withdrawal after delivery
Routine Antenatal Care
Schedule of care for an uncomplicated, low risk pregnancy
A singleton pregnancy where the mother is healthy3
Purpose
Identify women who need medical attention to reduce maternal and fetal morbidity and mortality
Women seen at decreasing intervals throughout pregnancy - complications more common later in pregnancy
Care Options
Public care
Free for all women resident in IIRE
DOMINO Scheme
Low risk pregnancies
Midwife led
Visits in community clinics and GP
Semi-Privtae
Fee-based option
Women with PMI
Private care
Fee-based option
Women with PMI
Maternity & Infant Care Scheme
Shared care scheme
Funded by state for all pregnant women ordinarily resident in IRE
Initial exam with GP prior to 12 weeks
5 GP visist during pregnancy
Additional 5 visits in high risk pregnancy
2 week check for baby
6 week check for mother + baby
All antenatal hospital visits
Schedule of Care
Dating scan -
Anomaly can - 21 weeks
First Contact / GP Visit
May be done in hopsital at booking visit or pt may opt to visit GP prior to the booking visit
More common with first time mothers
Checklist
Confirm pregnancy (UPT)
Assess BP + BMI
Check hx for high risk factors
Especially if on thyroxine - increase dose at this visit
Check red flags
Abdo pain
PV bleeding
May be due to ectopic / miscarriage
Discuss type of care and arrange referal
Start convo around pregnancy advice
Direct to reputable info
Foods to avoid
Exercise in pregnancy
Booking Visit
8-10 weeks
Checklist
Screen for complications
Assess
Hx
Age
High risk
Under 17
Over 35
History of current pregnany
EDD (need LMP and cycle length)
Spontaneous conception vs IVF
Early complications
Bleeding
Pain
Past Obs hx
Previous GDM / PET / APH / PPH / IUGR / Congenital anomalies
Previous preterm labour
Previous mode of delivery
Past Gynae Hx
Previous surgery
Myomectomy
LLETZ
May influence delivery recommendation or increase risk of preterm labour
PMHx
Diabetes
Epilepsy
Asthma
HTN
Renal disease
Mental illness
MedsHx
Preconceptual folic acid
Any high risk emds
FHx
Congenital anomalies
FH of PET
Diabetes
SHx
Occupation
Smoking / alcohol
Illicit drugs - must screen
Risk of Domestic violence
Exam
BMI
BP
Investigations
Bloods
FBC
Group / Rhesus and antibodies
HIV
Hep B&C
Syphilis (VDRL/TPHA)
Rubella
Varicella - not routine
Look for personal hx of chickenpox
Dating scan
Urinalysis
Send MSU if + for leucocytes or nitrates
Others
Haemoglobinopathy screen for SSD or Thalassaemia
TFTs in 1st degree relative w thyoid dysfunction
High vaginal swap (HVS) in abnormal discharge / GBS carrier
Manage
Low risk / high risk pathways
Medications / referrals / book relevant scans
Lifestyle advise
Vaccine advise
Flu
whooping cough
covid
Screen
Pre-eclampsia (PET)
Venous thromboembolism (VTE)
Gestational diabetes (GDM)
Small for Gestational Age Fetus (SGA)
Safeguarding in Pregnancy
Possibility of domestic violence should always be considered
Epidemiology
DV can increase during pregnancy
30% of women who experience DV are physically assaulted for the 1st time during pregnancy
Managment
Assess on her own
Open questions
Who's at home with yoy
Take note of pts affects and if concerns arise - more direct wuestions
Refer to Safeguarding MW / Social Work Teams
Women's aid
Screeing Complications / Risk Factors
Pre-Eclampsia
PET Risk Factors
One of the Following
CKD
Chronic HTN
Autoimmune disease
eg. SLE, antiphospholipid syndrome
T1/T2 DM
Previous PAT of HTN in pregnancy
Two or more of the following
Age > 40
BMI >35
First pregnancy
Pregnancy interval > 10 yr
Fhx PET
Multi-fetal pregnancy
PET Screening
Every antenatal check
Screen
Urinalysis for protein
BP measurement
Prophylaxis
75 - 150 Aspirin OD from 12 weeks until birth
VTE
Screening
All women should undergo a documented assessment of risk factors for VTE in early pregnancy or prepregnancy
Repear and document at any hopsital admission intrapartum and post-partum
Prophylaxis Indications
Reference the algorithm
Prophylaxis
LMWH
Gestational Diabetes
Risk Factors
BMI > 30
Fhx of 1st degree relative with T1/T2 DM
Glycosuria on 2 occasions of urinalysis
Previous macrosomic baby >4.5 kg
Ethnicity:: South asian, black, afro-caribbean, middle eastern
Previous GDM
Will have random BG at booking - OGGT arranged sooner in pregnancy if BG abnormal
Screening
OGTT at 28 weeks
For those with any risk factor
Small for Gestational Age (SGA) Babies
An infant born with birth weight less than 10th percentile
All women assessed at booking for RF
Screening
Serial measurement of symphysis fundal height (SFH) at each antenatal app from 24 weeks
Plot SFH on custom cart
Referal for US
Plots below 10th percentile
Serial measurements demonstrating slow or static growth by crossing of centiles
Women in whom measurement of SFH is inaccurate : BMI > 35 or large fibroids → Serial assessment of fetal size
Booking assessment
Reassess at 20 week
Reassess during 3rd trimester
Medications in Pregnancy
Folic Acid
0.4mg / day
3 months prior to conception to 12 weeks gestation
Vit D
10μg (400 units)
Continue until postnatal - advised in breastfeeding
Other Medications
Avoid all unless discussed with medical professional
Especially 1st 12 weeks
Vaccines
Flu Vaccine
Antytime in pregnancy
Whooping cough Vaccine
Boostrix-IVP
16-36 weeks
COVID-19 vaccine
Any stage
Initial vax of 2 dose of mRNA vax 21-28 days apart
Booster 3 months after last dose
If not rubella / varicella immune
Delay vaccine until after Pregnancy → live vaccine c/i in pregnancy
Lifestyle Advise in Pregnancy
Diet
Balanced diet with daily intake of 2500 calories
Avoid Listeriosis by
Drinking inly pasteurized milk
Avoid Pate, Soft cheese, uncooked foods
Avoid Toxoplasmosis by
Avoid cats / cat faeces
Avoid uncooked foods
Exercise
Continue to excise - may need to reduce intensity
Avoid contact sports
Ideal: Walking, swimming, yoga
Alcohol and Smoking
Avoid all alcohol
Especially in first 12 weeks
Reduce and stop smoking
Provide NRT if needed
Sleep
On side from 28 weeks
Education
Encourage antenatal education for women & partner
Known to alleviate fear and pain
Support breastfeeding
Travel
Airlines may ask for letter from MW / doctor after 27 weeks confirming EDD and that pregnancy is uncomplicated
Most airlines do not allow women to fly after 37 weeks
Consider risk of DVT and prophylactic LMWH if additional risk factoss
Sex
Sex is safe in uncomplicated pregnancy
Dating Scan
Timing
US scan between 11+2 and 14+1 weeks
Use
Check fetal viability
EDD calculation using crown-rump length (CRL)
Detect multiple pregnancy
Note
UK
Combined test takes place at this scan
Risk determined for trisomy 13, 18 and 21 using
Nucal translucency
Bloods for β-gCG
PAPPA
High risk pts
Offered non-invasive screening (Harmony/Paronrama)
Offere CVS / Amniocentesis
Ireland
Combined test privately
General Antenatal Check
At every check
Assess
History
Red Flags
PV fluid
PV bleed
Assess mood
Abdominal pain
Reduced foetal movements
Exam
BP
Urinalysis
SFH
Auscultation for
FHR
Management
Inform / signpost next app / scan
Support smoking cessation
Safety net
PV bleeding
Under 24W go to Early Pregnancy Unit via GP or
ED at maternity hopsital
PV bleeding, PV fluid, abdo pain, reduced fetal movements
Assessment unit / Labour ward at maternity hospital
Foetal Anomaly Scan
Timing
18+0 to 20+6 weeks
Function
Assess for structual fetal abnormalities
Position of placenta noted - reassessed after
32W
if low lying
28 Week Check
Bloods
Hb
Manage anaemia - PO iron verson infusion
Anti-D
In Mother Rh- carrying Rh+ baby
Detected on non-onvasive prenatal testing / cell free foetal DNA
OGTT
Performed if indicated
Iron and Anaemia
Anaemia in Pregnancy
Defined as 1st Trimester hb less than
110g/L
2nd/ 3rd trimester less than
105g/L
Postpartum hb less than
100g/L
Booking
Offere bloods to asses hb
Multiple pregnancy offerred additional FBC at 20-24 weeks
If booking Hb < 110
Oral iron
hb <110 at booking
28 weeks hb <105
Ferrous fumerate
Parenteral iron
Indicated when oral not tolerate / absorbed
Complinace is in doubt
Woman approaching term with insufficienct time for oral supplementation to be effetive
Common Conditions of Pregancy
Constipation
Increase fibre + fluid
1️⃣ line
Fybrogel
2️⃣ Line
Lactulose
Varicose Veins
Common - often improves considerably after pregnancy
Rx
Compression socks for symptoms
Risk factor on VTE risk scoring system
Dyspepsia / Hearburn
Cause
Mechanical and hormonal factors
Management
Avoid irritants
Smaller meals
Eat earlier in evening
Raise head of bed / cushions
Meds
Gaviscon - antiacid / alginates
Epigastric pain can be a symptom of PET
Vaginal Discharge
Common
Accompanying symptoms - itching, soreness, malodour, painful uresis - investigate
Investigations
Vaginal swap sterile speculum
Management
Treat causes
Candidiasis
Topical canestan cream + pessary - no applicator duing pregnancy
Oral fluclonazone is c/i in pregnancy
Pelvic Girdle Pain
Managment
Regular exercise
Yoga
Consider referral to physio
Haemorrhoids
Management
Minimise strain by ↑ fibre and fluids
Regular exercise to reduce constipation
Perianal hygiene to avoid dermatitis / irriation
No topical haemorrhoidal preperations licensed for use in pregnancy
