Antenatal care

Antenatal Care: Clinical Practice Guideline

Walk-In Clinic – Client Pathway

ANC Clinic – Client Pathway

Initial Risk Assessment History:

Personal condition: current pregnancy information, previous obstetric risk, medical &

surgical history, current medication, family history of risk factors. any complains in the current pregnancy.

Examination: Vital signs and the BMI results, Perform systematic

examination.

“Clients with more than ten (>10) weeks of gestational age

calculates BMI by using pre-pregnancy weight”.

Initial Risk Assessment Review screening test results.

CBC: Hb, WBC, Platelets level. Urine analysis (Routine & Microscpic) & urine culture.Blood grouping/ Rh identification. FBS or RBS Screening for syphilis (RPR test). Hepatitis B & C serology. Rubella IgG. HIV test. Ultrasonography (U/S)

Management

• according to the findings from clinical assessment and lab investigation results.

• Prescribe Routine Supplement. (folic acid)

• Issue Pregnancy Care notebook and document information

Follow-UP

No risk factor Primigravida:

-1st & 2nd trimester every 4 weeks -3rd trimester every 2 weeks

Multigravida: follow at specific gestational ages up to 34 wk according to the following schedule:

Booking (6-10 weeks), 11-14 weeks gestation, 22-24 weeks gestation, 28 weeks gestation, 30-32 weeks gestation 34weeks gestation.

High risk factor: Close follow up may needed based to client risk and according to available

management guideline.

Referral

No risk: referred at 34 wks gestation to WH. High risk: early referral to WH

Regular Follow up

Review risk & previous management. Review screening test result. Assess Gestational age (by week). Do general obstetric examination as per gestational age. Check Fetal heart sounds and movement (present or not). Assess position of the fetus (Longitudinal, oblique, transverse) and presenting

part; cephalic or breach (mainly in 3rd trimester). Risk grading and manage accordingly. Request for standard screening tests according to gestation age. Health counseling & education. In addition to give relevant educational material. Prescribe routine Supplement: folic acid, iron & vitamin D tablet (after 12 weeks

gestation). Maintain complete record (clinical form & notebook).

Late Enrolment

If pregnant women attend initial visit and she is ≥ 34 weeks: -Determine the reason of late antenatal care. - Assess the pregnancy risk factors, Ask about any complain. - Request for ANC standard screening tests. - Request for U/S & glucose 75 gm. - Check vital signs & BMI results.

Refer to ANC clinic by giving nearest appointment within 1 week to be seen by a physician.

At first ANC clinic: the physician should check the result, do obstetric examination, check fetal heart, and document all information at antenatal care clinical form & notebook then refer to nearest obstetric Hospital either secondary or tertiary Hospital based on client risks .

Screening tests during antenatal care visit

screening tests during antenatal care visit

Case 1 24 year-old Aisha , G2 P1, at 15 weeks gestation is found on routine prenatal CBC to have: hemoglobin9.0, hematocrit 26.3, MCV 75, RDW 18..

What is your Management?

Anemia HGB screening is requested at:

Booking visit & at 28 weeks.

If patient is on 2nd or 3rd trimester and she cannot tolerate oral iron supplement and Hb

level is ≤ 8 refer urgently to obstetric Hospital for IV ferosac and continue antenatal care

follow up at PHC Center.

Anemia

Mild

If Hb <11 g/dL, MCV, MCH are normal (normochromic, normocytic anemia)

Check Ferritin level: Ferritin level is <20 mcg/L treat as iron

deficiency anemia + manage according to above guideline.

Ferritin level is >20 mcg/L refer to hematologist & continue ANC at PHCC.

If Hb <11 g/dL, MCV, MCH are high (macrocytic, hyperchromic anemia)

Check B12 & folate. Refers to hematology department and continue

ANC at primary health care center. High Risk to B12 Deficiency anemia:

Patient With chronic illness. Family history of B12 deficiency. Previous history of blood transfusion. K/C of anemia. Vegetarians.

Counseling

iron rich food and factors inhibiting and promoting Iron absorption. should be taken on an empty stomach, 1 hr before meals, with a source of

vitamin C (ascorbic acid) such as orange juice to maximize absorption. Avoid taking it with some medication as it reduces iron absorption for

example: Antacids, PPI , bile acid sequestrates (cholestyramine & colestipol).

Most iron preparations inhibit the absorption of some medications such as; tetracycline, sulphonamides

.

S.E: Epigastric discomfort, nausea, diarrhea, or constipation may appear with a daily dose of 60 mg or more supplement should be taken with meals.

Stools may turn black, which is not harmful Treatment should continue.

Maintenance dose: If hemoglobin level becomes normal maintenance dose

of iron which is 65 mg /day .

Refer to WH Emergency

No Resolution

Obesity in pregnancy

(BMI) > = 30 kg/m2 at the first antenatal visit using current weight if < 10 weeks gestation and pre-pregnancy weight if > 10 weeks gestation

Recommended Weight Gain:

Management

Preconception Care: Counseling:

-Inform about risk of obesity during pregnancy and child birth .

-Advice on weight loss and lifestyle modification before getting pregnant .

-Consider healthy diet .Supplement:

-o If BMI ≥30 kg/m² Give folate supplement 5 mg daily, starting one month before conception and continue during

1st trimester .

Management

Antenatal Care: Measure weight, height and BMI (using current weight if < 10

weeks gestation and pre-pregnancy weight If > 10 weeks gestation) at booking visit.

Counseling: -Counsel about the recommended weight gain during pregnancy based on

her calculated BMI . - Advice in healthy eating, appropriate exercise - risk of obesity during pregnancy and child birth and counsel about signs of thromboembolism. - dietitian referrale -risks of long term obesity, possible of developing HTN& DM.

Prescription: BMI ≥30 kg/m² Prescribe folic acid 5 mg once daily. If BMI ≥40 kg/m²; Prescribe oral aspirin (enteric coated) 75-100

mg once daily. Maintenance dose of Vitamin D supplement 1,000 IU orally on

daily basis after 12 weeks of gestational age.

Referral: If BMI ≥40 kg/m²; regularly refer to obstetric Hospital for

antenatal follow-up, if client > 34 weeks of gestational age refer urgently

Thyroid disease Hypothyroidism:

Subclinical Hypothyroidism

Hyperthyroidism:Gestational Hyperthyroidism & Hyperemesis Gravidarum Graves’ Disease

Screening

ONLY for high risk for thyroid dysfunction:

-Personal history of thyroid dysfunction and/or thyroid surgery. -Family history

-Age > 30 years. -BMI ≥ 40 kg/m2.

-Positive Thyroid Peroxidase Antibodies (TPO Ab). - Clinical signs and symptoms or the presence of goiter.

- her autoimmune disease such as: DM1, vitiligo, adrenal insufficiency, hypoparathyroidism, . - History of miscarriage or preterm delivery.

- Case of infertility. - Received radiation to the head or neck area as a cancer treatment. - Use of amiodarone or lithium, or recent administration of iodinated radiologic contrast.

- Residing in an area of known moderate to severe iodine insufficiency .

Hypothyroidism

K/C of Hypothyroidism (Overt Hypothyroidism)

Management: Preconception: adjust the dose to reach a TSH level not higher than 2.5

μU/L prior to pregnancy. Newly pregnant: increase the dose by 25% -30%. Postpartum: Preconception dose.

Follow-up: Antenatal: Check TFT every 4-6 weeks. Postnatal: Check TFT at 6-8 weeks postpartum.

HypothyroidismNewly diagnosed hypothyroidism during pregnancy: Diagnosis: TSH1 (>2.5 μU/L) + low FT4 concentration. TSH >10.0 μU/L irrespective to FT4level.

Management: start with low dose & observe the response to treatment, if the patient

responding very well, continue with the same dose. If not, you can gradually increase the medication dose.

Start treatment to adjust TSH level not higher than the normal value which is based on pregnancy trimester.

Follow up : Postnatal: Check TFT at 6-8 weeks postpartum.

Dose: - TSH < 10 μU/L a 1 mcg/kg/day. - TSH > 10 μU/L 1.6 mcg/kg/day. Max f 200 mcg/day.

Subclinical Hypothyroidism :

Diagnosis: TSH (2.5- 10 mIU/L) with a normal FT4 level.

Management: Check thyroid peroxidase (TPO) antibodies:

If Positive, start treatment to adjust TSH level not higher the normal value based on trimester.

If Negative: treatment based on physician/patient decision. If the decision was for no treatment then continue monitor TFT level.

Follow up: Check TFTS in 4-6 wks.

Euthyroid with Thyroid Antibodies(Tab) Positive

Euthyroid woman with thyroid autoimmunity (not receiving L-thyroxin) who is Tab positive is at risk for developing for hypothyroidism. Close monitoring of TSH level is necessary.

Follow up: Check TFT every 4-6 weeks.

Treatment: o Therapy should be started once TSH level rise above trimester specific status. Counseling:

Medication should be taken in empty stomach. Ideally 30 minute to one hour before breakfast. Note: “Empty stomach means 3-4hrs after meal”. Certain drugs e.g.: cholestyramine, ferrous sulfate, calcium carbonate & antacid, may interfere with L-thyroxine absorption from the gut. L-thyroxine administration should be spaced at least 4 hours apart from these medications. Other drugs, especially the anticonvulsant phenytoin & carbamazepine and the antituberculous agent rifampin, may accelerate L-thyroxine metabolism, necessitating higher L-thyroxine dose. o If physician discover no response to treatment, always check: Proper ingestion of medication in empty stomach. Compliance to medication dose. History of taken other medications that may interfere in absorption.

Hyperthyroidism

Gestational Hyperthyroidism & Hyperemesis Gravidarum: Diagnosis: No prior history of thyroid disease or signs of Graves’s disease. TFT: Low serum TSH and an elevated FT4. Limited to the first half of pregnancy Serum T4 return to normal by 14-18 wks gestation.

Treatment: Antithyroid Drugs (ATD) are not indicated.

HyperthyroidismGraves’ Disease:

Preconception: Counseling: reach euthyroid state before attempting pregnancy.

Antenatal care: medications are Not available at PHCC

If graves’ disease diagnosed during pregnancy: Diagnosed during 1st Trimester begin prophlthiouracil. Diagnosed during 2nd trimester begin methimazol.

If graves’ disease diagnosed and treated prior to pregnancy: Currently on methimazole: switch to prophlthiouracil as soon as pregnancy

confirmed.

Medication dose: Mild hyperthyroidism start PTU 50 mg,

3times/day, or methamazole 5-10 mg/day.

severe hyperthyrodisium start PTU 100 mg, 3times/day, or methamazole 10-30 mg/day.

Referral:

Refer urgently to endocrine clinic at women’s Hospital and continue ANC at women’s Hospital.

Management and Referral Considerations for Common Risk Conditions during Pregnancy

Action Risk Condition

- Assess social, mental & health risk & wellbeing. - Provide standard antenatal care & follow-up unless the client has Risk. - Diet advice. - Ensure family support.

Age < 15 years

- Do U/S at 11-14 wks. For nuchal translucency & nasal bone. - Counsel about amniocentesis to rule out anomalies. If the client agreed refer to FMU (Feto Maternal Unit) at women’ Hospital to do the procedure. - Do U/S at 20 wks. of gestational age for checking detail anomalies.

Age ≥ 35 years “advance maternal age”

Action Risk Condition

Refere to WH. - Need U/S at 10-12 wks. For nuchal translucency & nasal bone by well trained staff. - Detail anomaly scan in FMU (Feto Maternal Unit), if abnormality discovered the client should be followed in tertiary care facility.

age ≥ 40 years

- Prescribe Aspirin 75-100 mg once daily. - Prescribe folic acid 5 mg once daily. - Regular Referral to the nearest obstetric Hospital (Secondary Care). Note:” If client > 34 wks of gestational age, urgently refer to the nearest obstetric hospital

(BMI) ≥ 40 kg/m2

-Diet advice . -Give iron + multivitamins supplement .

-Refer to dietitian at PHCC . -Monitor fetal well-being by U/S routinely unless if abnormality

discovered its need more often or refer to hospital based on abnormality result .

BMI < 18.5 kg/m2 or weight (less than) < 45kg

Action Risk Condition

Emergency referral to WH Unexpected Problem in Current Pregnancy: - Massive Polyhydramnious. - Oligohydramnious. - Vaginal Bleeding. - Absent fetal heart or fetal movement. - Decrease fetal movement (from 24wks gestation). - Signs of preterm labor.

Urgent Referral to FMU) depending on Trimester and type of Hazard for detailed anomalies scans between 20 -22 weeks.

Exposed to hazardous medication or radiation in current pregnancy

- Counsel the client about risk of abortion if keeping or removing IUCD. - Should not be removed in PHCC.

Note:” Would refer to emergency of the nearest obstetric hospital (secondary care)”

Pregnancy with IUCD in situ

Action Risk Factor- Refer to WH- Urgent Referral to WH if ≥ 20 wks gestation otherwise regular referral is acceptable. Note: “Multiple pregnancy ≥ 3 should be referred & followed in WH.”

Multiple Pregnancy

Emergency referral to WH Platelet < 30,000 irrespective to gestational age

- Request for U/S if available in your HC; If normal, continue antenatal care at PHCC. If abnormality is suspected, refer to emergency (WH)- If U/S is not available; emergency refer to the WH.

-Suspected hydatidiform mole. - Previous Molar Pregnancy

<-14wks Urgent referral to FMU at WH . > -14 weeks refer to emergency .

Rh –ve with Positive Rh antibodies in current pregnancy

- Request for U/S -Checks Beta-hCG level, Get at least 2-3 reading within 48hrs . -If ectopic confirmed refer to emergency to nearest obstetric

Hospital .

Suspect Ectopic Pregnancy

Action Risk

If chronic problem is stable : -Regular Referral WH and continue antenatal care at the same

hospital .

K/C of Chronic Disease : -Autoimmune/lupus .

-Congenital heart disease, cardiomyopathy, Hx of MI .

-IBD .-ITP .

-Kidney disease . -Pulmonary hypertension .

-ThromboembolicUrgent Referral to WH and continues antenatal care at the same hospital.

-Cancer . -Mental Disorder .

Urgent Referral to women’s Hospital (Tertiary care) and continues antenatal care at the same hospital .

-Bleeding disorder (ex. Hemophilia)

Urgent referral to endocrine clinic and continue antenatal care at the same Hospital .

Graves’s disease,Thyroid nodule & previous Hx of thyroid cancer .

Urgent referral WH -Epileptic disease. -Stop all antihypertensive medication .

-Prescribe aldoment drug; starting dose between 250 mg – 500 mg (depending on patient condition) .

-Prescribe 75 -100 mg of aspirin daily and stop at 32 weeks of gestational age .

-Give calcium supplement 1000 mg/ day . -Refer urgently to WH .

K/C of Chronic Hypertension :Women who have high BP ≥140/90 before or early pregnancy (before 20

weeks) .

Action to be taken Risk Factors- Confirmed: if two (2) reading of blood pressure ≥140/90 per week in a setting position. - Prescribe aldoment drug; starting dose between 250 mg – 500 mg- Give Ca supplement 1000 mg/ day. - Refer urgently to WH if pregnant ≥ 20wks of gestational age

Pregnancy induced hypertension: High BP≥140/90 that develops after 20 wks in without proteinuria and goes away after delivery

Emergency Referral to WH by ambulance BP ≥ 140 / 90 and with symptoms of pre-eclampsia: - Severe headache. - Problems with vision, such as blurring vision or flashing. - Severe pain just below the ribs. - Vomiting. - Sudden swelling of the face, hands or feet and sudden weight gain in short period

Urgent referral WHPrevious Obstetric Problem: - IUFD/still birth or neonatal death. - Fetal anomaly, congenital or genetic disease. - Down syndrome.

.

Urgent referral to FMU. abnormal WH.normal HC

Previous History of RH isoimmunization (+ ve combs test) or hydrops fetalies.

Urgent referra to WH Previous Hx of mid trimester miscarriage ( >16 wks gestation)

Regular referral to WH ≥ 2 previous subsequent abortions.

Prescribe aspirin 100 mg daily from 12 wks . -Close monitoring the fetal wellbeing by U/S at

26 & 28 wks . -Urgent referral to WH at 28wks .

Previous Hx of IUGR : ”Term baby with weight less than 2.5 kg ”

Emergency WH IUGR in Current Pregnancy: - IUGR with Reduce Fetal Movement

URGENT referral to WH -Only IUGR

-If C/S done at governmental obstetric Hospital :Regular Referral at 32 wks

-If C/S done outside governmental Hospital such as in private or abroad Hospital :Regular Referral at 28 wks .

-If C/S done at early gestational age “<37wks” refer as early as possible

Previous Cesarean Section “C/S ”

Contact :Close contact with no previous Hx of infection, refer

to emergency and continue Antenatal care at PHC .Active Lesion :

Assess the general condition of patient to rule out pneumonia :

-Give antipyretic . -Give calamine lotion .

-Avoid contact with others . -Emergency referrale to WH.

Positive Infectious Disease : -Chicken Pox

-1ST attack start (Acyclovir) and Urgent referral WH -2nd and more attack with active lesion need

urgent referral to WH

-Genitalia Herpes

-Check all serology of hepatitis B . -Check result of Hepatitis C .

-Urgent Referral to a specialist in Gastroenterology within nearest secondary

care . -Continue antenatal care at PHC .

-Hepatitis B

Give Treatment for client & partner with urgent referral to nearest obstetric hospital (secondary

care) for further investigation . -Syphilis

Emergency Referral to Women’s Hospital Patients on Teratogenic Drugs