The First Antenatal Visit Surya Krishnan Obstetrician

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The First Antenatal Visit

• Surya Krishnan
• Obstetrician
• Gynaecology Endoscopic Surgeon
• Royal Hospital for Women
• Royal Prince Alfred Hospital
• Prince of Wales Private Hospital

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Objectives

• Risk Assessment
• Maternal and Foetal well being
• Date the Pregnancy
• Comprehensive History

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Objectives

• Discuss first trimester screening
• Discuss nutrition, obesity and smoking
• Model of care
• Antenatal screens

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Risk Assessment

• Low risk Pregnancy
• Healthy women having a normal pregnancy
• Very suitable for shared care
• Primip or Multip
• No prior medical or obstetric issues

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Risk Assessment

• High risk Pregnancy
• Maternal
• Obesity
• Underlying medical conditions
• cardiovascular, renal, essential HT etc
• Previous obstetric or antenatal problem
• GDM, PET, Preterm
• Prior Intrapartum complication
• 3/4th tears, PPHs
• Socio-economic

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Risk Assessment

• Foetal
• Previous aneuploidy
• Congenital abnormality
• Stillbirth or neonatal death
• Prematurity

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Model of Antenatal Care

• Shared Care with General Practitioners
• With r/v ANC
• Doctors at ANC
• Midwives clinic/Team care
• High Risk clinic (Twins, HT, GDM, etc)
• Private Obstetrician (Low or High risk)

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Comprehensive History

• LMP
• Regular or irregular
• IVF cycle. ? Embryo transfer (how many)
• ? Clomid
• Planned or unplanned
• Obstetric history
• Parity/mode of delivery/tears/complications
• Gynaecological history
• Subfertility, PID, ectopic etc

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Comprehensive History

• Medical History
• Social and Family
• Smoking/alcohol/drug/allergies

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Common First Visit problems

• Hyperemesis Gravidarum
• Severe dehydration
• Looks unwell, loss gt5 body weight
• Psychosocial issues, ambivalence
• Risk of Wernickes Encephalopathy
• Admission
• IV Hydration, Thiamine

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Miscarriage

• 15-30 of all pregnancy
• May be asymptomatic
• Benefit of a dating or Nuchal scan
• If Suspicious
• Early pregnancy assessment at RHW or RPAH
• Conservative or ERPC

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Ectopic Pregnancy

• 7-10 of pregnancy
• Localizing abdominal pain and bleeding
• Risk factors
• PID, ectopic, endometriosis
• IUCD
• Refer to nearest early pregnancy unit.
• Salpingectomy vs MTX

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Dating the Pregnancy

• Get a Dating Scan
• 7-10 weeks
• The earlier the more accurate for EDC
• Confirms first trimester loss
• Implantation accidents
• Methotrexate vs Surgery
• Multiple pregnancy
• LMP
• Quant BHCG if uncertain

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First Trimester Screening

• Assess risk profile of mothers
• Advanced maternal age (gt35)
• Family Hx genetic conditions
• Consanguinity
• Abnormal thalassemia screen for both parent
• Recurrent miscarriages
• Previous child with a syndrome/malformation

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First Trimester Screen

• Genetic counselling
• Nuchal Translucency and serum screen
• Screening test only.
• gt90 accurate
• 11-13 weeks
• lt1/300 low risk, gt1/300 high risk
• Qualified and credited team-counselling
• Consider diagnostic test

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Prenatal diagnosis

• Chorionic Villous Sampling
• 1100 miscarriage risk
• From 10 weeks
• Diagnostic test
• Cytogenetics
• FISH for trisomy 13,18,21. in 48 hours
• Counselling by OBGYN.

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Prenatal Diagnosis

• Amniocentesis
• High risk prenatal screening test or risk factors
• Diagnostic test gt99 accurate
• From 15 weeks
• 1200 risk of miscarriage
• Prenatal Diagnosis does not detect all
  abnormalities

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Second Trimester Screening

• 15-18 weeks
• Triple test (serum)
• Needs accurate gestational age
• AFP, BHCG and uE3
• 60-70 at best with false positive

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Nutrition and Pregnancy

• Not the right time for dieting
• Weight gain of 7-20 kg in pregnancy
• If High BMI or low BMI
• Dietician
• Constipation issues

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Smoking and Alcohol
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Nutrition in pregnancy

• Folic Acid and pregnancy
• Taken 1 month before and for the first 3 months
• Prevents NTD
• Needs to take an additional 400ug/day
• Higher dose if has a past/family history

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Nutrition in Pregnancy

• Iodine supplement
• I deficiency affect thyroid function of mother ,
  neonate and neurodevelopment of child
• 50 of pregnant women are I deficient
• Major cause of lowered IQ in children (WHO)
• 150ug/day supplement in pregnant women

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Nutrition and Pregnancy

• Vitamin D
• Increasing incidence of Ricketts and poor teeth
• Dark skinned women with Veil
• Diet in early gestation influences bone growth
  and bone health in children
• Vitamin D 10ug/Day supplement

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Common Questions asked

• Can I eat Sushi?
• Yes.
• Avoid Swordfish, sharks and mackerels
• Tuna in moderation, and salmon-ok
• California roll is ok
• Look at the Koreans and Japanese!

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Common Questions

• Tea, Coffee and Coke
• 2-3 cups/day is safe
• gt8/day has an increased risk of still birth
• Impairs absorption of nutrients

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Common Questions

• Listeria infection
• Harmful to foetus and may cause stillbirth
• Listeria is destroyed by cooking
• Avoid
• Unpasturised milk
• Soft cheeses, ricotta, feta
• pate
• Processed meat (devon or ham)

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Herbs and Pregnancy
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Antenatal care first visit examination

• General
• Booking BP, Pulse, Weight
• CVS, Respiratory, Abdominal
• Breast and Thyroid
• PAP smear

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Initial recommended Test

• FBC, EUC
• Thalassemia screen
• Blood Group and Antibodies
• Hep B, HIV and HepC
• Syphillis (VDRL, RPR)
• Rubella

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Initial Recommended Tests

• Consider
• Vitamin D and Iodine levels
• Thyroid function test
• Varicella Zoster serology
• CMV and Parvovirus
• Fe studies

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Pelvic Floor and Pregnancy
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Pelvic Floor and Pregnancy

• Refer to pelvic floor or continence
  physiotherapist.
• Symptomatic prolapse
• Lower urinary tract symptoms (urge, stress,
  UTIs)
• Previous 3rd/4th degree tears
• Prevention of pelvic floor trauma at birth

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Conclusion of the First Visit

• Appointment schedule and structure
• Written information
• Number
• Timing
• Content of antenatal appointments
• Discussion
• Minimise inconvenience

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