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16 September 2014 2

Prenatal Care
Definition
A comprehensive antepartum care program involves
a coordinated approach to medical care and
psychosocial support that optimally begins before
conception and extends throughout the antepartum
period
This program includes :
1. preconceptional care
2. prompt diagnosis of pregnancy
3. initial prenatal evaluation
4. follow-up prenatal visits
American Academy of Pediatrics and The American
College of Obstretricians and Gynecologists 2007
History of prenatal care

In 1901, Mrs William began a program of nurse


visits to women enrolled in the home delivery
service of the Boston Lying-in hospital
In 1911, prenatal clinic was established
In 1915, J.W Williams concluded that 40% of 705
perinatal deaths could have been prevented by
prenatal care
In 1960, Dr jack Pritchard established a network
of university-operated prenatal clinics in Dallas
countrty

Williiams Obstretrics 23rd Edition p 189


High Risk Pregnancy

Definition
High risk pregnancy is one in which some
condition puts the mother, the developing fetus
at both or higher-than-normal risk for
complications during or after the pregnancy
and birth

Beers, Mark H., et al., editors. "High-Risk Pregnancies." In The Merck Manual of
Diagnosis and Therapy. Rahway, NJ: Merck Research Laboratories, 2004.
Recommended Consultation for Risk Factors
Identified in Early Pregnancy
Medical History and Conditions Initial laboratory Tests
Cardiac and pulmonary dissease HIV
Asthma Bronchiale CDE (Rh) of other blood isoimunization
Diabetes melitus Initial examination condilomata
Drug and alcohol use
Family history of genetic problem
Hypertension
Renal dissease
Epilepsi on medication
Haemoglobinophathy
Obstetrical History and Conditions
Age > 35 years at delivery
Cesarean delivery
Incompeten cervic
Prior neonatal and fetal death
Prior low birth weight
Second trimester pregnancy loss
Prior fetal structure and chromosomal abnormality
Williiams Obstretrics 23rd Edition p 198
Recommended Consultation for Ongoing Risk
Factors Identified During Pregnancy
Medical History and Conditions Examination and laboratory Findings
Drug and alcohol use HIV
Proteinuria CDE (Rh) of other blood isoimunization
Pyelonephritis Condilomata
Severe Systemic dissease that adversely Anemia
effect pregnancy Abnormal papsmear result
Abnormal MSAFP ( high or low )
Obstetrical History and Conditions
Blood pressure elevation, no proteinuria
Fetal growth restriction suspected
Fetal abnormality suspected by sonography
Fetal demise
Hydramnions or oligohydramnions by sonography
Multifetal gestation
Preterm labor threatened
Premature rupture of the membrane
Vaginal bleeding > 14 weeks
Herpes active lesion at 36 weeks Williiams Obstretrics 23rd Edition p 199
16 September 2014 8
How to keep small baby

Great Challenge

16 September 2014 9
Preterm infants

Slight 32-36 weeks


Feeding and temperature problems, some
have immature lungs
Moderate 28-31 weeks
Immature lungs, temperature control,
feeding problems, apneas
Severe < 28 weeks
Immature organ systems, intensive care
Treatment of prematurity
Specific treatment for prematurity will be
determined based on:
babys gestational age, overall health and
medical history.
extent of the disease.
tolerance for specific medications, procedures
or therapies.
expectations for the course of the disease.
Care of premature babies

Temperature-controlled beds.
Monitoring of temperature, blood pressure,
heart and breathing rates and oxygen levels.
Giving extra oxygen by a mask or with a
breathing machine.
Mechanical ventilators (breathing machines)
to do the work of breathing for the baby.
Management Respiratory
Distress Syndrom
Prenatal Care
Delivery Room Stabilisation
Surfactant Therapy
Oxygen Supplementation Beyond Stabilisation
Role of CPAP
Mechanical Ventilation (MV) Strategies
Avoiding or Reducing Duration of MV
Prophylactic Treatment for Sepsis
Supportive Care: thermal, fluid and nutrition, tissue
perfusion, ductus arteriosus
Miscellaneous Considerations

European Consensus Guidelines 2010 Update


Prenatal Imaging &
Fetal Intervention
PRENATAL IMAGING
In most cases, ultrasound is the method of choice for imaging the fetus, and the

majority of pregnant women in USA undergo at least one ultrasound

Sonographer skill and experience play a great role in the accuracy of ultrasound

Ongoing quality assurance is important

There have been exciting advances in the field of prenatal imaging within the past few

years including three-dimensional ultrasound and fetalMRI, and the future holds the

promise of great breakthroughs

It is expected that imaging modalities will continue to improve, and it is hoped that

techniques utilized in the fields of noninvasive prenatal diagnosis will continue to

advance

Accurate prenatal diagnosis of fetal abnormalities improves patient care by optimizing

patient counseling and allowing for informed patient and physician decision making
First Trimester Screening for Aneuploidy
Nuchal translucency measurement in the first trimester is the most powerful

marker for fetal Down syndrome

Combination of nuchal translucency with serum markers in the first trimester

detects up to 87% of cases of Down syndrome for a 5% false-positive rate

Septated cystic hygroma, or simple nuchal translucency of 3.0 mm or greater, are

indications for chorionic villus sampling (CVS) without need to await serum

marker results

First trimester absence of the nasal bones, reversal of flow in the ductus

venosus, and tricuspid regurgitation may have a limited role as second-line

screening tests for select high-risk patients by expert sonologists

These second-line screening test are unlikely to have any value for routine

general population screening


Second Trimester Screening for Aneuploidy
Quad marker serum screening is the most effective form of Down syndrome

screening in the second trimester (81% detection rate at a 5% false-positive rate)

Presence of a major structural malformation at second trimester sonographic

fetal anatomy survey is an indication for genetic amniocentesis

A range of minor markers at second trimester sonogrraphic fetal anatomy survey

can be utilized with likelihood ratios to adjust the risk of Down syndrome

Absence of major or minor markers at second trimester sonographic fetal

anatomy survey reduces the risk of fetal Down syndrome by 60%

Combinations of screening tests in both first and second trimesters, such as

integrated, stepwise, and contingency screening, may be more efficient than

screening in either trimester alone


Major and minor Structural Malformations
Sonographic Markers
Feature Down Syndrome Trisomy 18 Trisomy 13

Major structural Cardiac defects : Cardiac defects : Holoprosencephaly


malformations -AV canal defect -Double outlet right ventricle Orofacial clefting
-Ventricular septal -Ventricular septal defect Cyclopia
defect -AV canal defect Proboscis
-Tetralogy of Fallot Meningomyelocele Omphalocele
Duodenal atresia Agenesis corpus callosum Cardiac defects :
Cystic hygroma Omphalocele -Ventricularseptal
Hydrops Diaphragmatic hernia defect
Esophageal atresia -Hypoplastic left heart
Clubbed or rocker bottom Polydactyly
feet Clubbed or rocker
Renal abnormalities bottom feet
Orofacial clefting Echogenic kidneys
Cystic hygroma Cystic hygroma
Hydrops Hydrops
Major Structural Malformations and Minor
Sonographic Markers
Feature Down Syndrome Trisomy 18 Trisomy 13

Minor Nuchal thickening Nuchal thickening Nuchal thickening


Sonographic Mild ventriculomegaly Mild ventriculomegaly Mild ventriculomegaly
Markers Short humerus or femur Short humerus or femur Echogenic bowel
Echogenic bowel Echogenic bowel Enlarged cisterna magna
Renal pyelectasis Enlarged cisterna magna Echogenic intracardiac
Echogenic intracardiac focus Choroid plexus cysts focus
Hypoplastic nasal bones Micrognathia Single umbilical artery
Brachycephaly Strawberry-shaped head Overlapping fingers
Clinodactyly Clenched or overlapping Growth restriction
Sandal gap toe fingers
Widened iliac angle Single umbilical artery
Growth restriction Growth restriction
Relation Between Maternal Age and the Estimated
Rate of Chromosomal Abnormalities*

Risk of Chromosomal
Age Risk Of Down syndrome
Abnormality

20 1/1667 1/526
25 1/1250 1/476
30 1/952 1/385
35 1/385 1/202
36 1/295 1/162
37 1/227 1/129
38 1/175 1/102
39 1/137 1/82
40 1/106 1/65

* Age are at the expected time of delivery