Pregnancy

Routine antenatal care is vital for ensuring the health and well-being of both the mother and the developing fetus. The management of pregnancy-related complications is a critical part of antenatal care. Here’s a general overview:

Routine Antenatal Care:

Initial Visit (First Contact to 12 Weeks):

1. Medical History: Detailed medical, surgical, obstetric, and family history.
2. Physical Examination: Including pelvic exam and Pap smear if indicated.
3. Blood Tests:
   1. Blood group and Rh status
   2. Full Blood Count (FBC)
   3. HIV
   4. Hepatitis B
   5. Hepatitis C
   6. Syphilis
   7. Rubella immunity
   8. Consider Varicella
   9. Consider Iron, TSH
4. Urine Tests:
   1. βHCG
   2. For infection, protein, and glucose.
   3. Consider Chlamydia
   4. Consider Gonorrhoea
5. Ultrasound:
   1. Dating scan to confirm gestational age and viability and set the date for the 12 week U/S + Bloods.
   2. 12 week ultrasound alled the “nuchal translucency” (NT) ultrasound, this test measures the fluid-filled space at the back of the fetus’s neck. An increased amount of fluid here can be associated with chromosomal abnormalities.
      1. Blood Test: Measures levels of two pregnancy-specific substances in the mother’s blood:
         1. Free beta human chorionic gonadotropin (free β-hCG)
         2. Pregnancy-associated plasma protein-A (PAPP-A)
6. Counselling:
   1. Regarding diet, lifestyle, folic acid and iodine supplementation, avoidance of alcohol and tobacco, exercise, and prenatal vitamins.
      • Folate 400ug (5mg for at risk NTD)
      • Iodine 150ug
   2. Genetic counselling regarding the newly MBS funded 3 condition carrier screening (CF, SMA, Fragile X)
   3. Genetic counselling regarding NIPT (privately funded) for Trisomy 21, 18, 13 and Turners X0
7. Immunisations:
   • dTpa (for pertussis) @ 20-32/40 (Boostrix, Adacel)
   • Influenza @20-32/40
   • Pneumococcal (if a smoker)
   • If not immune
     • HBV (if high risk)
     • VZV vaccine – before or after pregnancy
       1. Zostervax is live (so contraindicated)
       2. Shingrix is unknown data for pregnancy
     • Rubella (live vaccine – before or after pregnancy)

Subsequent Visits (Up to 28 Weeks):

1. Frequency: Every 4-6 weeks.
2. Blood Pressure Monitoring: To screen for hypertension.
3. Urine Testing: For proteinuria and glycosuria.
4. Fetal Growth and Well-being: Fundal height measurement and fetal heart rate monitoring.
5. Second-Trimester Ultrasound: Usually around 18-22 weeks to assess fetal anatomy and placental position.
6. Glucose Screening: OGTT gestational diabetes usually around 24-28 weeks (> 8.5 mmol is threshold)

From 28 to 36 Weeks:

1. Frequency: Every 2-3 weeks.
2. Blood Pressure Monitoring: To screen for hypertension.
3. Urine Testing: For proteinuria and glycosuria.
4. Blood Tests: Repeat FBC, and if Rh-negative, check for antibodies and administer Rho(D) immune globulin at 28 weeks.
5. Third-Trimester Ultrasound: If there are concerns about fetal growth or amniotic fluid volume.
6. Counseling: Preterm labor signs, childbirth education, breastfeeding, and postpartum contraception.

From 36 Weeks to Delivery:

1. Frequency: Weekly.
2. Blood Pressure Monitoring: To screen for hypertension.
3. Urine Testing: For proteinuria and glycosuria.
4. Examination: Checking for signs of labor, cervical effacement, and dilation.
5. Group B Streptococcus Screening: Usually at 35-37 weeks.
6. Discussion: Birth plan, signs of labor, when to come to the hospital, and pain management options during labor.

Management of Pregnancy-Related Complications:

1. Hyperemesis Gravidarum
   1. Diet and lifestyle advice to maintain hydration
   2. Metoclopramide (Maxolon) 10mg oral TDS (Cat A)
   3. Ondansetron (Zofran) 4-8mg oral TDS (Cat B1)
   4. Complementary:
      • Vitamin B6 + Doxylamine
      • Ginger
      • Acupressure on the wrist at the PC6 point
   5. Thiamine supplementation if prolonged vomiting to prevent Wernicke’s
2. Gestational Diabetes:
   1. Screening: Oral glucose tolerance test @ 24-24 weeks (< 8.5)
   2. Management: Diet modification, exercise, blood glucose monitoring, insulin or oral hypoglycemics (Glibenclamide, Metformin and Acarbose only) if needed.
3. Hypertension Disorders:
   1. Screening: Regular blood pressure checks and urine protein measurements.
   2. Management: Depending on severity; may include lifestyle changes, antihypertensive medication, and early delivery if severe, such as in preeclampsia.
   3. Antihypertensive Medications safe in pregnancy:
      1. Methyldopa 250-1000mg oral BD-TDS
      2. Labetolol 100-1200mg oral BD
      3. Nifedipine SR 30-120mg oral daily
      4. Hydralazine 10-25mg oral QID
4. Preterm Labor:
   1. Screening: Regular check-ups to identify symptoms and cervical changes.
   2. Management: May include bed rest, hydration, tocolytics (Mg SO4, Nifedipine, Terbutaline), and steroids to enhance fetal lung maturity if delivery is imminent.
5. Intrauterine Growth Restriction (IUGR):
   1. Screening: Ultrasound to measure fetal size and amniotic fluid volume.
   2. Management: Close monitoring, may involve dietary changes, medications to improve placental blood flow, and early delivery if necessary.
6. Multiple Gestations:
   1. Screening: Ultrasound.
   2. Management: More frequent monitoring, nutritional counseling, consideration for cerclage if cervical insufficiency, and planning for delivery in a facility equipped for potential neonatal intensive care.
7. Anemia:
   1. Screening: FBC.
   2. Management: Iron supplements and, in severe cases, possibly intravenous iron therapy or blood transfusion.
8. Placental Complications (Placenta Previa/Abruptio Placentae):
   1. Screening: Ultrasound for placental position.
   2. Management: Avoidance of intercourse and exercise for previa, hospitalization for severe abruption, and planning for cesarean delivery if necessary.

The above represents a template for standard antenatal care and the management of common complications. Care must always be personalized based on individual risk factors, preferences, and the clinical scenario.