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PREGNANT

The Guidelines for the antenatal care of the mother and the baby in according the RCOG (revised 2008).
Antenatal information should be given to pregnant women according to the following schedule.

Antenatal information

Antenatal information should be given to pregnant women according to the following schedule.
At the first contact (4-6 wk), with a healthcare professional:
folic acid supplementation, food hygiene, including how to reduce the risk of a food-acquired infection, lifestyle advice, including smoking cessation, and the implications of recreational drug use and alcohol consumption in pregnancy, all antenatal screening, including screening for haemoglobinopathies, the anomaly scan and screening for Down’s syndrome, as well as risks and benefits of the screening tests.

At booking (ideally by 10 weeks):, how the baby develops during pregnancy
nutrition and diet, including vitamin D supplementation for women at risk of vitamin D deficiency, exercise, including pelvic floor exercises, pregnancy care pathway, breastfeeding, including workshops, participant-led antenatal classes, further discussion of all antenatal screening, discussion of mental health issues.

Before or at 36 weeks:
breastfeeding information, including technique and good management practices that would help a woman succeed preparation for labour and birth, including information about coping with pain in labour and the birth plan recognition of active labour care of the new baby, vitamin K prophylaxis, newborn screening tests, postnatal self-care, awareness of ‘baby blues’ and postnatal depression.

At 38 weeks:
Options for management of prolonged pregnancy.

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Frequency of antenatal appointments

A schedule of antenatal appointments should be determined by the function of the appointments.
For a woman who is nulliparous with an uncomplicated pregnancy, a schedule of ten appointments should be adequate. For a woman who is parous with an uncomplicated pregnancy, a schedule of seven appointments should be adequate.
Early in pregnancy, all women should receive appropriate written information about the likely number, timing and content of antenatal appointments associated with different options of care.
Gestational age assessment: LMP and ultrasound
Pregnant women should be offered an early ultrasound scan between 10 weeks 0 days and 14 weeks to determine gestational age and to detect multiple pregnancies. This will ensure consistency of gestational age assessment and reduce the incidence of induction of labour for prolonged pregnancy.
Crown–rump length measurement should be used to determine gestational age. If the crown–rump length is above 84 mm, the gestational age should be estimated using head circumference.

Lifestyle considerations

  • Working during pregnancy

    Pregnant women should be informed of their maternity rights and benefits. The majority of women can be reassured that it is safe to continue working during pregnancy. Further information about possible occupational hazards during pregnancy is available from the increased risk through occupational exposure.

  • Nutritional supplements

    Pregnant women (and those intending to become pregnant) should be informed that dietary supplementation with folic acid, before conception and up to 12 weeks of gestation, reduces the risk of having a baby with neural tube defects (anencephaly, spina bifida). The recommended dose is 400 micrograms per day. Iron supplementation should not be offered routinely to all pregnant women. It does not benefit the mother’s or the fetus’s health and may have unpleasant maternal side effects. Pregnant women should be informed that vitamin A supplementation (intake greater than 700 micrograms) might be teratogenic and therefore it should be avoided. Pregnant women should be informed that as liver and liver products may also contain high levels of vitamin A, consumption of these products should also be avoided. All women should be informed at the booking appointment about the importance for their own and their baby’s health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding. In order to achieve this, women may choose to take 10 micrograms of vitamin D per day, as found in the Healthy Start multivitamin supplement. Particular care should be taken to enquire as to whether women at greatest risk are following advice to take this daily supplement.

  • Food-acquired infections

    Pregnant women should be offered information on how to reduce the risk of listeriosis by: drinking only pasteurised or UHT milk not eating ripened soft cheese such as Camembert, Brie and blue-veined cheese (there is nο risk with hard cheeses, such as Cheddar, or cottage cheese and processed cheese) not eating pate (of any sort, including vegetable) not eating uncooked or undercooked ready-prepared meals.

    Pregnant women should be offered information on how to reduce the risk of salmonella infection by: avoiding raw or partially cooked eggs or food that may contain them (such as mayonnaise) avoiding raw or partially cooked meat, especially poultry.

  • Prescribed medicines

    Few medicines have been established as safe to use in pregnancy. Prescription medicines should be used as little as possible during pregnancy and should be limited to circumstances where the benefit outweighs the risk.

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  • Exercise in pregnancy

    Pregnant women should be informed that beginning or continuing a moderate course of exercise during pregnancy is not associated with adverse outcomes. Pregnant women should be informed of the potential dangers of certain activities during pregnancy, for example, contact sports, high-impact sports and vigorous racquet sports that may involve the risk of abdominal trauma, falls or excessive joint stress, and scuba diving, which may result in fetal birth defects and fetal decompression disease.
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  • Sexual intercourse in pregnancy

    Pregnant woman should be informed that sexual intercourse in pregnancy is not known to be associated with any adverse outcomes.

  • Alcohol and smoking in pregnancy

    Pregnant women and women planning a pregnancy should be advised to avoid drinking alcohol in the first 3 months of pregnancy if possible because it may be associated with an increased risk of miscarriage.

    If women choose to drink alcohol during pregnancy they should be advised to drink no more than 1 to 2 UK units once or twice a week (1 unit equals half a pint of ordinary strength lager or beer, or one shot [25 ml] of spirits. One small [125 ml] glass of wine is equal to 1.5 UK units).

    Although there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level there is no evidence of harm to the unborn baby.
    Women should be informed that getting drunk or binge drinking during pregnancy (defined as more than 5 standard drinks or 7.5 UK units on a single occasion) may be harmful to the unborn baby.

  • Smoking in pregnancy

    At the first contact with the woman, discuss her smoking status, provide information about the risks of smoking to the unborn child and the hazards of exposure to secondhand smoke. Address any concerns she and her partner or family may have about stopping smoking.
    Pregnant women should be informed about the specific risks of smoking during pregnancy (such as the risk of having a baby with low birthweight and preterm birth). The benefits of quitting at any stage should be emphasized.
    Offer personalised information, advice and support on how to stop smoking.
    Discuss the risks and benefits of nicotine replacement therapy (NRT) with pregnant women who smoke, particularly those who do not wish to accept the offer of help from the NHS Stop Smoking Service. If a woman expresses a clear wish to receive NRT, use professional judgement when deciding whether to offer a prescription.
    Advise women using nicotine patches to remove them before going to bed.

  • Cannabis use in pregnancy

    The direct effects of cannabis on the fetus are uncertain but may be harmful. Cannabis use is associated with smoking, which is known to be harmful; therefore women should be discouraged from using cannabis during pregnancy.

  • Air travel during pregnancy

    Pregnant women should be informed that long-haul air travel is associated with an increased risk of venous thrombosis, although whether or not there is additional risk during pregnancy is unclear. In the general population, wearing correctly fitted compression stockings is effective at reducing the risk.

  • Car travel during pregnancy

    Pregnant women should be informed about the correct use of seatbelts (that is, three-point seatbelts ‘above and below the bump, not over it’).

Management of common symptoms of pregnancy

  • Nausea and vomiting in early pregnancy

    Women should be informed that most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks of gestation and that nausea and vomiting are not usually associated with a poor pregnancy outcome. If a woman requests or would like to consider treatment, the following interventions appear to be effective in reducing symptoms:
    non pharmacological: ginger, P6 (wrist) acupressure
    pharmacological: antihistamines.
    Information about all forms of self-help and non-pharmacological treatments should be made available for pregnant women who have nausea and vomiting.

  • Heartburn

    Women who present with symptoms of heartburn in pregnancy should be offered information regarding lifestyle and diet modification.
    Antacids may be offered to women whose heartburn remains troublesome despite lifestyle and diet modification.

  • Constipation

    Women who present with constipation in pregnancy should be offered information regarding diet modification, such as bran or wheat fibre supplementation.

  • Haemorrhoids

    In the absence of evidence of the effectiveness of treatments for haemorrhoids in pregnancy, women should be offered information concerning diet modification. If clinical symptoms remain troublesome, standard haemorrhoid creams should be considered.

  • Varicose veins

    Women should be informed that varicose veins are a common symptom of pregnancy that will not cause harm and that compression stockings can improve the symptoms but will not prevent varicose veins from emerging.

  • Vaginal discharge

    Women should be informed that an increase in vaginal discharge is a common physiological change that occurs during pregnancy. If this is associated with itch, soreness, offensive smell or pain on passing urine there may be an infective cause and investigation should be considered.

  • Backache

    Women should be informed that exercising in water, massage therapy and group or individual back care classes might help to ease backache during pregnancy.

Screening for haematological conditions

  • Anaemia

    Pregnant women should be offered screening for anaemia. Screening should take place early in pregnancy (at the booking appointment) and at 28 weeks when other blood screening tests are being performed. This allows enough time for treatment if anaemia is detected. Haemoglobin levels outside the normal UK range for pregnancy (that is, 11 g/100 ml at first contact and 10.5 g/100 ml at 28 weeks) should be investigated and iron supplementation considered if indicated.

  • Blood grouping and red cell alloantibodies

    Women should be offered testing for blood group and rhesus D status in early pregnancy. It is recommended that routine antenatal anti-D prophylaxis is offered to all non-sensitised pregnant women who are rhesus D-negative. Women should be screened for atypical red cell alloantibodies in early pregnancy and again at 28 weeks, regardless of their rhesus D status. This recommendation is from the NICE clinical guideline on antenatal and postnatal mental health. Pregnant women with clinically significant atypical red cell alloantibodies should be offered referral to a specialist centre for further investigation and advice on subsequent antenatal management. If a pregnant woman is rhesus D-negative, consideration should be given to offering partner testing to determine whether the administration of anti-D prophylaxis is necessary.

  • Haemoglobinopathies

    Preconception counseling (supportive listening, advice giving and information) and carrier testing should be available to all women who are identified as being at higher risk of haemoglobinopathies, using the Family Origin Questionnaire from the NHS.

    Information about screening for sickle cell diseases and thalassaemias, including carrier status and the implications of these, should be given to pregnant women at the first contact with a healthcare professional. Screening for sickle cell diseases and thalassaemias should be offered to all women as early as possible in pregnancy (ideally by 10 weeks). The type of screening depends upon the prevalence and can be carried out in either primary or secondary care.
    Where prevalence of sickle cell disease is high (fetal prevalence above 1.5 cases per 10 000 pregnancies), laboratory screening (preferably high-performance liquid chromatography) should be offered to all pregnant women to identify carriers of sickle cell disease and/or thalassaemia.

    Where prevalence of sickle cell disease is low (fetal prevalence 1.5 cases per 10 000 pregnancies or below), all pregnant women should be offered screening for haemoglobinopathies using the Family Origin Questionnaire.
    If the Family Origin Questionnaire indicates a high risk of sickle cell disorders, laboratory screening (preferably high-performance liquid chromatography) should be offered.
    If the mean corpuscular haemoglobin is below 27 picograms, laboratory screening
    (Preferably high-performance liquid chromatography) should be offered.

    If the woman is identified as a carrier of a clinically significant haemoglobinopathy then the father of the baby should be offered counseling and appropriate screening without delay.

Screening for structural anomalies

  • Ultrasound screening for fetal anomalies should be routinely offered, normally between 18 weeks 0 days and 20 weeks 6 days.

    At the first contact with a healthcare professional, women should be given information about the purpose and implications of the anomaly scan to enable them to make an informed choice as to whether or not to have the scan. The purpose of the scan is to identify fetal anomalies and allow:

    • reproductive choice (termination of pregnancy)
    • parents to prepare (for any treatment/disability/palliative care/termination of pregnancy)
    • managed birth in a specialist centre
    • Intrauterine therapy

    Women should be informed of the limitations of routine ultrasound screening and that detection rates vary by the type of fetal anomaly, the woman’s body mass index and the position of the unborn baby at the time of the scan.

    If an anomaly is detected during the anomaly scan pregnant women should be informed of the findings to enable them to make an informed choice as to whether they wish to continue with the pregnancy or have a termination of pregnancy.

    Fetal echocardiography involving the four chamber view of the fetal heart and outflow tracts is recommended as part of the routine anomaly scan.
    Routine screening for cardiac anomalies using nuchal translucency is not recommended.

    When routine ultrasound screening is performed to detect neural tube defects, alpha-fetoprotein testing is not required.

  • Screening for Down’s syndrome

    All pregnant women should be offered screening for Down’s syndrome. Women should understand that it is their choice to embark on screening for Down’s syndrome. Screening for Down’s syndrome should be performed by the end of the first trimester (13 weeks 6 days), but provision should be made to allow later screening (which could be as late as 20 weeks 0 days) for women booking later in pregnancy. The ‘combined test’ (nuchal translucency, beta-human chorionic gonadotrophin, pregnancy associated plasma protein-A) should be offered to screen for Down’s syndrome between 11 weeks 0 days and 13 weeks 6 days. For women who book later in pregnancy the most clinically and cost-effective serum screening test (triple or quadruple test) should be offered between 15 weeks 0 days and 20 weeks 0 days.

    When it is not possible to measure nuchal translucency, owing to fetal position or raised body mass index, women should be offered serum screening (triple or quadruple test) between 15 weeks 0 days and 20 weeks 0 days.

    Information about screening for Down’s syndrome should be given to pregnant women at the first contact with a healthcare professional. This will provide the opportunity for further discussion before embarking on screening. Specific information should include:

    the screening pathway for both screen-positive and screen-negative results
    the decisions that need to be made at each point along the pathway and their consequences
    the fact that screening does not provide a definitive diagnosis and a full explanation of the risk score obtained following testing
    Information about chorionic villus sampling and amniocentesis
    Balanced and accurate information about Down’s syndrome.

    If a woman receives a screen-positive result for Down’s syndrome, she should have rapid access to appropriate counselling by trained staff.

    The routine anomaly scan (at 18 weeks 0 days to 20 weeks 6 days) should not be routinely used for Down’s syndrome screening using soft markers.

    The presence of an isolated soft marker, with an exception of increased nuchal fold, on the routine anomaly scan, should not be used to adjust the a priori risk for Down’s syndrome.

    The presence of an increased nuchal fold (6 mm or above) or two or more soft markers on the routine anomaly scan should prompt the offer of a referral to a fetal medicine specialist or an appropriate healthcare professional with a special interest in fetal medicine.

    Screening for infections

    Asymptomatic bacteriuria

    Asymptomatic bacterial vaginosis

    Chlamydia trachomatis

    Cytomegalovirus
    The available evidence does not support routine cytomegalovirus screening in pregnant women and it should not be offered.

    Hepatitis B virus
    Hepatitis C virus
    Pregnant women should not be offered routine screening for hepatitis C virus because there is insufficient evidence to support its effectiveness and cost-effectiveness.

    HIV
    Streptococcus Group B
    Pregnant women should not be offered routine antenatal screening for group B streptococcus because evidence of its clinical and cost-effectiveness remains uncertain.

    Syphilis
    Toxoplasmosis
    Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits.
    Pregnant women should be informed of primary prevention measures to avoid toxoplasmosis infection, such as:

    washing hands before handling food
    Thoroughly washing all fruit and vegetables, including ready-prepared salads, before eating
    Thoroughly cooking raw meats and ready-prepared chilled meals
    wearing gloves and thoroughly washing hands after handling soil and gardening
    avoiding cat faeces in cat litter or in soil.

Screening for clinical conditions

  • Gestational diabetes

    Screening for gestational diabetes using risk factors is recommended in a healthy population. At the booking appointment, the following risk factors for gestational diabetes should be determined:

    body mass index above 30 kg/m2
    previous macrosomic baby weighing 4.5 kg or above
    previous gestational
    family history of diabetes (first-degree relative with diabetes)
    family origin from middle east

    Women with any one of these risk factors should be offered testing for gestational diabetes
    In order to make an informed decision about screening and testing for gestational diabetes, women should be informed that:
    in most women, gestational diabetes will respond to changes in diet and exercise
    some women (between 10% and 20%) will need oral hypoglycaemic agents or insulin therapy if diet and exercise are not effective in controlling gestational diabetes
    if gestational diabetes is not detected and controlled there is a small risk of birth
    complications such as shoulder dystocia
    a diagnosis of gestational diabetes may lead to increased monitoring and interventions during both pregnancy and labour

    Screening for gestational diabetes using fasting plasma glucose, random blood glucose, glucose challenge test and urinalysis for glucose should not be undertaken.

  • Pre-eclampsia

    Blood pressure measurement and urinalysis for protein should be carried out at each antenatal visit to screen for pre-eclampsia.

    At the booking appointment, the following risk factors for pre-eclampsia should be determined:
    age 40 years or older
    nulliparity
    pregnancy interval of more than 10 years
    family history of pre-eclampsia
    previous history of pre-eclampsia
    body mass index 30 kg/m2 or above
    pre-existing vascular disease such as hypertension
    pre-existing renal disease
    multiple pregnancy

    More frequent blood pressure measurements should be considered for pregnant women who have any of the above risk factors.
    The presence of significant hypertension and/or proteinuria should alert the healthcare professional to the need for increased surveillance.

    Blood pressure should be measured as outlined below:
    • remove tight clothing, ensure arm is relaxed and supported at heart level
    • use cuff of appropriate size
    • inflate cuff to 20–30 mmHg above palpated systolic blood pressure
    • lower column slowly, by 2 mmHg per second or per beat
    • read blood pressure to the nearest 2 mmHg
    • Measure diastolic blood pressure as disappearance of sounds (phase V).

    Hypertension in which there is a single diastolic blood pressure of 110 mmHg or two consecutive readings of 90 mmHg at least 4 hours apart and/or significant proteinuria (1+) should prompt increased surveillance.

    If the systolic blood pressure is above 160 mmHg on two consecutive readings at least 4 hours apart, treatment should be considered.

    All pregnant women should be made aware of the need to seek immediate advice from a healthcare professional if they experience symptoms of pre-eclampsia.

    Symptoms include:
    • severe headache
    • problems with vision, such as blurring or flashing before the eyes
    • severe pain just below the ribs
    • vomiting
    • sudden swelling of the face, hands or feet

    Although there is a great deal of material published on alternative screening methods for Pre-eclampsia, none of these has satisfactory sensitivity and specificity, and therefore they are not recommended.

  • Preterm birth

    Routine screening for preterm labour should not be offered.

  • Placenta praevia

    Because most low-lying placentas detected at the routine anomaly scan will have resolved by the time the baby is born, only a woman whose placenta extends over the internal cervical os should be offered another transabdominal scan at 32 weeks. If the transabdominal scan is unclear, a transvaginal scan should be offered.

Fetal growth and wellbeing

  • Determination of fetal growth
  • Measurement of adhesion distance – uterine bed after 24 weeks of gestation, where ultrasound is not available
  • Biometrics and Doppler ultrasound, where ultrasonography can be performed
  • Determination of embryo projection (hands / ultrasound)
  • Embryo cardiology (according to medical indications)