Transcript Slide 1

DR. AKINWUNMI L. AKINWUNTAN
M.B;B.S(Ib), MHS Pop & RH (Ib), FMCOG(Nig),
FWACS
Having a baby is one of the most
important times in a woman’s life
and healthcare professionals want
to make sure this is a good and
safe experience
NICE 2008
INTRODUCTION
Antenatal care includes
Recording medical history,
Assessment of individual needs,
Advice and guidance on pregnancy and
delivery,
Screening tests,
Education on self-care during pregnancy,
Identification of conditions detrimental to
health during pregnancy,
First-line management and referral if necessary
Aims of Antenatal Care
1. Management of maternal symptomatic
problems.
2. Management of fetal symptomatic
problems.
3. Screening and prevention of fetal problems.
4. Preparation of the mother for childbirth.
5. Preparation of the couple for childbearing.
• Prenatal care generally consists of:
– monthly visits during the first two trimesters (from
week 1–28)
– fortnightly from 28 to week 36 of pregnancy
– weekly after week 36 (delivery at week 38–40)
• Assessment of parental needs and family
dynamic
The essential elements of a
focused approach to antenatal care
• Identification and surveillance of the pregnant
woman and her expected child
• Recognition and management of pregnancyrelated complications, particularly preeclampsia
• Recognition and treatment of underlying or
concurrent illness
• Screening for conditions and diseases such as anaemia,
STIs (particularly syphilis), HIV infection, mental health
problems, and/or symptoms of stress or domestic
violence
• Preventive measures, including tetanus toxoid
immunization, de-worming, iron and folic acid,
intermittent preventive treatment of malaria in
pregnancy (IPTp), insecticide treated bed nets (ITN)
• Advice and support to the woman and her family
for developing healthy home behaviours and
• A birth and emergency preparedness plan to
– Increase awareness of maternal and newborn
health needs
– Promote healthy behaviours in the home
– Help the pregnant woman and her partner prepare
emotionally and physically
ANOMALY SCREENING/PRENATAL
SCREENING/DIAGNOSIS
• REASONS
1. To enable timely medical/surgical intervention
before or after birth
2. To give the parents opportunity to decide on
termination or otherwise
3. To allow for parents to prepare psychologically,
financially and socially for a baby with a defect
FIRST TRIMESTER SCREENING
• Is a optional non-invasive evaluation that combines
maternal blood screening test with ultrasound
evaluation
• Is the most accurate non-invasive screening method
available NEJM Nov 2005
• The combined accuracy rate for the screen to detect
the chromosomal abnormalities ie Trisomy 21 and 18
is approximately 85% with a false positive rate of 5%
FIRST TRIMESTER SCREENING
•
This simply means:
– Approximately 85 out of every 100 babies affected by
the abnormalities addressed by the screen will be
identified
– Approximately 5% of all normal pregnancies will receive
a positive result or an abnormal level
– A positive test means that you have a 1/100 to 1/300
chance of experiencing one of the abnormalities
FIRST TRIMESTER SCREENING
It is important to realize that a positive
result does not equate to having
an abnormality, but rather serves as a
prompt to discuss further
testing
TRIPLE TESTS/TRIPLE SCREENING
• Also known as the:
– Kettering or Bart’s test
– Multiple Marker Screening Test
• Performed during the 2nd trimester to classify a
patient as either high-risk or low-risk for
chromosomal abnormalities (and neural tube
defects)
• Other possible conditions: Turners’ syndrome,
Triploidy, Trisomy 16 mosaicism
• The triple test measures the following three
levels in the maternal serum:
– alpha-fetoprotein (AFP)
– human chorionic Gonadotrophin (hCG)
– unconjugated estriol (UE3)
INTERPRETATION OF TRIPLE TEST
AFP
UE3
hCG
ASSOCIATED CONDITION
LOW
LOW
HIGH
DOWN’S SYNDROME
(Trisomy 21)
LOW
LOW
LOW
EDWARD’S SYNDROME
(Trisomy 18)
HIGH
N/A
N/A
NEURAL TUBE DEFECTS
(Spinal Bifida, Omphalocoele, Gastroschisis,
Multiple gestation
An Estimated risk is calculated and adjusted for the mother’s age, weight and
Ethnicity
QUADRUPLE (QUAD) TEST
• TRIPLE TEST PLUS
• SERUM INHIBIN A
– High in Trisomy 21
– Low in Trisomy 18
• The test in done btw 15wk to 22wk + 6days
• 81% sensitive and 5% false positive
ANOMALY SCREENING
• NUCHAL SCAN
– Assesses the soft tissue thickness at the nape of
the neck
– Carried out between 11 to 13 wks + 6 days
– Helps to identify higher chances of Chromosomal
problems eg Down’s Syndrome
– Higher thickness also in Congenital Heart Defects
NUCHAL SCAN
– NUCHAL TRANSLUCENCY
• Measured earlier in pregnancy at the end of the first
trimester: 10 to 14 weeks
• The max thickness of the translucent area btw the fetal skin
and the soft tissue overlying the cervical spine
• Normal thickness < 2.5mm
• PLUS FETAL HEART RATE VARIATION
– OTHER SOFT MARKERS
• Short Femur, Mild Pyelectasis, Ventriculomegaly, Choroid
plexus cyst, Hyperechoic bowel, Echogenic intracardiac foci,
2 vessel umbilical cord and abnormalities of extremities
AMNIOCENTESIS
• Performed at 15 to 16 weeks
• Most commonly used prenatal genetic diagnostic
test
• Cultured amniotic fluid cells are karyotyped
• To evaluate level of AFP
• To determine haematologic disorders like SCD,
Thalassemia etc
• Performed under sonographic guidance
• Culturing of amniocytes takes about 15 days
• Risk of pregnancy loss like 1: 200
CHORIONIC VILLUS SAMPLING
• Chorionic villus sampling (CVS) is usually
performed between 10 and 12 weeks of
gestation
• Involves aspiration of placental tissue rather
than amniotic fluid
• CVS can be transabdominal or transcervical
• Pregnancy loss rate about 1-2%
• Has its advantages – terminations can be early
PERCUTANEOUS UMBILICAL BLOOD
SAMPLING (PUBS)
• USS- guided umbilical blood sampling
• Performed as early as 16-18 weeks till term
• INDICATION
– Rapid Karyotyping
– Dx and Rx of inheritable disoders
– Fetal Anaemia
– Severe red blood cell alloimmunization
– Nonimmune fetal hydrops
CELL FREE FETAL DNA
• Available in the United States beginning 2011
• Based on DNA of fetal origin circulating in the
maternal blood
• Testing can potentially identify fetal aneuploidy
and gender of a fetus as early as 6 weeks
• Fetal DNA ranges from about 2-10% of the total
DNA in maternal blood
• Cell types- Nucleated RBC, CD34+ & Trophoblasts
EMBRYOSCOPY/FETOSCOPY
• Rarely done
• Involve putting a probe into a women's uterus
to observe (with a video camera) under local
anaesthesia
• To sample blood or tissue from the embryo or
fetus
• Therapeutic laser coagulation of placental
vessels in feto-fetal transfusion syndrome
CONCLUSION
• PD is best performed in a multidisciplinary
setting involving experienced Counsellors,
experts ultrasonographers, geneticists,
maternal fetal medicine and neonatal cares
• There are lots of ethical considrations involved
• Maternal/Parental anxieties should be
addressed
THANK YOU