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Antenatal Examinations

Description

This article cannot cover all areas of clinical practice associated with the proper care of pregnant women, but gives an overview of important areas based on the latest guidance. For the full advice offered by NICE on routine care of healthy pregnant women, see the first reference at the end of the article.1

Diagnosis of pregnancy and calculation of gestational age
  • Diagnosis of pregnancy is best confirmed using a urine-testing kit that determines the presence of beta-hCG.
  • Many women nowadays will have confirmed their own pregnancy by such means.
  • Where the absence of menses is the only current indicator of early pregnancy, it is important to confirm pregnancy using a testing kit.
  • An early ultrasound scan should be offered at 10–13 weeks, to determine gestational age and detect multiple pregnancies. This has added benefits of ensuring consistency of gestational age assessments and improving the performance of mid-trimester serum screening for Down's syndrome, and reducing the need for induction of labour at >41 weeks.
  • Crown-rump length is the best surrogate measure of gestational age.
  • Pregnant women who present at or beyond 14 weeks' gestation should be offered an ultrasound scan to estimate gestational age using head circumference or biparietal diameter.
Frequency and number of antenatal assessments in uncomplicated pregnancies
  • Nulliparous patients with uncomplicated pregnancies should be seen over a schedule of ten appointments.
  • Parous women with uncomplicated pregnancies should be seen over a schedule of seven appointments.
The first antenatal appointment1

NICE recommend that the first antenatal appointment takes place early in pregnancy (before 12 weeks), and that it may need to be booked as a double appointment due to the large amount of information and assessments that need to be gone into. The checklist below covers those areas that are considered important by NICE:

  • Give mother information on her antenatal care and an opportunity to ask any questions/raise any concerns. Consider topics such as:
    • Diet
    • Lifestyle:
    • Available pregnancy care services
    • Maternity and associated benefits
    • Working and finishing work when pregnant
    • Availability, purpose and logistics of screening tests in pregnancy
  • Identify women who may need special care (see list below in criteria for more specialised care section); plan pattern of care for pregnancy depending on parity/previous complications of pregnancy.
  • Check blood group and RhD status
  • Offer blood test to screen for:
  • Urine testing to screen for asymptomatic bacteriuria
  • Offer entry into screening programme for Down's syndrome (nuchal translucency US or serum screening)
  • Offer early ultrasound scan to assess gestational age
  • Offer 20 week ultrasound screening for fetal anomaly
  • Measure BMI
  • Check and record BP
  • Test urine for glycosuria/proteinuria

For a full schedule of assessments at each of the antenatal assessments and what areas they should cover, see the first reference below (NICE guidance) or the article on antenatal care.

Pelvic examination

Routine antenatal pelvic examination does not accurately assess gestational age, nor does it accurately predict preterm birth or cephalopelvic disproportion, so it is not recommended.

Breast examination

Routine breast examination is not recommended.

Weight

Patient should be weighed and her height measured so that her body mass index can be calculated as:

  • Weight (kg)/height (m) x height (m).
  • This can be used as a baseline for future weighing where it is clinically indicated.
Blood tests

These should be offered to test for:

  • Anaemia – if Hb <11g/dl early in pregnancy or <10.5g/dl at 28 weeks, investigate with a view to prescribing oral iron if confirmatory evidence of iron deficiency. Iron should not be routinely prescribed during pregnancy.
  • Rhesus status with a further test for Rh alloantibodies if Rhesus positive and anti-D therapy needed.
  • ABO blood group.
  • HIV status.
  • Hepatitis B status.
  • Atypical red cell alloantibodies .
  • Syphilis.
  • Consider screening for beta-thalassaemia, sickle cell disease and other inherited disorders in high-risk racial groups.3
Urine
  • Test for asymptomatic bacteriuria early in pregnancy using dipstick testing; send MSU if indirect test is positive.
  • Test for proteinuria every time BP is taken.
  • Check for glycosuria at every visit, if more than 2 then test random plasma venous glucose and determine need for oral glucose tolerance test on basis of that result; there is no evidence of benefit from routine screening for gestational diabetes mellitus. See glucose tolerance tests.
Blood pressure

Schedule further appointments accordingly to allow appropriate monitoring of BP.

Previous history

Enquire into the areas listed below, and ask about any previous significant previous physical or psychiatric illness. Women with a history of significant psychiatric illness should be offered a referral to psychiatric services to screen for problems and advice on appropriate support.1

  • Occupation for any associated risks
  • Smoking
  • Alcohol and recreational drug use
  • Domestic violence4
  • Psychiatric illness

Advise and refer accordingly if any areas of concern come to light.

Abdominal examination
  • Offer estimation of fetal size by measuring symphysis-fundal distance at each examination to look for fetus that is small or large for gestational age.
  • After 36 weeks, palpate abdomen for possible malpresentation and confirm with US if suspected.
Ultrasound

Offer a US examination early in pregnancy (preferably at 10–13 weeks) to:

  • Determine gestational age
  • Detect multiple pregnancies
  • Help with later screening for Down's syndrome.
  • At 11–14 weeks offer nuchal translucency screening for Down's syndrome with other tests if available.
  • 18–20 weeks offer screening ultrasound for congenital anomalies.
  • If placenta over the cervical os, offer a scan at 36 weeks for placenta praevia.
Criteria for more specialised care1

Women with the associated conditions below, or who have had the problems listed associated with previous pregnancies should be referred for obstetric or other advice as appropriate. This list is not exhaustive:



Document references
  1. NICE Clinical Guideline; Antenatal care (October 2003).
  2. Ahmed S, Green J, Hewison J; What are Pakistani women's experiences of antenatal carrier screening for beta-thalassaemia in the UK? Why it is difficult to answer this question? Public Health. 2002 Sep;116(5):297-9. [abstract]
  3. Leung TN, Lau TK, Chung TKh; Thalassaemia screening in pregnancy. Curr Opin Obstet Gynecol. 2005 Apr;17(2):129-34. [abstract]
  4. Department of Health; Domestic Violence: A Resource Manual for Healthcare Professionals, 2000.
  5. RCOG; Alcohol Consumption and the Outcomes of Pregnancy, 2006.

Internet and further reading
  • RCOG; Alcohol and Pregnancy - information for pregnant women, 2006.
  • RCOG; Routine Ultrasound During Pregnancy, 2000.
  • RCOG; Recreational exercise and pregnancy, patient information, 2006.
  • Exercise and Pregnancy, Royal College of Obstetricians and Gynaecologists (2006)
  • RCOG; Index page for publications related to pregnancy and its complications, access to a wide range of resources.
Acknowledgements EMIS is grateful to Dr Sean Kavanagh for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 1808
Document Version: 23
DocRef: bgp171
Last Updated: 20 Jun 2007
Review Date: 19 Jun 2009






















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