the first antenatal visit

1. The First Antenatal Visit Surya Krishnan Obstetrician Gynaecology Endoscopic Surgeon Royal Hospital for Women Royal Prince Alfred Hospital Prince of Wales Private Hospital

3. Objectives Risk Assessment Maternal and Foetal well being Date the Pregnancy Comprehensive History

4. Objectives Discuss first trimester screening Discuss nutrition, obesity and smoking Model of care Antenatal screens

5. Risk Assessment Low risk Pregnancy Healthy women having a normal pregnancy Very suitable for shared care Primip or Multip No prior medical or obstetric issues

6. Risk Assessment High risk Pregnancy Maternal Obesity Underlying medical conditions cardiovascular, renal, essential HT etc Previous obstetric or antenatal problem GDM, PET, Preterm Prior Intrapartum complication 3/4th tears, PPH�s Socio-economic

7. Risk Assessment Foetal Previous aneuploidy Congenital abnormality Stillbirth or neonatal death Prematurity

8. Model of Antenatal Care Shared Care with General Practitioners With r/v ANC Doctors at ANC Midwives clinic/Team care High Risk clinic (Twins, HT, GDM, etc) Private Obstetrician (Low or High risk)

9. Comprehensive History LMP Regular or irregular IVF cycle. ? Embryo transfer (how many) ? Clomid Planned or unplanned Obstetric history Parity/mode of delivery/tears/complications Gynaecological history Subfertility, PID, ectopic etc

10. Comprehensive History Medical History Social and Family Smoking/alcohol/drug/allergies

11. Common First Visit problems Hyperemesis Gravidarum Severe dehydration Looks unwell, loss >5% body weight Psychosocial issues, ambivalence Risk of Wernicke�s Encephalopathy Admission IV Hydration, Thiamine

12. Miscarriage 15-30% of all pregnancy May be asymptomatic Benefit of a dating or Nuchal scan If Suspicious Early pregnancy assessment at RHW or RPAH Conservative or ERPC

13. Ectopic Pregnancy 7-10% of pregnancy Localizing abdominal pain and bleeding Risk factors PID, ectopic, endometriosis IUCD Refer to nearest early pregnancy unit. Salpingectomy vs MTX

14. Dating the Pregnancy Get a Dating Scan 7-10 weeks The earlier the more accurate for EDC Confirms first trimester loss Implantation accidents Methotrexate vs Surgery Multiple pregnancy LMP Quant BHCG if uncertain

15. First Trimester Screening Assess risk profile of mothers Advanced maternal age (>35) Family Hx genetic conditions Consanguinity Abnormal thalassemia screen for both parent Recurrent miscarriages Previous child with a syndrome/malformation

16. First Trimester Screen Genetic counselling Nuchal Translucency and serum screen Screening test only. >90% accurate 11-13 weeks <1/300 �low risk�, >1/300 �high risk� Qualified and credited team-counselling Consider diagnostic test

17. Prenatal diagnosis Chorionic Villous Sampling 1:100 miscarriage risk From 10 weeks Diagnostic test Cytogenetics FISH for trisomy 13,18,21. in 48 hours Counselling by OBGYN.

18. Prenatal Diagnosis Amniocentesis High risk prenatal screening test or risk factors Diagnostic test: >99% accurate From 15 weeks 1:200 risk of miscarriage Prenatal Diagnosis does not detect all abnormalities

19. Second Trimester Screening 15-18 weeks Triple test (serum) Needs accurate gestational age AFP, BHCG and uE3 60-70% at best with false positive

20. Nutrition and Pregnancy Not the right time for �dieting� Weight gain of 7-20 kg in pregnancy If High BMI or low BMI Dietician Constipation issues

21. Smoking and Alcohol

23. Nutrition in pregnancy Folic Acid and pregnancy Taken 1 month before and for the first 3 months Prevents NTD Needs to take an additional 400ug/day Higher dose if has a past/family history

24. Nutrition in Pregnancy Iodine supplement I deficiency affect thyroid function of mother , neonate and neurodevelopment of child 50% of pregnant women are I deficient Major cause of lowered IQ in children (WHO) 150ug/day supplement in pregnant women

25. Nutrition and Pregnancy Vitamin D Increasing incidence of Ricketts and poor teeth Dark skinned women with Veil Diet in early gestation influences bone growth and bone health in children Vitamin D 10ug/Day supplement

26. Common Questions asked Can I eat Sushi? Yes. Avoid Swordfish, sharks and mackerels Tuna in moderation, and salmon-ok California roll is ok Look at the Koreans and Japanese!

27. Common Questions Tea, Coffee and Coke 2-3 cups/day is safe >8/day has an increased risk of still birth Impairs absorption of nutrients

28. Common Questions Listeria infection Harmful to foetus and may cause stillbirth Listeria is destroyed by cooking Avoid Unpasturised milk Soft cheeses, ricotta, feta pate Processed meat (devon or ham)

29. Herbs and Pregnancy

30. Antenatal care: first visit examination General Booking BP, Pulse, Weight CVS, Respiratory, Abdominal Breast and Thyroid PAP smear

31. Initial recommended Test FBC, EUC Thalassemia screen Blood Group and Antibodies Hep B, HIV and HepC* Syphillis (VDRL, RPR) Rubella

32. Initial Recommended Tests Consider Vitamin D and Iodine levels Thyroid function test Varicella Zoster serology CMV and Parvovirus Fe studies

33. Pelvic Floor and Pregnancy

34. Pelvic Floor and Pregnancy Refer to pelvic floor or continence physiotherapist. Symptomatic prolapse Lower urinary tract symptoms (urge, stress, UTI�s) Previous 3rd/4th degree tears Prevention of pelvic floor trauma at birth

35. Conclusion of the First Visit Appointment schedule and structure Written information Number Timing Content of antenatal appointments Discussion Minimise inconvenience