ANTENATAL CARE.

OK, so you’re pregnant! What can you expect, and from who?

What type of antenatal care should I choose?

There are two types of antenatal clinic to choose from:

  • Public Hospital Care.  Low risk pregnancies are managed by the midwife with or without your GP.  You’ll have a handheld record where visits are recorded.
  • Private antenatal care following a referral from your GP. Care is led by a private obstetrician with their midwife.

Tell me more about public hospital antenatal care!

The GP refers you to your local public hospital. The hospital will accept the referral based on:

  • You living in their ‘catchment area’
  • The GP attaching routine test results

There are two ‘types’ of routine public hospital antenatal care:

  • GP Shared care: you see your GP during the pregnancy, and the hospital ‘only’ see you at the major landmarks, and then ‘take over’ completely towards the end of your pregnancy.
  • Midwife-led care: you ‘only’ see the midwife / hospital team during your pregnancy. Of course you may see your GP for any reason, but all routine appointments are at the hospital. Care is tending to move towards this at least in Brisbane.

Your first hospital antenatal clinic visit with the midwife and/or obstetrician will be at around 16 weeks, with further visits at 28 weeks, 34 weeks – and after that depending on circumstances. This interface between GP & hospital antenatal care is carefully informed & structured according to detailed guidelines from the RACGP, RANZCOG, Queensland GovernmentBrisbane’s Mater Hospital (for example).

You carry your “shared care” antenatal health record to all GP or hospital appointments. This shared care record is where the doctor and/or midwife write notes. That way,  everyone including yourself knows exactly where you’re at and what has been discussed. The GP, hospital midwife & Obstetrician all communicate via letters and by updates in your shared care record. The book also indicates what appointments and tests are due & when.

GP Shared maternity Care in The Three trimesters of pregnancy

Antenatal Care is divided fairly neatly into the 3 trimesters of pregnancy.

  • 1st Trimester: weeks 1 through to 12
  • 2nd Trimester: weeks 13 through to 27
  • 3rd Trimester: weeks 28 through to the delivery of the baby
First Trimester Screening in general practice

1st Trimester antenatal care

There is a lot to cover in the first 1-2 antenatal visits.

What sort of tests are offered, and why?

Your first 12 weeks are a time of tremendous change in your body. Your body is developing the home that will grow and nurture your baby (or babies!) for 40 weeks. It is important to understand that every pregnancy is different. You may experience some of the following symptoms with each pregnancy you have and you may never experience any of these symptoms.

  • Fatigue
  • Tender or swollen breasts
  • Bloating, cramping, or low back ache
  • Frequent need to urinate
  • Nausea with or without vomiting
  • Dizziness and fainting
  • Constipation
  • Headache

Conception begins about 2 weeks before you last period would have been due. It takes a little less than a week (about 6 days) for your newly fertilized baby to make the trek from your fallopian tube to your uterus. Once it arrives in the uterus, it will implant in the lining and begin to release the hormone human gonadotrophin hormone (HCG). The presence of this hormone is the basis for pregnancy tests. Both over-the-counter &  the medical centre pregnancy tests are the same and there is generally no need to confirm a positive test!

By 6 weeks from the date of your last period, the volume of blood in your body will have increased by 50%. Your metabolism will have increased by about 20%. This combination of increased metabolism and increased volume of blood may make you feel warmer, sweat more (especially in the feet and hands), and will result in your body temperature increasing from 37°C to 37.8°C.

Routine antenatal clinic Visits in the 1st trimester

During your first trimester, your visits to the Medical Centre to see your GP will consist of tests aimed at determining the viability of the pregnancy, the fetal number, the normality of the fetuses, and identify and develop a management system for any underlying emotional or medical conditions.

Your first visit will take longer than your other visits. If you want to invite your partner or a close friend or family member to come with you that is fine with us. It gives them a great opportunity to get involved with the pregnancy and get a feel for what will be happening over the coming months. Along with information about lifestyle and prior pregnancies, you will be asked to provide a detailed medical history as well as a family medical history. Based on the date of your last period, an estimated delivery date (EDD) will be calculated. Bear in mind that the expected date of delivery is very much an approximate date of delivery. The word expected is misleading.

If you smoke, your GP can refer you to resources to help you quit. It is very important to the development of your baby that you do not smoke or drink alcohol while pregnant.

Nutrients in pregnancy

A healthy diet and a reputable pregnancy supplement is a good place to start.

However, additional supplement may be required for individual nutrients.

Folic acid (at least 0.4mg) is included in all reputable pregnancy supplements. A higher 5mg of folic acid is also recommended for women whose BMI is over 30, or have multiple pregnancy. In addition, the 5mg dose is recommended for women who have a family history of neural tube defects, take anticonvulsants, or have a pre-pregnancy diagnosis of diabetes.

Other nutrients included in pregnancy supplements are Vitamin B12, Vitamin D, Calcium, Iron and Iodine. However, you may need extra supplementation of specific nutrients.

Vegetarians will need at least 2.6 ug per day of Vitamin B12.

Women who have a low vitamin D level will generally need 1000IU to 2000IU per day.

Calcium is a tricky one. The guidelines suggest 1000mg per day of dietary calcium so uou may need additional calcium supplementation. Use this calcium dietary calculator, and check the dose of calcium already in your pregnancy supplement.

Iron Defiency in Pregnancy

There are good arguments to treat iron deficiency in pregnancy before anaemia occurs¹. The main reasons are:

  • It is easier to treat mild iron deficiency because lower doses of iron tablets are better tolerated
  • Treating simple iron deficiency will prevent iron deficiency anaemia. Iron deficiency anaemia is associated with reduced fetal growth, low birth weight and preterm birth.

Ferritin is the best measure of iron. The “normal range” varies between 15 and 30. The average birth results in 500mls of blood loss which is equivalent to 30 ug/L of ferritin.

Therefore, many doctors will suggest adding “iron studies” to the battery of blood tests done at the beginning of the pregnancy, and treating low ferritin proactively.

The dose of “elemental iron” required to replenish iron stores is at least 100mg per day. Normal multi-vitamin pregnancy supplements contain only a low dose of iron (5mg to 60mg). The dose iron in different commercially available iron preparations varies from 5mg 1o 105mg. As you can see, it’s a bit of a minefield so make sure that you are taking a proper dose of iron when you have iron deficiency. Some women will need an Iron Infusion. During pregnancy, an Infusion is usually performed in a hospital setting. This completes the argument for treating mild deficiency early with low doses of iron – preferably pre-pregnancy.

Routine Tests in the 1st Trimester.

As part of your initial examination, a number of blood and urine tests will be performed.  It is safe to have a cervical cancer screening test and this should not be delayed until after delivery. You can expect the following tests during your first trimester:

FBC – full blood count. This is an indicator of general health and includes a count of white blood cells, red blood cells, and platelets. Anemia or infection can be detected.

Blood Group and Antibodies – This group of tests determines your blood type in case you need a transfusion at any time during your pregnancy or during or after birth. Even if you know your blood group and type from prior tests, a current test will be performed to confirm. Your blood group can be A, B, AB, or O. The Rhesus factor (Rh) factor will also be determined and it will be noted as a “+” or “-“ after the blood group; and it will be said as “positive” or “negative”   Most of the population has a positive Rh factor and you can then forget about it.

Complications can arise when the mother is Rh negative and the baby is Rh positive. Your blood will then also be checked for antibodies at 26-28 weeks.

HepBsAg – Active Hepatitis B infection (acute or chronic). Hepatitis B can be passed from mother to child. If you test positive for Hepatitis B, you will be referred for a plan of treatment to protect your baby by vaccination soon after birth and continued monitoring during the first few years of life

HIV – This viral infection can also be passed from mother to child. If you receive a positive result, you will be counselled and referred. It is not recommended that an HIV positive mother breastfeed her baby. In addition, the baby will need to be monitored and undergo testing during the first few years of life to detect any possible infection.

Rubella titre – This test determines your immunity level to rubella. You will almost certainly have been vaccinated against Rubella as a child. However, your level of immunity can change over time. This is why the test is performed with each pregnancy.

If the test shows that you are not immune, it is not safe to give you an immunization while you are pregnant – The MMR needle is given in the medical centre shortly after delivery. You will need to be especially careful to avoid situations where you might be exposed to Rubella for the first 20 weeks of your pregnancy.

Syphillis – This sexually transmitted disease is caused by a bacterial infection. Women rarely have symptoms. If your test is positive, you will be treated for the infection. It is important that you receive the proper treatment for this disease. It can cause miscarriage or preterm birth. Babies born with congenital syphilis may have developmental delays.

MSU – Midstream Urine test (also called CSU) refers to the method in which the urine is collected. Your urine sample will be tested to detect infection. Bacteria in the urine does not always cause symptoms and is linked to kidney infection, low birth weight & premature delivery. Antibiotic treatment may prevent low birth weight.

Ultrasound – An “early pregnancy ultrasound” (or dating scan) can be used to confirm pregnancy, detect heart beat (after around 6 weeks), look for twins, & determine the estimated due date. A scan may also be arranged to exclude an ectopic pregnancy.

First Trimester Screening

Standard first trimester screening is with a combined ultrasound and blood test.  n ultrasound at 11 to 13 weeks (around 12 weeks) is used to visualize and measure the fluid sac at the back of the baby’s head. This can be an early indicator of a chromosomal abnormality such as Down’s Syndrome. The results of this scan are combined with the results of a blood test taken a week or so earlier to give a “risk score” for a variety of Chromosomal abnormalities. Standard First trimester screening is not medicare rebatable. The decision is an individual choice for women / couples and not an “automatic” routine test. Around 80% of women do decide to have this test.

The results of the screen are not a “yes” or “no” but expressed as a probability of the conditions being looked for. A risk of around 1 in 300 or greater of any of the conditions is considered a “high risk” and invasive testing may be considered. However, the level of risk that a woman / couple accept will vary – both because of personal opinion & circumstances, and because there is a small risk that invasive testing will cause a miscarriage. It goes without saying that the decision to terminate a pregnancy based on a specific abnormality is also far from straightforward.

Non-invasive prenatal testing (NIPT) for fetal DNA in the mother’s blood is now available for under $450 directly from your GP. The NIPT blood test looks for tiny fragments of the foetus DNA in the mother’s blood to search for specific chromosomal abnormalities (Downs, Edward & Patau Syndrome and some sex chromosome abnormalities). The NIPT test  is both more specific and more sensitive than standard first trimester screening for these specific abnormalities. A huge study of NIPT published in the NEJM in 2014 found 38 cases of Down syndrome. The NIPT test found all 38 cases whereas standard screening found 32 of the 38 cases.

The NIPT testing is currently most often considered when the risk is higher – such as over 35 years of age.

It should be emphasized that standard first trimester screening is not just about screening for chromosomal abnormalities & will also detect some major foetal structural abnormalities & determine the probability of other chromosomal abnormalities. Therefore the NIPT test is usually additional to standard ultrasound/blood test screening.

Bear in mind that the expected date of delivery is very much an approximate date of delivery. The word “expected” is misleading.

Second Trimester Care n general practice

2nd Trimester antenatal care

The 2nd Trimester is often a quiet time in antenatal care!

A key miletone is the detailed morphology ultrasound scan at around 19 weeks.

During your second trimester, your “belly” will begin to show. You may begin to feel much better and healthier as first trimester nausea diminishes. If your appetite waned in the first trimester you will find it returning in the second. Nutrition for you and the baby is important. As you feel better, you may resume physical activity. The most awesome change in the second trimester is that you will begin to feel your baby move. You may think it is just wind at first or even nervous butterflies, but as the movements become stronger and more pronounced you will know for sure it is your baby.

Antenatal Clinic Visits. During the second trimester, you will visit about every 4 to 6 weeks, depending on your health and how your pregnancy is progressing.

Physical Exam. Your blood pressure will be checked. The doctor will feel your belly to ensure that your uterus is growing at the normal rate. You won’t need to undress for this exam, but since it can’t be performed through clothing, be sure to wear something that provides easy access to your abdominal region. Fundal height is a marker of the growth of your baby & measured with a measuring tape. The doctor will also usually use a Doppler to listen to the baby’s heart.

In addition, urine dipsticks may be used to test for the presence of protein or glucose. Small amounts of protein are normal in urine. If your test indicates elevated levels it can be a sign of high blood pressure or pre-eclampsia that your GP and Obstetrician will want to further investigate.

Tests During the Second Trimester. Many of the blood tests that were performed during your first visit in the first trimester won’t need to be performed again.

Blood Tests – Sometime between weeks 26 and 28 you will have another Full Blood Count and a Glucose Test. The glucose test is either a glucose tolerance test that takes 2 hours, or a glucose challenge test that takes 1 hour (the type of test is determined by The shared care guidelines). The full 2 hour glucose tolerance test is more sensitive for gestational diabetes than the 1 hour glucose challenge test.

Your GP will also arrange a glucose tolerance test earlier in pregnancy where there are risk factors for gestational diabetes. The test at 26 to 28 weeks will still be required if the earlier test is negative. This earlier test is often arranged at around 16 weeks of pregnancy for women with:

  • Previous gestational diabetes or previous birth of a large baby
  • A close relative with diabetes
  • BMI over 30
  • Age over 40
  • Some ethnic groups
  • Diagnosis of polycystic ovarian syndrome.

If you are Rhesus negative (from your first trimester blood test), your blood will be tested for antibodies during this trimester. Most times, the antibody test will be “nil antibodies detected”. If the test results are “antibodies detected” it means that antibodies have formed in your blood due to the presence of foreign red blood cells in your body. Under normal circumstances, the mother’s blood is kept separate from the baby’s blood through the use of a membrane in the placenta. In rare cases, a small bit of the baby’s blood can cross over the placenta and mix into the mother’s blood. Queensland hospitals’ guidelines recommend an injection of Anti-D immunoglobulin is given to all rhesus negative women at 28 weeks and 34 weeks to prevent antibodies occurring.

Ultrasound – An abdominal Ultrasound is routine between 18 and 20 weeks. This is the “detailed morphology” scan.  As the name suggests, this report is very detailed and gives information about the location of the placenta, most physical defects, and a measurement of the baby’s growth. It is often possible to determine gender but if you won’t want to know the gender, be sure to remind The Radiographer.

Please bear in mind that the appointments with a specialist radiographer (sonographer) are sometimes booked several weeks ahead.

Invasive Tests – Invasive tests may be performed when there are significant risks of abnormalities that cannot be diagnosed using ultrasound alone, and where a diagnosis will affect the decision to continue the pregnancy. The typical scenario is a “positive” (high risk) first trimester screening result. The two major invasive tests are amniocentesis and CVS.

Amniocentesis is performed between 14 and 18 weeks. This test is used to culture a sample of cells from the amniotic fluid to determine the presence of a genetic disorder. A sample of the fluid is taken from the amniotic sac via the abdomen. Results take 2 to 3 weeks. The results indicate the baby’s genetic makeup. While it is highly accurate, there are over 5,000 different genetic markers for different defects. Amniocentesis cannot screen 100% for all defects. Chorionic Villous Sampling (CVS) is another invasive test that may be performed earlier than amniocentesis – from 11 weeks. Samples are taken from the placental cells.

Third Trimester Care in General Practice

3rd Trimester antenatal care

Antenatal care in the 3rd trimester “kicks off” with a blood test at around 28 weeks.

The frequency of antenatal visits increases in The 3rd trimester to around 2 weekly.

The third trimester is a time for a wide range of emotions: and that is completely normal. Feelings of joy can mix with anxiety. This is also the time to start planning for your first breastfeed. During the third trimester, your baby is growing and your body begins to undergo changes in preparation for birth. Your antenatal visits will become more frequent.

Frequency of Visits. From weeks 28 to weeks 36, you will probably have a visit every 2 weeks at the antenatal clinic under shared care arrangements. Starting in week 36, you will visit 1-2 weekly until birth. You will finalise your birth plans with the hospital provider after 34 weeks. This includes discussing your pain management options.

Physical Exam. Your GP will continue to monitor your blood pressure and feel your belly and listen to the baby’s heartbeat. More focus will be on the baby’s size and position.   If all is progressing normally, there should not be any further blood or urine tests.

No matter what trimester you are in, your GP and the medical professionals at your Medical Centre are committed to providing you and your baby the best in antenatal care. Feel free to discuss questions or concerns you have during any visit. Also, remember that we always welcome your partner or family member to accompany you. This is an exciting time in your life and we are excited to be a part of it.

Whooping cough Vaccine in Pregnancy

Whooping Cough vaccine is included in the national childhood immunisation program. However, the baby is not covered against pertussis until after their third vaccination at 6 months. Babies under 6 months are susceptible to whooping cough which  is a serious illness in babies

National guidelines strongly advocate that women are vaccinated in the third trimester of every pregnancy. Why is this? Because the vaccination will lead to a surge of antibodies in pregnancy. These antibodies are passively transferred from the mother to the baby. The best time to be vaccinated is between 28 and 32 weeks. These are government funded vaccines.

It is also recommended that others who will be around the newborn have a booster vaccine if it has been at least 10 years since their last vaccine. This would be the father and often grandparents or other carers. The booster is best given at least 2 weeks before the expected birth date.

The flu vaccine is also government funded in pregnancy. There is an increased risk of maternal complications from influenza in pregnancy, and it has been shown that flu vaccination in the mother protects babies from influenza.

References
1: Medicine today, Dr Kidson-Gerber, 4/2016, vol 17, no.4

Kid’s Health Blog

WRITTEN BY: Dr Richard Beatty
REVIEWED/UDPATED:
CREATED: