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Specific Health Protection during Antenatal Visits

Specific Health Protection during Antenatal Visits
1. Anemia
2. Other nutritional deficiencies
3. Toxemias of pregnancy (TOP)
4. Tetanus
5. Syphilis
6. German measles
7. Rh status
8. HIV infection
9. Hepatitis B infection
10. Prenatal genetic screening

• Surveys across India show the prevalence of anemia to be 50 – 60% among low SES women especially in the third trimester
• The major etiological factors are iron and folic acid deficiencies
• Anemia is associated with
– Premature birth
– Postpartum hemorrhage
– Puerperal sepsis and
– Thromboembolic phenomena in the mother
Iron and folic acid supplementation
• one tablet of IFA (100 mg elemental iron and 0.5 mg folic acid) every day for at least 100 days.
– This is the prophylactic dose of IFA.
• If a woman is anemic (Hb <11 g/dl or she has pallor), give her two tablets of IFA per day for three months.
– This means a woman with anemia in pregnancy needs to take at least 200 tablets of IFA.
– This is the therapeutic dose of IFA.
• Start IFA at the prophylactic dose as early as possible, preferably as soon as the pregnancy is registered
– However, ensure that the woman is able to tolerate the intake of IFA, as iron has a tendency of aggravating the nausea and vomiting, which are a part of morning sickness during the first trimester
Other nutritional deficiencies
– Take measures to protect against nutritional deficiencies like:
• Protein, vitamins, and minerals
• E.g. vitamin A and Iodine deficiency
• In some MCH centers, fresh milk, skimmed milk, capsules of vitamin A and D are also supplied free of cost

Toxemias of pregnancy (TOP)
– Presence of albumin in urine and increased BP indicate TOP
– Early detection and management is indicated
• If the BP is high (more than 140/90 mmHg; or diastolic more than 90 mmHg), check the BP again after 1 hour.
• If it is still high, test the woman's urine for the presence of albumin,
– as the combination of a high BP and proteinuria is sufficient to categorize the woman as having pre-eclampsia.
• If the diastolic BP of the woman is above 110 mmHg, it is a danger sign pointing towards severe eclampsia.
• Refer the woman to the CHC/FRU IMMEDIATELY after giving her a dose of Nifedipine.
• A woman with pregnancy-induced hypertension (PIH)/pre-eclampsia requires hospitalization for daily/ alternate day monitoring of BP, the level of protein in the urine and foetal condition

Administration of two doses of Inj. TT to a pregnant woman is an important step in the prevention of neonatal tetanus
• If the woman is not immunized earlier
– Give Two doses of TT
– The first dose of TT should be given just after the first trimester, or as soon as the woman registers for ANC, whichever is later.
– Second dose one month after the first dose, but preferably at least one month before the EDD
– Minimum interval between the two doses – 1 month
– If the women has reported late in the pregnancy, no pregnant woman should be denied even a single dose of TT
• If the woman has received Inj. TT during a previous pregnancy:
– One booster dose would suffice
– This booster dose would cover even the subsequent pregnancies during the next 5 years
– It is advised not to inject TT at every successive pregnancy because of the risk of hyper immunization and side effects
– However, in case of doubt, give two injections

• It is preventable cause of pregnancy wastage in some countries
• Pregnancies during primary and secondary syphilis often end in
– spontaneous abortion,
– still birth,
– perinatal death or
– congenital syphilis in the newborn
• Syphilitic infection in the pregnancy is transmissible to the fetus
– Neurological damage with mental retardation is a serious consequence of congenital syphilis
• The transmission does not occur before 4th month but after the 6th month by which time the Langhan’s cell layer has completely atrophied
• Infection of the fetus is most likely to occur if the mother has primary or secondary syphilis, rather than in late syphilis
• Routinely during antenatal care, woman’s blood is tested for syphilis at the first visit
• Ideal would be to test again in late pregnancy as the mother can get infected during pregnancy also
• For preventing congenital syphilis:
– Ten daily injections of procaine penicillin (6,00,000 units) are adequate

German measles
• A long term prospective study in Great Britain found that if rubella was contracted in the first 16 weeks of pregnancy, fetal death or infant death occurred in 17% of off-springs
• Among survivors who were followed up to 8 yr. 15% had major defects, mostly
– Cataract
– Deafness
– Congenital heart diseases
– Another 16% had minor defects
• Ideal would be to prevent infection during pregnancy by way of preventing and controlling rubella in the general population
• In many countries, vaccination of all school aged children with rubella vaccine is done followed by;
– Vaccination of all women in childbearing age who are seronegative
• Before vaccinating, it is advisable that
– Pregnancy be ruled out and
– Contraception used for 8 weeks after vaccination
– As the vaccine contains live, attenuated virus

Rh Status
The fetal RBC’s may enter the maternal circulation during:
• Labor
• Caesarean section
• Therapeutic abortion
• External cephalic version and
• Spontaneously, in late pregnancy
If the mother is Rh –ve and the child is Rh +ve, this provokes formation of Rh antibodies (iso-immunization)
• These Rh antibodies can cross placenta and produce fetal hemolysis
• As the exposure to fetal RBC occurs late in pregnancy, mostly during labor, the first child is not affected even if he/she is Rh positive
• The subsequent pregnancies, if with Rh positive child, the mother can react to the smallest intrusion of fetal RBCs by producing antibodies which can cause hemolysis in the fetus.
The clinical presentation may be:
– Hydrops fetalis, Icterus gravis neonatorum, Kernicterus’, Congenital hemolytic anemia
Hence, the blood group and Rh typing is a routine procedure during early pregnancy
If the woman is Rh negative and the husband is Rh positive, she is kept under surveillance for Rh antibody levels during antenatal care
• The blood is examined at:
– 28 weeks and
– 34 – 36 weeks for presence of Rh antibodies
– Rh anti D immunoglobulin should be given
– At 28 weeks of gestation and if the baby is Rh positive, and
– Again within 72 hours of delivery/abortion.
• Post maturity should be avoided
• If evidence of hemolysis in utero, mother should be shifted to an equipped center specialized to deal with the Rh problems

HIV infection
• HIV infection may pass from an infected mother to her fetus:
– Through placenta or
– During delivery or
– By breast feeding
• About 1/3 children of HIV positive mothers get infected through this route
• The risk is higher if the mother
– is newly infected or
– has already developed AIDS
• Voluntary prenatal HIV testing should be done as early in pregnancy as possible in the high risk, which includes
– if she or her partner has a number of sexual partners
– she has a sexually transmitted disease
– she/partner is a IV drug user
• in high prevalence areas, even Universal confidential voluntary screening of pregnant women may allow infected women to choose
– therapeutic abortion
– make informed decision on breast feeding
– receive appropriate care

Hepatitis B infection
• It is believed that a high prevalence of HBV infection in some regions may be due to spread of infection from HBV carrier mothers to their babies
• Most infections appear to occur at birth
• Transmission to the baby can occur after delivery if both surface antigen and e antigen are positive
• Vertical transmission can be blocked by immediate post-delivery administration of HB immunoglobulin and hepatitis B vaccine to the baby

Prenatal genetic screening
• It includes screening for:
– Chromosomal abnormalities associated with serious defects
– Direct evidence of congenital structural anomalies and
– For hemoglobinopathies and
– Other inherited conditions detectable by biochemical assay
• Universal genetic screening is generally not recommended
• The screening is offered in order to make the option of therapeutic abortion when severe defects are detected
• Examples of screening is for
– Trisomy 21 (Down’s syndrome)
– Sever Neural tube defects
• Women who are high risk and should be screened include:
– aged ≥35 years
– those who already have and afflicted child

1. Preventive Medicine in Obstetrics, Pediatrics and Geriatrics, Park’s Textbook of Preventive and Social Medicine: 23rd edition, 2015
2. Maternal Health Division, Department of Family Welfare, Ministry of Health & Family Welfare, Government of India: August, 2005. Guidelines for Pregnancy Care and Management of Common Obstetric Complications by Medical Officers. Available on, downloaded on 20th Dec 2016
3. Maternal Health Division, Department of Family Welfare, Ministry of Health & Family Welfare, Government of India: April 2010, Guidelines for Antenatal Care and Skilled Attendance at Birth by ANMs/LHVs/SN available

Antenatal Care:
Components of Antenatal Care:
Prenatal Advice:
Risk Approach in Antenatal Care:
Ensuring Complete Registration of Antenatal Women in the Jurisdiction:
Specific Health Protection during Antenatal Visits;
Lecture on Antenatal Care: