China’s Guide to Preconception and Pregnancy Health Care (1st Edition) II: Pregnancy Health Care
The main feature of health care during pregnancy is the requirement to systematically provide evidence-based prenatal screening programs at specific times. The schedule of prenatal visits is determined by the purpose of the prenatal visit.
I. The number of prenatal checkups and gestational week
A reasonable number of prenatal checkups and gestational weeks can not only ensure the quality of pregnancy care, but also save health care resources. For pregnant women without comorbidities in developing countries, WHO (2006) recommends that at least four antenatal checkups are needed, and the gestational weeks are <16 weeks, 24-28 weeks, 30-32 weeks and 36-38 weeks of pregnancy. According to the current status of pregnancy care and the need for prenatal checkup programs in China, the recommended gestational weeks for prenatal checkups in this guideline are: 6 to 13 weeks +6, 14 to 19 weeks +6, 20 to 23 weeks +6, 24 to 28 weeks, 30 to 32 weeks, 33 to 36 weeks, and 37 to 41 weeks of gestation. For those with high-risk factors, increase the number of times as appropriate.
B. Contents of prenatal checkups
(A) First prenatal checkup (6-13 weeks +6)
1.Health education and guidance.
(1) Awareness and prevention of miscarriage.
(2) Nutrition and lifestyle guidance (hygiene, sex life, exercise and sports, travel, work)
(3) Continue folic acid supplementation 0,4-0,8mg/d until the third trimester, and continue to take a multivitamin containing folic acid if available.
(4) Avoid contact with toxic and harmful substances (such as radiation, high temperature, lead, mercury, benzene, arsenic, pesticides, etc.) and avoid close contact with pets.
(5) Use drugs carefully and avoid using drugs that may affect the normal development of the fetus.
(6) If necessary, get tetanus or influenza vaccination during pregnancy.
(7) Change bad habits (such as smoking, alcoholism, drug abuse, etc.) and lifestyles; avoid high-intensity work, high-noise environments and domestic violence.
(8) Maintain mental health, relieve mental stress, and prevent the occurrence of psychological problems during pregnancy and after delivery.
2. Routine health care.
(1) Establish a pregnancy health care manual.
(2) Carefully inquire about menstruation, determine the week of pregnancy, and project the expected date of delivery.
(3) Assess risk factors during pregnancy. (3) Assess the maternal history, especially the history of bad pregnancy and delivery such as miscarriage, premature birth, stillbirth, stillbirth, history of reproductive tract surgery, any fetal malformation or mental retardation in young children, pre-pregnancy preparation, family history and genetic history of myself and my spouse. Pay attention to the presence of pregnancy complications, such as chronic hypertension, heart disease, diabetes, liver and kidney disease, systemic lupus erythematosus, blood disorders, neurological and psychiatric diseases, etc., and promptly request consultation from relevant disciplines; those who are not suitable to continue the pregnancy should be informed and promptly terminate the pregnancy; those who continue the pregnancy in high-risk pregnancy should be evaluated for referral. If there is any vaginal bleeding in this pregnancy, there are no factors that may cause teratology.
(4) Physical examination. Including measurement of blood pressure and body mass, calculation of BMI; routine gynecological examination (if not done in the first 3 months of pregnancy); fetal heart rate measurement (by Doppler auscultation, around 12 weeks of pregnancy).
3.Must check items.
(1) Routine blood count.
(2) urine routine.
(3) blood type (ABO and Rh).
(4) liver function
(5) kidney function.
(6) fasting blood sugar; (7) HBsAg
(7) HBsAg.
(8) Syphilis spirochetes.
(9) HIV screening.
(Note: Items that have been checked within 6 months before pregnancy can be checked without repeating).
4.Prepared items.
(1) Hepatitis C virus (HCV) screening.
(2) Anti-D titer test (Rh-negative)
(3) 75g OGTT (for high-risk pregnant women or those with symptoms).
(4) Thalassemia screening (Guangdong, Guangxi, Hainan, Hunan, Hubei, Sichuan, Chongqing, etc.)
(5) Thyroid function test.
(6) Serum ferritin (those with hemoglobin <105g/L) test.
(7) Tuberculin (PPD) test (for high-risk pregnant women).
(8) Cervical cytology test (for those who have not been examined within the first 12 months of pregnancy)
(9) Cervical discharge test for gonococcus and Chlamydia trachomatis (for high-risk pregnant women or those with symptoms)
(10) Testing for bacterial vaginosis (BV) (for those with a history of preterm delivery)
(11) Early maternal serologic screening for fetal chromosomal aneuploidy abnormalities [pregnancy-associated plasma protein A (PAPP-A) and free beta-hCG, 10-13 weeks gestation + 6. Precautions: fasting; ultrasonography to determine gestational week; determine body mass on day of blood draw. In high-risk individuals, consider chorionic villus biopsy or combine with midtrimester serologic screening results before deciding on amniocentesis.
(12) Ultrasonography. Ultrasonography is performed in early pregnancy: to determine intrauterine pregnancy and gestational week, fetal viability, number of fetuses or nature of twin chorionic villi, and uterine adnexal condition. The nuchaltranslucency (NT) is measured at 11 to 13 weeks +6 weeks of gestation; the gestational week is approved; NT is measured according to the British Fetal Medicine Foundation standards].
(13) Chorionic villus biopsy (10 to 12 weeks of gestation, mainly for high-risk pregnancies).
(14) Electrocardiogram.
(II) Antenatal checkups at 14 to 19 weeks of gestation +6
1.Health education and guidance.
(1) Awareness and prevention of miscarriage.
(2) Knowledge of pregnancy physiology.
(3) Guidance on nutrition and lifestyle.
(4) The significance of screening for fetal chromosomal aneuploidy abnormalities in midtrimester.
(5) Hemoglobin <105g/L, serum ferritin <12μg/L, supplementation with elemental iron 60-100mg/d.
(6) Start calcium supplementation at 600mg/d.
2. Routine health care.
(1) Analyze the results of the first prenatal examination.
(2) Ask about vaginal bleeding, diet and exercise.
(3) Physical examination, including blood pressure and body mass, to assess whether the maternal body mass growth is reasonable; fundal height and abdominal circumference, to assess whether the fetal body mass growth is reasonable; fetal heart rate measurement.
3.Required items: None.
4.Prepared items.
(1) Midtrimester maternal serological screening for fetal chromosomal aneuploidy abnormalities (15-20 weeks of gestation, the best week of gestation for testing is 16-18 weeks). The best gestational week is 16-18 weeks.
(2) Amniocentesis for fetal karyotype (16-21 weeks of gestation; for pregnant women aged ≥35 years at the due date or for those at high risk).
(3) 20 to 23 weeks of gestation +6 prenatal checkups
1.Health education and guidance.
(1) Awareness and prevention of preterm labor.
(2) Nutrition and lifestyle guidance.
(3) The significance of fetal system ultrasound screening.
2.Routine health care.
(1) Ask about fetal movement, vaginal bleeding, diet and exercise.
(2) Physical examination is the same as 14 to 19 weeks of gestation +6 prenatal examination.
3.Must check items.
(1) Fetal system ultrasound screening (18 to 24 weeks of gestation) to screen for serious fetal malformations.
(2) Routine blood and urine tests.
4.Preparatory tests: cervical assessment (ultrasound measurement of cervical length).
(4) Antenatal checkups at 24-28 weeks of gestation
1.Health education and guidance.
(1) Awareness and prevention of preterm labor.
(2) The significance of gestational diabetes mellitus (GDM) screening.
2.Routine health care.
(1) Ask about fetal movement, vaginal bleeding, contractions, diet and exercise.
(2) Physical examination is the same as the prenatal examination from 14 to 19 weeks of gestation +6.
3.Compulsory checkups.
(1) GDM screening. First perform 50g glucose screening (GCT), if the blood glucose is 7,2~11,1mmol/L, then perform 75g OGTT; if it is >11,1mmol/L, then measure fasting blood glucose. The international recently recommended method is that it is not necessary to perform 50g GCT first, and those who have the condition can directly perform 75g OGTT, whose normal upper limit is 5,1mmol/L for fasting blood glucose, 10,0mmol/L for 1h postprandial blood glucose, and 8,5mmol/L for 2h postprandial blood glucose; or by testing fasting blood glucose as the screening standard.
(2) Urine routine.
4. Preparation items.
(1) Anti-D titer test (for Rh negative).
(2) Cervicovaginal discharge for fetal fibronectin (fFN) level (for those at high risk of preterm delivery).
(E) Prenatal checkups at 30 to 32 weeks of gestation
1.Health education and guidance.
(1) Guidance on mode of delivery.
(2) Start to pay attention to fetal movement.
(3) Breastfeeding guidance.
(4) Instruction on newborn care.
2.Routine health care.
(1) Ask about fetal movement, vaginal bleeding, contractions, diet and exercise.
(2) Physical examination is the same as the prenatal examination from 14 to 19 weeks of gestation +6; fetal position examination.
3.Must check items.
(1) Blood routine, urine routine.
(2) Ultrasound examination: fetal growth and development, amniotic fluid volume, fetal position, placenta position.
(4) Preparation items: ultrasound measurement of cervical length or cervicovaginal secretion to detect fFN level for those at high risk of preterm delivery.
(VI) Prenatal checkups at 33 to 36 weeks of gestation
1.Health education and guidance.
(1) Guidance on lifestyle before delivery.
(2) Knowledge about childbirth (symptoms of labor, guidance on delivery methods, labor analgesia).
(3) Newborn disease screening.
(4) Prevention of depression.
2.Routine health care.
(1) Ask about fetal movement, vaginal bleeding, contractions, skin pruritus, diet, exercise, and preparation for delivery.
(2) Physical examination is the same as the prenatal examination at 30 to 32 weeks of pregnancy.
(3) Compulsory check-up items: urinary routine.
4.Preparatory items.
(1) Screening for Group B Streptococcus (GBS) at 35 to 37 weeks of gestation: Pregnant women with high-risk factors (such as combined diabetes, GBS infection in newborns born in previous pregnancies, etc.), culture of perianal and lower 1/3 of vaginal secretions.
(2) Liver function and serum bile acid test from 32 to 34 weeks of gestation [Pregnant women in areas with high incidence of intrahepatic cholestasis during pregnancy (ICP).
(3) Electronic fetal heart monitoring [no-load test, (NST)] examination starting at 34 weeks of gestation (high-risk pregnant women).
(4) Electrocardiogram review (high-risk pregnant women)
(7) Antenatal checkups from 37 to 41 weeks of gestation
1.Health education and guidance.
(1) Knowledge related to childbirth (symptoms of labor, guidance on delivery methods, labor analgesia).
(2) Guidance on immunization of newborns.
(3) Instruction on puerperium.
(4) Intrauterine monitoring of the fetus.
(5) Hospitalization and induction of labor when the pregnancy is ≥ 41 weeks.
2.Routine health care.
(1) Ask about fetal movement, contractions, redness, etc.
(2) Physical examination is the same as prenatal examination at 30 to 32 weeks of gestation; cervical examination and Bishop score are performed.
3.Must check items.
(1) Ultrasonography: assess fetal size, amniotic fluid volume, placental maturity, fetal position and the ratio of peak systolic to end-diastolic flow velocity of umbilical artery (S/D ratio), etc.
(2) NST examination (1 time per week).
4.Ready items: None.
(3) Contents of routine examination during pregnancy are not recommended
1.Extra-pelvic measurements: There is sufficient evidence that extra-pelvic measurements do not predict cephalopelvic disproportion at delivery. Therefore, it is not necessary to routinely check external pelvic measurements during pregnancy. For pregnant women with vaginal delivery, the pelvic outlet diameter can be measured in late pregnancy.
2. Serological screening for Toxoplasma gondii, cytomegalovirus and herpes simplex virus: At present, there are no mature screening methods for these three pathogens, and serological specific antibody tests for pregnant women cannot confirm when a pregnant woman is infected, whether the fetus is involved and whether there are any long-term sequelae, nor can the serological screening results of pregnant women be used to decide whether a pregnancy should be terminated. It is recommended that preconception screening or targeted screening during pregnancy should not be conducted for all pregnant women to avoid psychological fear and unnecessary interventions.
3.BV screening: the incidence of BV during pregnancy is 10% to 20%, which is related to the occurrence of preterm delivery. Pregnant women at high risk of preterm delivery can be screened for BV, but routine BV screening should not be performed for all pregnant women.
4. cervicovaginal discharge test fFN and ultrasonographic assessment of the cervix: in pregnant women at high risk of preterm labor, the value of these two screening tests is that negative results suggest no possibility of preterm labor in the near future, thus reducing unnecessary interventions. However, there is insufficient evidence to support cervicovaginal secretion fFN testing and ultrasound cervical assessment in all pregnant women.
5.Checking urine protein and blood routine at each antenatal visit: urine protein and blood routine tests are not required at each antenatal visit, but repeated urine protein and blood routine tests may be performed in pregnant women with gestational hypertensive disease and gestational anemia.
6. Thyroid function screening: Hypothyroidism in pregnant women affects the development of neurointelligence in children, and some experts recommend screening thyroid function [free triiodothyronine (FT3), free thyroxine (FT4) and thyrotropin (TSH)] in all pregnant women, but there is not enough evidence to support screening of thyroid function in all pregnant women. .
7. Tuberculosis screening: At present, there is insufficient evidence to support screening for tuberculosis (including PPD tests and chest X-rays) in all pregnant women. High-risk pregnant women (those in areas with high TB prevalence, poor housing conditions, HIV infection, and drug addiction) can be screened for TB at any time of pregnancy.
Article source: China Obstetrics and Gynecology Online