What are the guidelines for antepartum care?

Guidelines for Antepartum Care

Comprehensive antepartum care should include routine prenatal visits, appropriate screening tests, risk assessment, and preventive interventions to reduce maternal and fetal morbidity and mortality. This approach ensures optimal pregnancy outcomes through evidence-based practices.

Essential Components of Antepartum Care

Routine Prenatal Care

• Routine antenatal and postnatal care is considered essential and should continue for all pregnant women, with modifications as needed based on individual risk factors 1
• Care initiated at 10 weeks or earlier improves pregnancy outcomes 2
• After 28 weeks of gestation, social distancing should be observed more stringently for pregnant women, especially during pandemic situations 1

Mental Health Assessment

• Health professionals should inquire about mental health during every consultation and connect women to relevant resources 1, 3
• Universal screening for depression, anxiety, intimate partner violence, substance use, and food insecurity is recommended early in pregnancy due to their impact on pregnancy outcomes 2

Risk Assessment and Prevention

• Identification and treatment of periodontal disease decreases preterm delivery risk 2
• Screening for gestational diabetes between 24 and 28 weeks is recommended for all pregnant women 2
• Low-dose aspirin (81 mg daily) is recommended for women at high risk of preeclampsia, starting between 12 and 28 weeks of gestation, optimally before 16 weeks 1, 2

Trimester-Specific Care

Second Trimester

• Detailed fetal anatomy ultrasound should be performed 1
• Fetal echocardiogram is recommended for women with pregestational diabetes 1
• Low-dose aspirin 81 mg daily should be started between 12 and 28 weeks of gestation (optimally before 16 weeks) for women at risk of preeclampsia 1

Third Trimester

• Antepartum fetal surveillance starting at 32 to 34 weeks of gestation (e.g., nonstress test, amniotic fluid assessment, biophysical profile) for high-risk pregnancies 1
• Testing for group B Streptococcus should be performed between 36 and 37 weeks 2
• Ultrasound for fetal growth assessment should be conducted, especially for women with risk factors 1

Special Considerations

Venous Thromboembolism (VTE) Prevention

• Risk assessment for VTE should be performed for all pregnant women 1
• For pregnant women with hereditary thrombophilia and family history of VTE, antepartum antithrombotic prophylaxis is suggested 1
• Postpartum antithrombotic prophylaxis is recommended for women with certain thrombophilias regardless of family history 1
• The risk of venous thromboembolism is increased in people with COVID-19, and pregnancy is a known hypercoagulable state, requiring careful assessment for prophylaxis 1, 3

Management of Pre-existing Conditions

Pregestational Diabetes

• Strict glycemic control, screening for comorbidities, diagnostic testing, preeclampsia prophylaxis, fetal surveillance, and individualized planning regarding timing and mode of delivery are essential 1
• Consider cesarean delivery if estimated fetal weight is ≥4500 g 1
• Delivery timing should be based on glycemic control, vascular complications, and prior pregnancy outcomes 1

Obesity

• Women with obesity (BMI ≥30 kg/m²) should receive counseling about pregnancy risks including gestational diabetes, hypertension, miscarriage, and stillbirth 1
• Nutritional advice, exercise recommendations, and pregnancy risk counseling are strongly supported by evidence 1
• Early establishment of venous access during labor is recommended for women with a BMI above 40 4

COVID-19 Management in Pregnancy

• Pregnant women with COVID-19 should receive essential antenatal and postnatal care with appropriate precautions 1
• Consider differential diagnoses such as pulmonary embolism and sepsis when evaluating pregnant women with COVID-19 symptoms 1
• For confirmed cases of COVID-19, refer women for fetal growth surveillance via ultrasound 14 days after symptom resolution 1
• Continuous electronic fetal monitoring is recommended during labor for all cases of suspected or confirmed COVID-19 1

Delivery Planning

• Delivery timing should be individualized based on maternal and fetal conditions 1
• For women with good glycemic control and no vascular complications, delivery at 39 0/7 to 39 6/7 weeks of gestation is recommended 1
• For women with poor glycemic control, vascular complications, or prior stillbirth, delivery at 36 0/7 weeks to 38 6/7 weeks may be appropriate 1
• For women with pregnancy complications such as fetal growth restriction or preeclampsia, delivery timing should be individualized depending on complication severity 1

Common Pitfalls and Caveats

• Failure to initiate care early (before 10 weeks) may lead to missed opportunities for early interventions and risk assessment 2
• Overlooking mental health screening can result in untreated perinatal depression and anxiety 1, 3
• Inadequate assessment of VTE risk may lead to preventable thromboembolic events 1
• Not considering the impact of pre-existing conditions like diabetes and obesity on pregnancy outcomes can lead to suboptimal care 1
• Delaying or omitting fetal growth surveillance in high-risk pregnancies may result in missed opportunities to detect growth abnormalities 1