Recommended Approach to Antenatal Care
The World Health Organization recommends a minimum of 8 antenatal care contacts throughout pregnancy, with midwife-led continuity of care throughout the antenatal, intrapartum, and postnatal periods to improve maternal and neonatal outcomes. 1
First Trimester Care (0-12 weeks)
- Initiate antenatal care as early as possible, ideally within the first 12 weeks of gestation, as early initiation is associated with improved maternal and neonatal outcomes 2
- Conduct comprehensive preconception counseling for women planning pregnancy, including:
- Optimization of glycemic control for women with diabetes (target A1C <6.5%) 1
- Folic acid supplementation (400-800 mg daily) 1
- Potassium iodide supplementation (150 mg daily) 1
- Screening for diabetes, thyroid disease, and sexually transmitted infections 1
- Review of all medications for potential teratogenicity (particularly ACE inhibitors, ARBs, and statins) 1
- Start low-dose aspirin (81-150 mg daily) before 16 weeks of gestation for women with risk factors for preeclampsia:
- Major risk factors: prior preeclampsia, chronic hypertension, pregestational diabetes, BMI >30, chronic kidney disease, antiphospholipid syndrome 1
- Minor risk factors (≥2): advanced maternal age, family history of preeclampsia, short duration of sexual relationship, primiparity, primipaternity, connective tissue disorders 1
- Provide calcium supplements (1200 mg daily) if dietary calcium intake is low 1
Second Trimester Care (13-26 weeks)
- Perform detailed fetal anatomy ultrasound 1
- For women with pregestational diabetes, schedule fetal echocardiogram 1
- Continue low-dose aspirin for preeclampsia prevention 1
- Screen all women for gestational diabetes in mid-pregnancy 2
- Screen women with risk factors for gestational diabetes in the first trimester 2
- Conduct dilated eye examination for women with preexisting diabetes 1
Third Trimester Care (27-40 weeks)
- Begin antepartum fetal surveillance at 32-34 weeks for high-risk pregnancies, including those with pregestational diabetes 1
- Monitor for signs of preeclampsia, particularly in women with risk factors 1
- For women with placenta accreta spectrum, plan delivery at 34 0/7-35 6/7 weeks in a center with appropriate expertise 1
- Consider antenatal corticosteroids for pregnant patients with singleton pregnancies between 34 0/7 and 36 6/7 weeks who are at high risk of preterm birth within 7 days 3
- Avoid antenatal corticosteroids in pregnant patients with pregestational diabetes due to risk of worsening neonatal hypoglycemia 3
- For women without maternal or fetal indications, do not offer elective delivery before 39 weeks, but offer induction at 41 weeks with recommendation for delivery before 42 weeks 2
Special Considerations for Diabetes in Pregnancy
- Women with preexisting diabetes should ideally receive preconception care in a multidisciplinary clinic including an endocrinologist, maternal-fetal medicine specialist, registered dietitian, and diabetes educator 1
- Monitor for development or progression of diabetic retinopathy with dilated eye examinations before pregnancy or in first trimester, then every trimester and for 1 year postpartum 1
- Screen for comorbidities including foot examination, thyroid function, urinary protein evaluation, and electrocardiogram 1
- Optimize glycemic control before and during pregnancy to reduce risk of congenital anomalies, preeclampsia, macrosomia, and preterm birth 1
Factors Associated with Late Initiation of Antenatal Care
- Age ≥25 years is associated with 1.62 times higher odds of late antenatal care initiation 4
- Recognition of pregnancy by missed period rather than early testing increases risk of late initiation 4
- Lack of advice to start antenatal care early increases risk by 3.36 times 4
- Lower educational level (primary education) is associated with 2.22 times higher odds of late initiation 4
- Unplanned pregnancy is significantly associated with late antenatal care initiation 5
- Incorrect perception about timing of first antenatal visit contributes to late initiation 5
Common Pitfalls to Avoid
- Delaying first antenatal visit beyond the first trimester, which occurs in approximately 47-59% of pregnancies in some regions 4, 5
- Failing to identify and counsel women at high risk for preeclampsia who would benefit from early aspirin prophylaxis 1
- Inadequate preparation for delivery in women with placenta accreta spectrum, which requires multidisciplinary planning and delivery at an experienced center 1
- Overlooking the importance of preconception care, particularly for women with preexisting conditions like diabetes 1
- Insufficient attention to mental health issues during pregnancy, which require timely specialist referral 6