Multiple symptoms occur in a healthy uncomplicated preg-nancy; most can be managed with conservative treatments and maternal reassurance. However, further investigation may be required to exclude unusual or insidious presentations of other pathologies.
Nausea and vomiting
It is estimated that nausea is experienced in 80–85% of all pregnancies and associated with vomiting in approximately 50%. The condition of hyperemesis gravidarum can be diag-nosed if these symptoms lead to fluid, electrolyte or nutri-tional imbalance requiring hospital treatment.
For the majority of women symptoms of nausea and vomiting in pregnancy resolve spontaneously within 16 to 20 weeks of gestation and are not usually associated with a poor pregnancy outcome. Systematic review of evidence and RCT data show that dietary ginger, wrist acupressure and prescribed antihistamines appear to be effective in reducing symptoms.1
58 Routine antenatal care: an overview
ANTENATAL OBSTETRICS
Heartburn
Symptoms of heartburn are caused by gastro- oesophageal acid reflux due to relaxation of the distal oesophageal sphincter and reduced gastric motility in pregnancy, and are not asso-ciated with any adverse outcomes in pregnancy, but generally worsen with gestation. Symptoms of heartburn should be dif-ferentiated from presenting epigastric pain in pre-eclampsia by checking maternal blood pressure and urinalysis.
Current guidance recommends that women should be offered information regarding lifestyle and diet modifica-tion (timing of meals, pormodifica-tion size and posture). If symptoms remain, RCT data show that antacids are safe and effective at relieving heartburn.1
Constipation
Symptoms of constipation are due to reduced gastric motility and transit in pregnancy, and appear to improve with gesta-tion. Systematic review of RCT data show that dietary changes with wheat or bran fibre supplements improve symptoms and, though laxative treatment is effective, it is associated with increased abdominal pain and diarrhoea.1
Haemorrhoids
Observational studies estimate the incidence of haemor-rhoids in the third trimester as 8%. There is currently no evi-dence for the safety or effectiveness of topical treatments in pregnancy. Women should be offered information concerning dietary changes (to increase fibre content) and advised that, if symptoms remain, standard haemorrhoid creams may be considered.1
Varicose veins
Varicose veins are caused by the pooling of blood in the surface veins, commonly in the legs, due to inefficient valves and rela-tive pelvic obstruction. RCT evidence shows that compression stockings do not prevent varicose veins occurring, but appear to improve leg symptoms for women in pregnancy.1
Backache
Back pain affects 30–60% of pregnant women and worsen with gestation. A number of RCTs have investigated interven-tions such as shaped pillows, exercises in water, massage, back care classes and acupuncture with small numbers, but have failed to identify clear effectiveness or safety. Current guid-ance recommends that exercising in water, massage therapy and group or individual back care classes might help to ease backache during pregnancy.1
Symphysis pubis dysfunction
Pelvis girdle pain is estimated to affect at least 20% of pregnant women.12 Systematic review of the limited evidence availa-ble shows that normal activity, exercises to improve posture
and acupuncture may improve symptoms. Pharmacological pain-relief options have not been investigated for effective-ness, but guidance highlights that medications prescribed must be appropriate for pregnancy.1,14
SUMMARY
Routine antenatal care describes the standard schedule of appointments, investigations and interventions offered to all pregnant women from healthcare services. Women who receive antenatal care have lower maternal and perinatal mor-tality and better pregnancy outcomes. Antenatal care aims to identify risk factors for the development of complications in pregnancy and birth, prevent or treat these complications if they occur, and offer screening for specific pathologies in both the woman and the baby. The package of care also aims to provide the woman and her family with information to enable an improved experience of pregnancy, birth and early parenthood.
Key References
1. National Collaborating Centre for Women’s and Children’s Health. Antenatal Care: Routine care for the healthy pregnant woman. NICE Clinical guideline Number 62. CG062. London: NICE, 2008 Mar.
2. Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gülmezoglu M, Mugford M, Lumbiganon P, Farnot U, Bersgjø P; WHO Antenatal Care Trial Research Group.
WHO systematic review of randomised controlled trials of routine antenatal care. Lancet 2001;357:1565–70.
3. Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gülmezoglu M. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database Syst Rev
KEY POINTS
The aims of antenatal care are to:
● Provide high-quality information that can be easily understood;
● Provide an informed choice about the pathways of antenatal care;
● Offered evidence-based treatment options for medical conditions pre-existing or arising in pregnancy;
● Identify and screen for maternal and fetal complications;
● Assess maternal and fetal wellbeing throughout pregnancy;
● Provide advice and education on the normal symptoms of pregnancy.
The recommended NICE clinical antenatal care pathway can be found within the guidance and website link: http://
pathways.nice.org.uk/pathways/antenatal-care#content=view- index&path=view%3A/pathways/antenatal-care/routine-care-for-all-pregnant-women.xml.
Summary 59
ANTENATAL OBSTETRICS
2001;4:CD000934. Review. Update in: Cochrane Database Syst Rev 2010;10:CD000934.
4. Dowswell T, Carroli G, Duley L et al. Alternative versus standard packages of antenatal care for low-risk preg-nancy. Cochrane Database Syst Rev 2010;10:CD000934.
5. Department of Health (1993). Changing Childbirth.
Report of the Expert Maternity Group. London: HMSO.
6. Department of Health. Maternity Matters: Choice, access and continuity of care in a safe service. London: Department of Health, 2007. Available from: http://www.dh.gov.
uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_073312.
7. Banta D (2003). What is the efficacy/effectiveness of antenatal care and the financial and organizational implications? Copenhagen: WHO Regional Office for Europe Health Evidence Network (HEN) report.
December 2013. Available from: http://www.euro.who.
int/Document/E82996.pdf.
8. British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review). HIV Medicine 2014;15:1–77. http://www.bhiva.
org/documents/Guidelines/Pregnancy/2012/BHIVA-Pregnancy-guidelines-update-2014.pdf.
9. NICE Antenatal Care: Evidence Update May 2013. A summary of selected new evidence relevant to NICE clinical guideline 62 ‘Antenatal Care’ (2008) Evidence Update 41.
10. RCOG. Alcohol consumption and the outcomes of pregnancy. Statement No. 5. London: RCOG: 2006.
11. Anderson A, Hure A, Forder P, Powers J, Kay-Lambkin F, Loxton D. Predictors of antenatal alcohol use among Australian women: a prospective cohort study. BJOG 2013;120:1366–74.
12. Royal College of Physicians. Physical and Shift Work in Pregnancy. Occupational aspects of management.
A national guideline. London: RCP, 2009.
13. RCOG. Air travel and pregnancy. Scientific Impact Paper No. 1. London: RCOG, May 2013. Available from: www.
rcog.org.uk/womens-health/clinical-guidance/
air-travel-and-pregnancy.
14. Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J 2008;17:794–819.
INTRODUCTION
Pre-existing or chronic hypertension is one of the most com-mon conditions in women of child-bearing age, and is becom-ing more prevalent1 due to trends of increasing maternal age2 and obesity.3 Chronic hypertension is estimated to affect 1–5% of pregnant women,4 and is frequently diagnosed for the first time during antenatal care. Underlying pathology for secondary hypertension is identified in a small proportion of women, and should be sought in all women who are newly diagnosed during pregnancy. Similarly hypertension recog-nised postnatally should be monitored, and if persistent inves-tigated appropriately.
Women with chronic hypertension have worse pregnancy outcomes than normotensive women, with both maternal and neonatal complications being reported. Pre-pregnancy counselling, increased antenatal surveillance and postpartum review are therefore recommended.