Pregnancy antenatal care disorders in pregnancy

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antenatal care schedule visits guidelines pregnancy disorders 2024

I now have comprehensive content from Creasy & Resnik's Maternal-Fetal Medicine (the leading textbook) plus current ACOG guidance. Let me compile the full answer.

Pregnancy: Antenatal Care & Disorders in Pregnancy

A comprehensive guide based on Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice and current clinical guidelines.

1. ANTENATAL CARE (ANC)

Purpose and Goals

Antenatal care aims to:

Identify and manage pre-existing maternal disease
Screen for pregnancy-specific complications
Provide health education and counseling
Optimize timing and mode of delivery
Deliver evidence-based preventive services (screening labs, imaging, vaccinations, counseling)

The WHO defines ANC around a "positive pregnancy experience" - patient-centered care that addresses physical, emotional, and social health.

Schedule of Visits

Traditional schedule (low-risk singleton pregnancy):

Gestational Age	Visit Content
8-12 weeks (1st visit)	Dating ultrasound; blood group & Rh; CBC; urine culture; rubella/varicella immunity; HIV, syphilis, hepatitis B, gonorrhea/chlamydia screening; nuchal translucency; thyroid function if indicated
11-14 weeks	First-trimester combined screening (PAPP-A + free β-hCG + NT ultrasound) for aneuploidies
15-20 weeks	Maternal serum alpha-fetoprotein (AFP) or quad screen; offer cell-free fetal DNA
18-22 weeks	Detailed anatomy ultrasound survey; fetal echocardiography if indicated
24-28 weeks	Glucose challenge test / OGTT for gestational diabetes; CBC; repeat antibody screen if Rh-negative; Rh immunoglobulin (anti-D) at 28 weeks
28-32 weeks	Fetal growth assessment; review symptoms (preeclampsia, preterm labor)
35-37 weeks	Group B Streptococcus (GBS) rectovaginal swab; review birth plan
38-41 weeks	Cervical assessment; discuss post-dates management

The ACOG 2025 Tailored Prenatal Care consensus recommends individualizing the number of visits - reducing routine visits for healthy low-risk pregnancies (currently 12-14 in-person visits) and increasing visits for higher-risk pregnancies. Telehealth visits may substitute for some in-person visits.

Content of Each Visit

Every visit should include:

Blood pressure measurement
Weight and BMI
Urine dipstick (protein, glucose, leukocytes)
Fundal height measurement (after 20 weeks)
Fetal heart rate auscultation
Assessment for symptoms (headache, visual changes, epigastric pain, vaginal bleeding/discharge, reduced fetal movements)
Emotional and mental health screening

Vaccinations in Pregnancy

Influenza (inactivated): any trimester
Tdap (tetanus/diphtheria/pertussis): 27-36 weeks in every pregnancy
COVID-19 (mRNA): recommended in pregnancy
Hepatitis B: if not previously immune
RSV vaccine: 32-36 weeks (Abrysvo)

2. DISORDERS IN PREGNANCY

A. Hypertensive Disorders of Pregnancy

These affect approximately 85 per 1000 deliveries in the US and are a leading cause of maternal and perinatal mortality.

Classification:

Disorder	Definition
Chronic hypertension	BP ≥140/90 before 20 weeks or pre-existing
Gestational hypertension (gHTN)	New-onset BP ≥140/90 after 20 weeks; no proteinuria/organ involvement
Preeclampsia	gHTN + proteinuria (≥300 mg/24h) OR severe features
Eclampsia	Preeclampsia + grand mal seizures
Superimposed preeclampsia	Preeclampsia developing on chronic hypertension

Preeclampsia

Risk factors (from Creasy & Resnik's, p. 1057):

Nulliparity (population attributable fraction 32.3%)
Prior preeclampsia
Chronic hypertension (25% risk of superimposed preeclampsia)
Chronic renal disease
Pregestational diabetes mellitus (overall 20% risk; up to 70% in White class F/R)
Antiphospholipid syndrome
IVF conception
Family history
Extremes of maternal age
Black/African-American race (related more to severity than incidence)

Diagnosis (ACOG criteria):

BP ≥140/90 mmHg on two occasions ≥4 hours apart after 20 weeks
PLUS: proteinuria ≥300 mg/24h OR protein:creatinine ratio ≥0.3 OR dipstick ≥2+

Severe features (any one qualifies):

Systolic BP ≥160 or diastolic BP ≥110 mmHg
Thrombocytopenia (<100,000/μL)
Renal insufficiency (creatinine >1.1 mg/dL or doubling)
Impaired liver function (elevated transaminases 2x normal)
Pulmonary edema
New-onset headache unresponsive to medication
Visual disturbances

HELLP Syndrome = Hemolysis, Elevated Liver enzymes, Low Platelets - a severe variant.

Management of preeclampsia with severe features:

Delivery is the definitive treatment
At ≥34 weeks: delivery recommended
At <34 weeks: expectant management in a tertiary hospital with intensive monitoring:
- Vital signs, urine output, and symptoms every 8 hours
- Serial labs at least daily initially; then 1-2x weekly when stable
- Daily fetal well-being assessment (CTG/BPP)
- Fetal growth scan at least every 3 weeks
- Intrapartum: IV magnesium sulfate for seizure prophylaxis (superior to phenytoin and diazepam; shown efficacious in the Magpie trial of 10,000 women)
- Antihypertensives targeting BP <160/105 mmHg

Symptoms preceding eclampsia:

Headache: 83%
Hyperreflexia: 80%
Proteinuria: 80%
Edema: 60%
Clonus: 46%
Visual signs: 45%
Epigastric pain: 20%

(Creasy & Resnik's, p. 1070)

B. Gestational Diabetes Mellitus (GDM)

Pathophysiology: Normal pregnancy induces insulin resistance (due to placental hormones - human placental lactogen, progesterone, cortisol). GDM occurs when pancreatic β-cells cannot compensate.

Screening:

Universal screening at 24-28 weeks with 50g glucose challenge test (GCT); threshold ≥130-140 mg/dL at 1 hour
If GCT positive: 100g 3-hour OGTT (Carpenter-Coustan criteria) or 75g 2-hour OGTT (IADPSG criteria)

Complications:

Maternal: preeclampsia, cesarean delivery, type 2 DM later
Fetal/neonatal: macrosomia, shoulder dystocia, neonatal hypoglycemia, polycythemia, jaundice, stillbirth
Long-term: child obesity and metabolic syndrome

Management:

Medical nutrition therapy (MNT) - first-line
Blood glucose monitoring (fasting + 1h or 2h postprandial)
Insulin (preferred pharmacologic agent in pregnancy; glyburide and metformin used but cross placenta)
Fetal surveillance (growth scans, BPP/NST from 32-36 weeks in insulin-requiring GDM)
Postpartum: 75g OGTT at 4-12 weeks postpartum

C. Preterm Labor and Birth

Definition: Labor occurring before 37 completed weeks of gestation. Preterm birth is the leading cause of neonatal mortality and morbidity worldwide.

Subtypes:

Spontaneous preterm labor (with intact membranes)
Preterm premature rupture of membranes (PPROM)
Indicated/iatrogenic preterm birth (due to maternal or fetal complications)

Risk factors: Prior preterm birth, cervical insufficiency/short cervix (sonographic CL <25 mm), multiple gestation, uterine anomalies, infections (bacterial vaginosis, UTI), smoking, low BMI

Prevention:

Vaginal progesterone: for singleton pregnancy with short cervix (<25 mm) on ultrasound at 16-24 weeks
17-hydroxyprogesterone caproate (17-OHPC): for women with prior spontaneous preterm birth (history-indicated; though recent trial data have questioned efficacy)
Cervical cerclage: for cervical insufficiency (history-indicated or ultrasound-indicated)
Correction of modifiable risk factors
Early access to prenatal care is associated with lower rates

Treatment when in preterm labor:

Antenatal corticosteroids (betamethasone 12 mg IM x 2 doses, 24h apart): at 23-34 weeks; accelerates fetal lung maturity; reduces RDS, IVH, NEC
Tocolytics (nifedipine, indomethacin, atosiban): delay delivery 48h to allow steroids and maternal transfer
Magnesium sulfate for neuroprotection at <32 weeks: reduces cerebral palsy risk
GBS prophylaxis (penicillin G) if GBS status unknown or positive

D. Antepartum Hemorrhage

Causes:

Cause	Features
Placenta previa	Painless bright-red bleeding; placenta overlies or near internal os; diagnosed on ultrasound
Placental abruption	Painful bleeding; premature separation of normally implanted placenta; associated with hypertension, trauma, cocaine use
Vasa previa	Fetal vessels traverse membranes over cervical os; rupture causes fetal exsanguination; diagnosed with color Doppler
Uterine rupture	Rare; scar dehiscence; severe abdominal pain, fetal bradycardia, hemodynamic instability

E. Fetal Growth Restriction (FGR)

Definition: Estimated fetal weight (EFW) or abdominal circumference <10th percentile for gestational age.

Causes:

Placental: inadequate uteroplacental perfusion (most common), preeclampsia, abruption
Fetal: chromosomal anomalies, congenital infections (TORCH), structural anomalies
Maternal: malnutrition, smoking, anemia, renal disease, thrombophilias

Surveillance: Serial ultrasound biometry + umbilical artery Doppler; absent/reversed end-diastolic flow is ominous and warrants delivery planning.

F. Thyroid Disease in Pregnancy

Hypothyroidism: Treat with levothyroxine; TSH targets 0.1-2.5 mIU/L in 1st trimester; untreated causes adverse neurodevelopment
Hyperthyroidism (Graves'): Propylthiouracil (PTU) preferred in 1st trimester; methimazole acceptable in 2nd/3rd trimester
Universal TSH screening in pregnancy remains debated; ACOG recommends targeted screening of high-risk women

G. Infections in Pregnancy

Infection	Consequence	Prevention/Treatment
Group B Streptococcus	Neonatal sepsis/meningitis	Screen at 35-37 weeks; intrapartum penicillin G prophylaxis
Toxoplasma	Congenital toxoplasmosis	Avoid raw meat/cat feces; treat with spiramycin
Rubella	Congenital rubella syndrome (CRS)	Screen immunity; vaccinate post-delivery
CMV	Leading cause of congenital deafness	No vaccine; hygiene counseling
Parvovirus B19	Fetal hydrops, aplastic crisis	Supportive; intrauterine transfusion if hydrops
Listeria	Miscarriage, stillbirth, neonatal sepsis	Avoid unpasteurized dairy; amoxicillin treatment
Syphilis	Congenital syphilis	Universal 1st trimester screening; benzathine penicillin
HIV	Mother-to-child transmission	ART; C-section if viral load >1000; avoid breastfeeding

H. Other Important Conditions

Intrahepatic cholestasis of pregnancy (ICP): Pruritus (especially palms/soles); elevated bile acids; associated with stillbirth; treat with ursodeoxycholic acid; deliver at 37 weeks
Hyperemesis gravidarum: Severe nausea/vomiting causing dehydration and weight loss >5%; treat with IV fluids, thiamine, ondansetron/metoclopramide, corticosteroids if refractory
Deep vein thrombosis (DVT)/VTE: Pregnancy is a hypercoagulable state; treat with LMWH (heparin does not cross placenta)
Iron deficiency anemia: Most common anemia in pregnancy; treat with oral iron (ferrous sulfate 325 mg TID)

3. FETAL MONITORING IN ANTENATAL CARE

Test	Indication	Interpretation
Non-stress test (NST)	Standard fetal surveillance	Reactive = 2 accelerations ≥15 bpm x 15 seconds in 20 minutes
Biophysical profile (BPP)	Additional surveillance	Score /10; ≥8 reassuring; ≤4 indicates delivery
Umbilical artery Doppler	FGR with suspected placental insufficiency	Absent or reversed end-diastolic flow = high-risk
Contraction stress test (CST)	Equivocal NST	Negative CST (no late decels) = reassuring
Cervical length (transvaginal US)	Preterm birth risk	CL <25 mm at 16-24 weeks = high risk

Sources:

Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice, Creasy & Resnik's (9780323828499)
ACOG 2025 Tailored Prenatal Care Consensus
NICE Antenatal Care Guideline NG201

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