Antenatal Care

Booking Visit (Ideally before 10 weeks)

• Full history: medical, obstetric, family, social, mental health
• Risk assessment: identify women who need additional care pathways
• BMI calculation and weight management advice
• Blood pressure and urinalysis
• Booking blood tests:
  • Blood group and RhD status, antibody screen
  • FBC (haemoglobin, MCV)
  • Haemoglobin electrophoresis (sickle cell and thalassaemia screening)
  • Infection screening: HIV, hepatitis B, syphilis, rubella immunity
• Urine culture (asymptomatic bacteriuria screen — treat if positive to prevent pyelonephritis)
• Offer information about screening tests, lifestyle advice (diet, folic acid, vitamin D, exercise, smoking cessation, alcohol avoidance)

Screening Tests Timeline

| Gestation | Test/Intervention | |-----------|-------------------| | <10 weeks | Booking appointment, booking bloods | | 10-14 weeks | Dating scan (crown-rump length for accurate EDD) | | 11-13+6 weeks | Combined screening for Down's, Edwards', Patau's (NT + hCG + PAPP-A) | | 15-20 weeks | Quadruple test if combined screening missed | | 18-20+6 weeks | Anomaly scan (fetal anatomy survey) | | 24-28 weeks | OGTT if risk factors for GDM; anti-D for RhD-negative women | | 28 weeks | Repeat FBC, antibody screen; RAADP (anti-D if RhD-negative) | | 36 weeks | Check presentation; offer ECV if breech | | 38-41 weeks | Discuss options for prolonged pregnancy; membrane sweep from 39-40 weeks | | 41-42 weeks | Offer induction of labour |

Appointment Schedule

• Nulliparous: approximately 10 appointments
• Multiparous: approximately 7 appointments
• Each visit: BP, urinalysis, symphysis-fundal height (SFH) from 24 weeks

Symphysis-Fundal Height (SFH)

• Measured from 24 weeks at each appointment
• Plot on customised growth chart (GROW chart)
• SFH should be within 2cm of gestational age (approximate guide)
• Reduced or static growth: refer for ultrasound assessment (fetal biometry, amniotic fluid, umbilical artery Doppler)
• Single SFH measurement below 10th centile or crossing centiles: refer for USS growth assessment

Gestational Diabetes Screening

• Risk factors: BMI >30, previous GDM, previous macrosomic baby (>4.5kg), first-degree relative with diabetes, ethnicity with high prevalence
• OGTT at 24-28 weeks (or as soon as possible after booking if previous GDM)
• Diagnostic thresholds (NICE): fasting ≥5.6 mmol/L OR 2-hour ≥7.8 mmol/L
• Note: WHO thresholds differ (fasting ≥5.1, 1-hour ≥10.0, 2-hour ≥8.5) — NICE uses higher fasting threshold

Mental Health Screening

• Ask about current and past mental health at booking and at each trimester
• Use Whooley questions:
  1. "During the past month, have you often been bothered by feeling down, depressed or hopeless?"
  2. "During the past month, have you often been bothered by having little interest or pleasure in doing things?"
• If positive: consider PHQ-9 or GAD-7 for further assessment
• Enquire about previous severe mental illness, perinatal mental illness, current treatment

Lifestyle Advice

• Folic acid: 400mcg daily until 12 weeks (5mg if: previous NTD, anti-epileptic drugs, BMI >30, diabetes)
• Vitamin D: 10mcg (400 IU) daily throughout pregnancy and breastfeeding
• Avoid: alcohol (no safe level), smoking, illicit drugs, unpasteurised dairy, raw/undercooked meat, liver/pate (vitamin A excess), certain fish (shark, swordfish, marlin — mercury)
• Exercise: 150 minutes moderate activity per week; avoid contact sports and lying flat after 1st trimester
• Caffeine: limit to 200mg/day

Important Facts for MRCOG

• Combined screening: 11-13+6 weeks (NT + hCG + PAPP-A)
• Anomaly scan: 18-20+6 weeks
• GDM diagnostic thresholds (NICE): fasting ≥5.6 OR 2-hour ≥7.8
• SFH measured from 24 weeks; plot on customised growth chart
• Asymptomatic bacteriuria: screen at booking and treat if positive (reduces pyelonephritis risk)
• High-dose folic acid (5mg) for: previous NTD, diabetes, BMI >30, anti-epileptics
• Routine infection screening: HIV, Hep B, syphilis (NOT Hep C, NOT rubella vaccination status in UK since 2016)
• Offer ECV at 36 weeks for breech presentation

Source: NICE CG62 / NG201 (2021)

Read the original on nice.org.uk

Clinically reviewed by NHS obstetricians and gynaecologists · Source last updated 2021

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