- The document discusses the benefits of first trimester antenatal care, including screening for fetal anomalies and maternal-fetal complications. It notes that detailed ultrasound examination and markers in the first trimester can predict many complications later in pregnancy and allow for early intervention. Conditions like Down's syndrome, open neural tube defects, congenital heart defects, preeclampsia, and fetal growth restriction can potentially be detected through a combination of ultrasound assessment, medical history, and serum markers in the first trimester. This represents a shift away from traditional late pregnancy surveillance to an earlier risk assessment approach through innovations in first trimester screening.

1. • Medical Director-Shrikhande Fertility Clinic, Nagpur
• Chairperson Designate ICOG 2020
• National Corresponding Editor-Journal of OB/GY of India JOGI
• Clinical Secretary National AMWI
• Past Senior Vice President FOGSI
• Founder Patron & President –ISOPARB Vidarbha Chapter
• Received Nagpur Ratan Award at the hands of Union Minister Shri Nitinji Gadkari
• Received Bharat excellence Award for women’s health
• Received Mehroo Dara Hansotia Best Committee Award for her work as Chairperson HIV/AIDS
Committee, FOGSI
• Received appreciation letter from Maharashtra Government for her work in the field of SAVE
THE GIRL CHILD
• Immediate Past President Menopause Society, Nagpur
• Past President Nagpur OB/GY Society 2005-06
• Visited 96 FOGSI Societies as invited faculty
• Delivered 16 orations and 450 guest lectures
• Publications- 20 National & 11 International
• Sensitized 2 lakh boys and girls on Do’s & Don'ts of adolescent health
Dr. Laxmi Shrikhande
Nagpur
MBBS;MD;FICOG;FICMU;FICMC

2. What’s new in Ante Natal Care ?
Dr Laxmi Shrikhande
Nagpur

3. Traditional care
• Pregnancy management typically involves reacting to maternal and fetal
problems only after they develop.
• Because most fetal and maternal complications become apparent late in
pregnancy, it has been traditionally thought that is when the most intensive
surveillance should be implemented.

4. Nicolaides KH. A model for a new pyramid of prenatal care based on the 11 to 13 weeks’
assessment. Prenat Diagn 2011;31:3–6.

5. New shift
• some very important complications that occur later in pregnancy can be
predicted in the first trimester itself.
• Inverted pyramid helps in dividing cases into high risk & low risk in the first
trimester
Nicolaides KH. Turning the pyramid of prenatal care. Fetal Diagn Ther 2011;29: 183–96.

7. PRECONCEPTIONAL CARE
AND ITS RELEVANCE

8. Better The Future
-Pre Conceptional Counselling

9. Better The Future
-Pre Conceptional Counselling

10. PRECONCEPTION ADVICES
• BMI
• BP
• Lifestyle counselling
• Garbh sanskar spiritual
• Folic acid supplimentation
• Anemia correction if detected
• Sugar / Thyroid
• Correction of endocrine factors
• Thalassemia screen

11. Pre-conceptional counseling-Vaccination
• FOGSI recommends vaccination counseling as a part of
pre-pregnancy counseling (unvaccinated women)
• History of occurrence of vaccine preventable diseases,
previous vaccinations administered and allergic reactions
to vaccinations must be recorded.
• Rubella ,Hepatitis B and Varicella vaccination should be
given preferably during postmenstrual period
• Pregnancy should be deferred for 3 months in case of
Rubella vaccine

12. ANTENATAL CARE

13. Why Antenatal surveillance ??
1.Triage mothers to High Risk & Low Risk
2.Screen the fetus for
• Chromosomal errors
• Structural Defects
• Growth abnormalities
3.Predict and prevent maternal complications
4.Decide the time and mode of safe delivery

14. HOW TO DO
SURVEILLANCE?

15. CASE
• Mrs. M
• 26 year old
• Overdue by 10days
• UPT positive
• Natural conception
• First antenatal visit
• First Trimester.
How would you proceed. What would you advise?

17. First Trimester
What would you advise / look for?

18. FIRST TRIMESTER

19. First-trimester screening for fetal aneuploidy
 Fetal aneuploidy is a major cause of perinatal morbidity and mortality as well
as long term disabilities.
 All diagnostic prenatal tests used to diagnose fetal aneuploidy carry a risk of
miscarriage and are expensive.
 Therefore, starting with a screening test that has the highest possible
detection rate and lowest false-positive rate is of critical importance
Akolekar R, Beta J, Picciarelli G, et al. Procedure-related risk of miscarriage following amniocentesis and chorionic villus sampling: a
systematic review and meta-analysis. Ultrasound Obstetrics Gynecol 2015;45:16–26.

20. First-trimester screening for fetal aneuploidy
• Until the advent of cfDNA technology, first-trimester combined screening
(maternal age and history, gestational age, NT measurement, PAPP-A, and
free beta-hCG) performed at 11 to 13 weeks’ gestation was arguably the most
robust screening test for fetal aneuploidy available.
• combined test can identify more than 90% of fetuses with trisomy 21.
• The detection rate of trisomies 18 and 13 is about 95% for the same
Wright D, Syngelaki A, Bradbury I, et al. First-trimester screening for trisomies 21, 18 and 13 by ultrasound and biochemical
testing. Fetal Diagn Ther 2014;35: 118–26.
Kagan KO, Hoopmann M, Abele H, et al. First-trimester combined screening for trisomy 21 with different combinations of
placental growth factor, free b-human chorionic gonadotropin and pregnancy-associated plasma protein-A. Ultrasound
Obstet Gynecol 2012;40:530–5.

21. First-trimester screening for fetal aneuploidy
• The effectiveness of the first-trimester combined screen can be further
augmented by the addition of other fetal markers, such as nasal bone
evaluation and Doppler evaluations of the ductus venosus and blood flow
across the tricuspid valve.
• There is evidence that the effectiveness of first-trimester screening could also
be further enhanced by including additional maternal serum markers, such as
placental growth factor (PlGF) and maternal serum alpha-fetoprotein (AFP).
Maiz N, Wright D, Ferreira AFA, et al. A mixture model of ductus venosus pulsatility index in screening for
aneuploidies at 11–13 weeks’ gestation. Fetal Diagn Ther 2012;31:221–9.
Kagan KO, Staboulidou I, Cruz J, et al. Two-stage first-trimester screening for trisomy 21 by ultrasound assessment
and biochemical testing. Ultrasound Obstetrics Gynecol 2010;36:542–7.

22. First-trimester screening –structural defects
About half of the congenital structural defects can now be diagnosed in the first
trimester because of improvements in ultrasound technology, NT thickening and
the presence of other ultrasound markers can herald the presence of structural
defects, and detailed evaluation of fetal anatomy is becoming widely recognized
as an integral part of the first-trimester ultrasound.
Rossi AC, Prefumo F. Accuracy of ultrasonography at 11-14 weeks of gestation for detection of fetal structural anomalies: a
systematic review. Obstet Gynecol 2013;122:1160–7. 28.
Van Mieghem T, Hindryckx A, Van Calsteren K. Early fetal anatomy screening: who, what, when and why? Curr Opin Obstet Gynecol
2015;27:143–50.

23. First-Trimester Detection of Open Neural Tube Defects
• Once it was recognized that the appearance of anencephaly is different in the
first trimester from that in the second trimester, early diagnosis of this defect
has become routine.
• However, the diagnosis of open spina bifida has remained a challenge.
• This situation changed when it was recognized that examination and
measurements of structures located in the posterior fossa can provide clues to
the presence of open neural tube defects (ONTDs) even in the first trimester.
Chaoui R, Nicolaides KH. Detecting open spina bifida at the 11-13-week scan by assessing intracranial translucency and the posterior
brain region: mid-sagittal or axial plane? Ultrasound Obstet Gynecol 2011;38:609–12.

24. First-Trimester Detection of Open Neural Tube Defects
In a prospective, multicenter first-trimester screening study including about
15,500 normal fetuses and 11 fetuses with open spina bifida, all affected cases
were identified or at least suspected by a detailed assessment of the posterior
fossa at 11 to 13 weeks’ gestation.
Chen FCK, Gerhardt J, Entezami M, et al. Detection of spina bifida by first trimester screening - results of the
prospective multicenter Berlin it-study. Ultraschall Med 2015. http://dx.doi.org/10.1055/s-0034-13994

25. First-Trimester Detection of Congenital Cardiac Defects
 The association between CHDs and NT measurement is well documented.
 In a meta analysis that included 20 studies, the detection rate for major CHDs
based on NT measurement alone was estimated at 44% for a 5.5% false-
positive rate.
 Doppler evaluation of blood flow across the tricuspid valve and ductus
venosus further improves screening for CHDs.
Chelemen T, Syngelaki A, Maiz N, et al. Contribution of ductus venosus Doppler in first-trimester screening for major cardiac
defects. Fetal Diagn Ther 2011;29: 127–34. 33.
Papatheodorou SI, Evangelou E, Makrydimas G, et al. First-trimester ductus venosus screening for cardiac defects: a meta-
analysis. BJOG 2011;118:1438–45. 34.
Pereira S, Ganapathy R, Syngelaki A, et al. Contribution of fetal tricuspid regurgitation in first-trimester screening for major
cardiac defects. Obstet Gynecol 2011; 117:1384–91.

26. First-trimester estimation of gestational age
• Finally, first-trimester crown-rump length measurement represents the most
accurate method for establishing the gestational age in the general population.
• Accurate gestational age is a critical piece of information that influences
essentially all decisions
Committee opinion no 611: method for estimating due date. Obstet Gynecol 2014;124:863–6

27. First-trimester assessment of multiple gestations
• Perinatal risk of morbidity and mortality is always increased in multiple
gestations. However, the level of risk depends greatly on chorionicity.
• This assessment is best accomplished in the first trimester, as at this time the
ultrasound appearance of a dichorionic/diamniotic dividing membrane is vastly
different from that of a monochorionic/diamniotic membrane.
• This difference becomes more blurred as the pregnancy progresses.
• Estimation of chorionicity in the first trimester allows accurate counseling
regarding the risk of the pregnancy.
Sebire NJ, Snijders RJ, Hughes K, et al. The hidden mortality of monochorionic twin pregnancies. Br J Obstet
Gynaecol 1997;104:1203–7.
Kagan KO, Gazzoni A, Sepulveda-Gonzalez G, et al. Discordance in nuchal translucency thickness in the
prediction of severe twin-to-twin transfusion syndrome. Ultrasound Obstet Gynecol 2007;29:527–32

28. First-trimester prediction of maternal-fetal complications
• Discussion regarding first-trimester screening often focuses on fetal
aneuploidy and structural anomalies.
• However, maternal and fetal complications that are related to abnormal
placentation are much more common than both of these problems combined.
Sharp AN, Alfirevic Z. First trimester screening can predict adverse pregnancy outcomes. Prenat
Diagn 2014;34:660–7.

29. First-trimester prediction of maternal-fetal complications
• Most placental architecture, including placental maternal blood circulation, is
established by the end of the first trimester; no further anatomic modifications
are evident after the fourth month of pregnancy.
• These 2 facts serve to support the 2 following assertions.
• First, the validity of methods used at the end of the first trimester in screening
for placental dysfunction has a sound physiologic basis.
• Second, in order for any treatment to be successful in reducing the risk of
complications related to placental dysfunction, it must be instituted early in
pregnancy.

30. First-trimester prediction of maternal-fetal complications
• The 2 often-interrelated complications of pregnancy that are major causes of
maternal-fetal morbidity and mortality are PE and small-for-gestational-age
(SGA) fetuses.
• A meta-analysis of 9 published studies has shown that the use of low-dose
aspirin (75 mg/d) reduces the risk of PE but only if treatment is initiated before
16 weeks’ gestation.
• This finding was confirmed in a more recent meta-analysis.
Bujold E, Roberge S, Lacasse Y, et al. Prevention of preeclampsia and intrauterine growth restriction with
aspirin started in early pregnancy: a meta-analysis. Obstet Gynecol 2010;116:402–14.
Roberge S, Nicolaides KH, Demers S, et al. Prevention of perinatal death and adverse perinatal outcome
using low-dose aspirin: a meta-analysis. Ultrasound Obstet Gynecol 2013;41:491–9.

31. First-trimester prediction of maternal-fetal complications
• First-trimester screening for these complications can be improved by using additional markers.
• One is the estimation of downstream resistance by measuring the pulsatility index (PI) in the uterine
arteries.
• Second is maternal blood pressure measurement in the late first trimester.
• Third is evaluation of certain placental product levels in maternal serum, such as PAPP-A and PlGF.
• Fetal Medicine Foundation (FMF) algorithm suggests that, detection of early PE (requiring delivery
before 34 weeks’ gestation) would be approximately 90% based only on historical factors, maternal
blood pressure measurement, and uterine artery PI.
• The addition of PAPP-A and PlGF levels increases the detection rates to 96%.
Poon LC, Nicolaides KH. First-trimester maternal factors and biomarker screening for preeclampsia. Prenat Diagn 2014;34:618–27.
Velauthar L, Plana MN, Kalidindi M, et al. First-trimester uterine artery Doppler and adverse pregnancy outcome: a meta-analysis
involving 55,974 women. Ultrasound Obstet Gynecol 2014;43:500–7.
Wright D, Akolekar R, Syngelaki A, et al. A competing risks model in early screening for preeclampsia. Fetal Diagn Ther
2012;32:171–8.

32. Future applications of first-trimester screening protocols
• Screening for SGA without PE has shown some promise.
• The risk is increased with an increase in the uterine PI and maternal mean
arterial pressure.
• Decreased maternal serum PAPP-A, free beta-hCG, PlGF, placental protein
13 (PP13), and A disintegrin and metalloproteinase 12 (ADAM12) also
increase the risk of SGA.
• For a false positive rate of 10%, the combination of these markers along with
maternal characteristics could identify approximately 75% of SGA fetuses
delivering before 37 weeks’ gestation and 45% that deliver at term.
Beta J, Akolekar R, Ventura W, et al. Prediction of spontaneous preterm delivery from maternal factors, obstetric history and placental
perfusion and function at 11-13 weeks. Prenat Diagn 2011;31:75–83.
Nanda S, Akolekar R, Sarquis R, et al. Maternal serum adiponectin at 11 to 13 weeks of gestation in the prediction of macrosomia.
Prenat Diagn 2011;31: 479–83.
Poon LCY, Karagiannis G, Staboulidou I, et al. Reference range of birth weight with gestation and first-trimester prediction of small-for-
gestation neonates. Prenat Diagn 2011;31:58–65

33. Future applications of first-trimester screening protocols
• The fact that risk of spontaneous preterm delivery is associated with cervical
shortening is well established in the second trimester, and the same seems to
hold in the first trimester.
• Cervical length measurement obtained transvaginally and adhering to strict
guidelines in combination with maternal characteristics is likely to be used in
the future to select a high-risk group that may benefit from close follow-up and
possible treatment.
• Preterm delivery prediction does not seem to be improved by the use of either
maternal serum biochemistries or uterine artery PI.
Greco E, Gupta R, Syngelaki A, et al. First-trimester screening for spontaneous preterm delivery with maternal characteristics and
cervical length. Fetal Diagn Ther 2012;31:154–61.
Retzke JD, Sonek JD, Lehmann J, et al. Comparison of three methods of cervical measurement in the first trimester: single-line, two-
line, and tracing. Prenat Diagn 2013;33:262–8.

34. Future applications of first-trimester screening protocols
• First-trimester screening for gestational diabetes mellitus (GDM) is possible using
maternal serum biochemistries.
• Adiponectin and sex hormone–binding globulin are reduced and visfatin is increased
in association with increased risk for GDM.
• Combination of maternal characteristics and biochemical markers can identify about
75% of pregnancies that will develop GDM for a 20% false-positive rate.
• Screening fetal macrosomia/large for gestational age (LGA) using first-trimester
parameters has shown some promise.
• The risk of LGA increases with increased NT measurement, increased levels of
maternal serum free beta-hCG and PAPP-A, and a decreased level of adiponectin.
• For a 10% false-positive rate, the combination of these factors and maternal
characteristics can detect approximately 40% of LGA fetuses.
Ferreira AFA, Rezende JC, Vaikousi E, et al. Maternal serum visfatin at 11-13 weeks of gestation in gestational diabetes
mellitus. Clin Chem 2011;57:609–13.
Thadhani R, Powe CE, Tjoa ML, et al. First-trimester follistatin-like-3 levels in pregnancies complicated by subsequent
gestational diabetes mellitus. Diabetes Care 2010;33:664–9.

35. Screening in the 1st trimester
• Time window: 8 - 14 weeks
• Ultrasound Marker:
• NT
• Biochemical markers:
• PAPP-A
• Fb-hCG
• Marker combination:
• Combined test: NT, PAPP-A, Fb hCG

36. Uterine Artery Doppler

38. Performance of difference methods of screening for T-21, K.NICOLAIDES 2011

39. Second Trimester screening

40. SECOND
TRIMESTER

41. Cervical length screening routine to prevent
preterm labour and for guideline for cx stitch
• Asymptomatic singleton pregnancy a tvs cl <25 mm in second trimester
• Screen at 11-13 weeks and then at 22-24 weeks
Recent evidence says cx stitch does not help and progesterone may be
the only treatment option here.
Routine mcdonald stitch practise should be individualised

42. • MA + NIPT(OPTIONAL)
• Dual Marker
• NT + NB + TR + DV
First
trimester
• Quad Marker
• Genetic Sonogram
Second
trimester
Integrated 1st and 2nd
trimester screening
DR – 97%
FPR – 2.5%

43. Vaccination In Pregnancy

44. Why vaccinate women ???
• Vaccination
before during and after pregnancy
helps protect women from serious infections .
• It can also help in improving the women’s health in
general .
• It is an important preventable measure which should be
adopted rationally

45. Vaccination
• Tetanus Toxoid – ONE DOSE
• Tdap/Triple Vaccine –SECOND DOSE AT
24 WEEKS
• Influenza vaccine 24 weeks onwards
• HepB can be given if not immunised
• Targetted Vaccine in case of travel to
endemic areas
• Post partum – HPV vaccine

46. Third Trimester Screen

47. THIRD TRIMESTER

48. Antepartum fetal surveillance
• Antepartum fetal surveillance is the assessment of fetal well being in
utero before the onset of labor
• Early detection of fetus at risk so that timely management to prevent
further deterioration
• To find out normal fetuses and avoid unnecessary interventions

49. The Various Methods of Antepartum Fetal Surveillance
1) Clinical assessment by uterine growth
2) Fetal movement count by the mother
3) Ultrasound for fetal growth
4) Non stress test and cardiotocography
5) Vibroacoustic stimulation test
6) Contraction stress test
7) Nipple stimulation test
8) Biophysical profile
9) Modified biophysical profile
10) Doppler studies
11) Fetal lung maturation studies
12) Placental grading

50. KICK CHART
How important is it?

51. Recording
•Every kick / roll is 1 movement
•Count 10 movements everyday
•Should be around 6 in 1 hour
•If < 6 movements in 2 hours
•Call doctor & come for CTG / USG assessment

52. About baby’s movements
An active baby is usually a healthy baby. You
will feel your baby stretch, kick, roll and turn
every day. Some babies are more active than
others. All babies have periods of sleep during
which they are not as active. You will get to
know your baby’s pattern of movements and
when your baby is most active.
You should feel your baby’s movements
throughout the day, each day from 28 weeks of
pregnancy until the baby is born.
When during my pregnancy should I count
my baby’s movements?
Your health care provider may ask you
to count your baby’s movements once
every day.
If you think there is a decrease in your
baby’s movements this is an important sign that
your baby may not be well. Count your baby’s
movements to be sure that you feel at least 6
movements in 2 hours.
Reference:
Society of Obstetricians and Gynaecologists of Canada (2007).
Fetal Health Surveillance : Antepartum and Intrapartum Consensus
Guideline. Journal of Obstetrics and Gynaecology Canada. 29(9).
FETAL MOVEMENT
COUNT CHART
PLEASE BRING THIS CHART WITH YOU EACH
TIME YOU SEE THE DOCTOR/MIDWIFE
IMPORTANT PHONE NUMBERS:
DOCTOR:
MIDWIFE:
HOSPITAL:
DUE DATE:
OTHER INSTRUCTIONS:
For 24-hour nurse advice and health information call
Health Link Alberta:
1-866-408- LINK (5465)– Toll Free
In Calgary call 403-943- LINK (5465)
In Edmonton call 780-408-LINK (5465)
ADDRESS:
NAME:
HS0001-132 (2012/11)
How do I count my baby’s movements?
• Get into a comfortable position – lying on
your side or sitting. Place one or both of your
hands on your abdomen.
• Count each time that you feel your baby
move. If you feel many movements all at
once, count each movement that you feel.
• Write down the date and the time that you
start counting on the fetal movement chart.
• Make a mark on the chart each time your baby
moves.
• Stop counting when you have counted 6
movements.
• Write down the time you stopped counting.
• Do not count for more than 2 hours
What if I don’t feel 6 movements in 2 hours?
Count your baby’s movements once a day. You
should feel 6 or more movements in 2 hours.
If you count fewer than 6 movements in 2 hours
do not wait. Go to the hospital or birthing unit.
Your baby’s heart rate and movements will be
checked using a fetal monitor. This is called a
non-stress test or NST.
If you live too far from a hospital or birthing
unit, immediately contact your health care
provider for advice.

53. FOGSI OLD CHECK LIST OF 2009,MODIFIED IN 2017 AT FOGSI T.O.G.

54. First-Trimester Detection
• Fetal aneuploidies-pt gets time to opt for mTP
• Fetal structural defects-NTD, Cardiac
• Complications in multiple pregnancies -chorinicity
• Exact dating of pregnancy
• Preeclampsia-aspirin
• Gestational diabetes
• Fetal growth restriction
• Preterm delivery-cervical length
• Rh Negative-Fetal anaemia

57. A CHILD GIVES BIRTH TO A MOTHER

58. My World of sharing happiness!
Shrikhande Fertility Clinic
Ph- 91 8805577600
shrikhandedrlaxmi@gmail.com

60. The Art of Living
Anything that
helps you to
become
unconditionally
happy and loving
is what is called
spirituality.
H. H. Sri Sri Ravishakar