Answering those Curly First Antenatal Visit Questions

Benchmark antenatal assessment (revised June 2020)

Height & Weight

CBC: low MCV or MCHC → Hb-EPG testing ± DNA analysis for α-thalassaemia

• consider testing high-risk subgroups despite normal MCV and MCHC
• repeat Hb & Platelets @ 28/40: investigate any anaemia

Blood Group & Antibody Screen: at beginning of each pregnancy

• repeat @ 28/40 for Rh-negative women

MSU: biochemistry & culture

Pre-test counselling and antibody screening*

• HIV Ab (I & II)
• HepB_sAb / HepB_cAb → HepB_sAg and HepB_eAg
• Hep C Ab → RNA PCR (viral load) indicative of 6% perinatal transmission risk
• Rubella IgG: each pregnancy
• Varicella IgG: when no or uncertain history of previous illness
• Syphilis: T. pallidum haemagluttination assay (TPHA) or particle assay (TPPT)
  • Note: cheaper rapid plasma reagent test (RPRT) less sensitive for latent syphilis

Vaccinations

• Influenza: early in season is optimal regardless of gestation
• Pertussis: single dTpa booster 3rd trimester of each pregnancy
  • optimal timing: 28-32 weeks

Trisomy 21 Screening:

Positive predictive values will vary according to the underlying prevalence (i.e. pre-test probability) for aneuploidy in the group sampled.

• MA = maternal age
• NT = nuchal translucency
• β-HCG = free B human chorionic gonadotrophin
• PAPP-A = pregnancy associated plasma protein A
• AFP = Alpha-fetoprotein
• UE3 = oestriol

Cell-free DNA (cfDNA) screening

Consider cfDNA in isolation from other clinical findings and test results. Discuss the risks, benefits, and alternative methods of prenatal screening and diagnostic testing, including option of no testing, with all patients. Given the performance of conventional screening methods, the limitations of cell-free DNA screening performance, and the limited data on cost-effectiveness, conventional screening methods remain the most appropriate choice for first-line screening for most women in general obstetric population. Review the Family History re: whether to offer other screening or prenatal diagnosis also for other conditions. Consider baseline obstetric USS regardless: to confirm viability, number of foetuses, and gestational dating. Any foetal structural anomalies identified warrant formal diagnostic testing rather than cfDNA screening.

• Screening only looks for common aneuploidies (trisomies 13, 18, 21) ± sex chromosome composition (if requested)—i.e. nil assessment of risk of anomalies like neural tube defects (NTDs) or ventral wall defects; ∴ still offer these patients maternal serum α-FP screening or USS evaluation.
• Tell those patients who request cfDNA screening for earlier sex identification that cfDNA screening also assesses risk of trisomies: if that information is not desired, the screening should not be performed.
• Discuss limitations and benefits of cfDNA screening in context of alternative screening and diagnostic options: i.e. cfDNA screening does not replace precision obtained with diagnostic tests such as chorionic villous sampling (CVS) or amniocentesis. Limited ability to identify all chromosome abnormalities.
• False Positive: including but not limited to placental mosaicism, vanishing twins, and maternal malignancies but, beyond that, a positive cfDNA for aneuploidy does not determine trisomy from translocation, which affects risk of recurrence. ∴ Cannot base management decisions, including termination of pregnancy (TOP), on result of cfDNA screening alone: i.e. diagnostic testing with amniocentesis or CVS recommended before any pregnancy termination decision.
• 2% False Negative: i.e. carries residual risk of one of the common trisomies and does not ensure fetus is free of another chromosome abnormality or genetic condition: for “Indeterminate” or “Uninterpretable” (i.e. a “no call”) cfDNA screening test results → offer further genetic counselling and comprehensive ultrasound scan (USS) evaluation and diagnostic testing because of an increased risk of aneuploidy.
• Parallel / simultaneous testing with multiple screening methodologies for aneuploidy is not cost-effective, however; cfDNA screening as follow-up for patients with positive traditional screening test result is reasonable for patients wanting to avoid a diagnostic test.
• Routine cfDNA screening for microdeletion syndromes should not be performed
• Not recommended in multiple pregnancy

Ultrasound Scanning (USS): Foetal morphology and placental localisation @ 18-20 weeks.

Late Tests of Foetal Wellbeing clinically indicated for assessment of feto-placental function—i.e. suspicion for or risk of placental insufficiency, inability to clinically ascertain foetal growth, > 41 (especially 42) weeks gestation: USS /  cardiotocography (CTG).

Group B Streptococcal disease (GBS): 15-25% asymptomatic carriage rate → 1 in 200 neonatal sepsis if mum untreated: ∴ week 35-37 screening with combined low vaginal then anorectal swab (can self-collect) into selective enrichment broth medium.

General Advice

Potential teratogens

Medications Contraindicated in Pregnancy: Category X

Vitamin A derivatives	Birth defects
Thalidomide	Severe limb and other defects
DES*	Cancer vagina / cervix in later life
Warfarin	Multiple birth defects	use LMWH instead
Danazol	Malformations female foetal sex organs

*DES = diethylstilboestrol 

Medications to Avoid in Pregnancy

Phenytoin	congenital facial anomalies	Carbamazepine safer
NSAIDs	Abortion, stricture ductus arteriosus
Amiodarone	arrhythmias and growth restriction	Digoxin safer

No change is recommended for anti-epileptic drugs (AEDs) after pregnancy occurs. Encourage patients to register with APR (tel: 1800 069 722). Offer USS @ 11–13 weeks and expert morphology ultrasound scans at 18–20/40. Monitor serum levels of AEDs at least once in each trimester. Remain vigilant for increase seizure frequency in labour and delivery. Terminate epileptic seizures using intravenous benzodiazepine.

 Antibiotics to Avoid in Pregnancy

Metronidazole (relative)	Hepatic failure
Chloramphenicol	Grey baby syndrome
Aminoglycosides	Ototoxicity
Tetracyclines	Teeth discolouration and liver failure
Nitrofurantoin
Fluoroquinolones
Sulfonamides
Trimethoprim	Structural defects e.g. cleft palate

 

Alcohol is a teratogen. The sensitivity of the fetus to the adverse effects of alcohol varies between women and between the different stages of gestation. Internationally there is no consensus on the safe level of alcohol during pregnancy and breast feeding. There is good quality evidence that drinking excessive amounts of alcohol during pregnancy can damage fetal development. However, the minimum or threshold level at which alcohol begins to pose a significant threat to pregnancy is not known. The likelihood of an adverse fetal effect increases with increased volume and frequency of alcohol consumption. Until better evidence is available, RANZCOG currently recommends that women avoid intake of alcohol during pregnancy.

X-Ray exposure from a single diagnostic procedure does not result in harmful fetal effects: exposure < 5 rad not associated with increase in fetal anomalies or pregnancy loss. The foetus most radiation sensitive at 8-15 weeks (childhood cancers). Concern re: high-dose ionizing radiation exposure should not prevent medically indicated diagnostic X-ray procedures from being performed on pregnant woman, although imaging modalities not associated with ionizing radiation and not associated with known adverse foetal effects (e.g. USS, MRI) should be considered instead of X-rays where appropriate. Consultation with an expert in dosimetry calculation may be helpful in calculating estimated fetal dose when multiple diagnostic X-rays are performed on a pregnant patient. Therapeutic radioactive iodine, however, is contraindicated during pregnancy. Radiopaque and paramagnetic contrast agents are unlikely to cause harm and may be of diagnostic benefit, but these agents should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Lifestyle: diet, supplements, weight gain, smoking (recreational drugs), exercise, work, travel

Vitamin and mineral supplementation

Supplement with 0.4 mg folate daily to aid in prevention of neural tube defects (NTDs). Recommend much higher doses (5 mg per day) where known risk of NTD or risk of malabsorption. Routine supplementation of iron not recommended in every pregnancy – check Hb at first visit and again @ 28 weeks. Iodine supplementation with 150 mcg/day is indicated for all pregnant, those planning pregnancy, and breast-feeding women. Vegetarians and vegans should be supplemented with Vitamin B12 in pregnancy and lactation. Vitamin K administered in late pregnancy to women with proven cholestasis of pregnancy. If the woman avoids dairy in her usual diet and does not consume alternative high calcium foods, she should take a calcium supplementation of at least 1000 mg per day. Supplement women who eat little seafood with W-3 fish oil or commercially available pregnancy supplement. Supplement with 1,000 IU Vitamin D3 daily if Vitamin D level 30–49 nmol/L or 2,000 IU Vitamin D3 daily if Vitamin D level < 30 nmol/L, and repeat Vitamin D level @ 28 weeks gestation. For pregnant women with Vitamin D level > 50 nmol/L, supplement daily with 400 IU Vitamin D as part of a pregnancy multivitamin.

Targeted screening for thyroid disease in early pregnancy: those with symptoms or a history of thyroid disease. Otherwise, consider testing TSH in/if:

• > 30 years old
• area of endemic iodine insufficiency
• Family History of thyroid disease
• anti-TPO antibodies
• type 1 diabetes
• history of preterm delivery or miscarriage
• history of head or neck radiation
• morbid obesity

Institute of Medicine’s guide for pregnancy assumes 0.5-2kg weight gain during the first trimester (T1) and presumes linear gestational weight gain throughout the second (T2) and third (T3) trimesters.

Gestational Diabetes

Reduce perinatal morbidity by screening and treating women for gestational diabetes: biochemical screening @ 26-28 weeks gestation (earlier if prior GDM or current obesity ± repeat @ 26-28/40). Note that a 75 g two-hour Pregnancy Oral Glucose Tolerance Test (POGTT) with the following Who-stipulated thresholds:

Group B Streptococcal Disease (GBS)

Giving intrapartum Penicillin prophylaxis ≥ 4 prior hours to delivery to women at risk of transmission of GBS to their newborns (15-25% asymptomatic carriage rate) prevents the otherwise 1 in 200 risk of early-onset newborn sepsis. Too early screening is not predictive of status at term  Screen pregnant women @ week 35-37 with combined low vaginal then anorectal swab (can self-collect) into selective enrichment broth medium. PCR based rapid (< 1 hour) tests not universally available

Clinical risks for early-onset GBS infection in newborn:

• Preterm ≤ 37 weeks
• Ruptures membranes ≥ 18 hours
• Maternal fever ≥ 38°C
• Previous GBS infected baby: chemoprophylaxis regardless of current colonisation status
• GBS bacteruria during that pregnancy: intrapartum chemoprophylaxis
• Known carriage of Group B Strep in current pregnancy

Penicillin given to a woman with no history of β-lactam allergy has a risk of anaphylaxis of 4 in 10,000 to 4 in 100,000.

Request sensitivity testing at time of screening culture to decide on treatment for those with penicillin allergy ( 20% of GBS resistant to clindamycin, 30% to erythromycin). Where impractical or inappropriate to collect swabs for assessment of GBS colonisation, it is recommended that the obstetric risk factor strategy be adopted. For elective Caesarean section (not in labour, no rupture of membranes) no additional prophylaxis is recommended, irrespective of carriage. Incidence of late-onset GBS infection (7-89 days after birth) remains unchanged in Australia.

Exercise and Sport in Pregnancy

Risk: setting the record straight

Women with normal pregnancies who are already active can continue to play many sports during pregnancy without affecting the course or outcome of their pregnancy. Women who are not active can begin a training program of moderate intensity and low impact after seeking medical advice. Medical evidence in this area is still developing and inconclusive, there are risks pregnant sportswomen should consider:

Hyperthermia (overheating) in the foetus (especially T1): Pregnant women should avoid prolonged overheating during exercise. Taking the following precautions will help a pregnant player reduce the risk of overheating:

• drinking plenty of water and other fluids regularly (to maintain hydration levels)
• eating nutritious and regular meals (to maintain energy)
• avoiding exercise in the hottest or most humid parts of the day, especially prolonged exercise
• ensuring that indoor exercise spaces are cool and well ventilated
• resting or substituting frequently when playing team sports
• limiting participation in sport in the third trimester to three sessions or less each week, and
• reducing exercise intensity as the pregnancy progresses

Traumatic injury to mother or foetus

The risk of traumatic injury to a mother or foetus during sport or physical activity is theoretical and very small. Serious abdominal injuries of the kind that may compromise a mother or her foetus are rare and are usually associated with motor vehicle accidents or domestic violence. The stage of pregnancy is an important factor in determining whether and how long pregnant women should continue to participate in sport. In the first trimester, the foetus is contained within its mother’s pelvis and so is protected from injury by the skeletal structure of its mother’s body. As pregnancy continues, the foetus moves higher in its mother’s body and becomes more susceptible to injury from a blow or other impact. Different activities may be appropriate for women indifferent stages of pregnancy. Physically active pregnant women should consider the likelihood of injuries in their sports, in consultation with their medical advisers. They should then decide whether they can accept that risk, for themselves and their foetuses, by continuing to play. Risks will vary according to individual circumstances (the kind of sport played, the fitness of the woman concerned and so on). However, there are some particular physical and health factors concerning active pregnant women that sporting organisations, administrators, coaches, officials, and the women themselves, should be aware of:

• Theoretically, pregnant women may be more vulnerable to falls because the growing foetus causes a shift in their centre of gravity, which can affect their balance and coordination in later months.
• Theoretically, hormonal changes in preparation for the birth may also result in ligament and joint laxity, making women vulnerable to injuries or falls (they should also avoid excessive stretching and jerky ballistic movements as a result)
• As the foetus rises higher in the mother’s abdomen later in the pregnancy, it is more vulnerable to direct impact injuries. Sports Medicine Australia recommends that pregnant women avoid sports such as scuba diving, parachuting, water-skiing, martial arts, gymnastics, horse-riding and trampolining. Some medical studies have shown that vigorous exercise throughout pregnancy may result in a slightly lower birth weight. This has been attributed to the reduced development of fat cells.

Sports Medicine Australia recommends pregnant women (indeed, all athletes) stop exercising if they experience abnormal symptoms, such as:

• pain, particularly chest and abdominal pain
• headache
• an unusually high heart rate
• decreased foetal movements
• insufficient weight gain
• amniotic fluid leakage
• nausea
• uterine contractions
• vaginal bleeding
• sudden swelling of ankles, hands, and face
• dizziness; or
• unusual shortness of breath

There is a very low risk of abdominal injury in women athletes . . . Most sports-related abdominal injuries are just not the sort of thing that would lead to foetal distress or other damage to the foetus anyway. [2]

Duty of care to Unborn Child

Pregnant athletes owe a duty of care to their unborn children to take reasonable care to avoid foreseeable risks of injury. They can usually fulfil that duty by obtaining advice from appropriately qualified medical practitioners as to the risks involved in participating in a particular sport while pregnant and following that advice. [3]

Travel

Surprisingly, women find many reasons to travel while pregnant, not least of which is for recreation and that the pregnancy was simply a case of bad timing, as 50% of pregnancies are unplanned. Further, couples now often look forward to a “Babymoon” vacation before the many sleepless nights that usually accompany a newborn baby. And then there are the career frequent flyers. For these people it might be worthwhile mentioning that the foetus is most radiosensitive at 8-15 weeks (childhood cancers) and that the maximum recommended exposure during pregnancy is 1 millisievert, or about 200 flying hours—that’s about half a dozen long-haul return trips over the course of the pregnancy (not many women would consider managing that feat). Of course, there is also the real risk of venous thromboembolism to consider.

The riskiest group of travellers, pregnant women among them, is those who are visiting friends and relatives (VFR), especially if travelling to high-risk locations like a Refugee Camp in Kenya, West Africa, for instance. Notably also, malaria immunity quickly wanes after leaving an endemic area. Moreover, most VFRs need immunisation but cost is often an issue. Finally, this group of travellers is inherently prone to underestimate the risk of travel; they should be offered pro-active screening prior to falling pregnant, wherever possible.

Migrants are the main source of congenital rubella cases in developed countries. Australians born between 1966 and 1980 may be susceptible to measles or rubella, and 10% of 30-year-olds are not immune to varicella (much higher in those from the topics). Many adults in their 30s have not had pertussis boosters since infancy, as this immunisation was only returned to the school-aged schedule in 2005. And the Australian cocooning strategy against pertussis in pregnancy recommends immunisation after gestational week 28.

For those pregnant women who intend to travel but can afford to choose the timing of their trip, tell them that the late second trimester is the safest, most comfortable time to fly as the 15% miscarriage of the first trimester has passed, when various travel vaccinations are deemed less risky, nausea and fatigue has often settled, and the physical discomfort has not fully set in. Also, beyond 24/40 gestation there are increasing travel insurance restrictions. There are also airline restrictions to consider in late pregnancy. Qantas Airways, for instance, will not permit a woman who is beyond 36 weeks gestation on a flight longer than 4 hours. The restrictions are greater still for multiple pregnancies: no long-haul flight beyond 32 weeks gestation; no domestic flight after 36 weeks gestation.

When travelling after the first 28 weeks of pregnancy, you must carry a certificate or letter from a registered medical practitioner or midwife confirming: the estimated date of delivery (EDD); whether a single or multiple pregnancy; and that there are no complications with the pregnancy.

Flights of four hours or more: flying is permitted for pregnant women who are free of complications up to the end of the 36th for single pregnancies or up to the end of the 32nd week for multiple pregnancies. Fit-to-fly medical clearance is required for any woman having complications with her pregnancy.

Flights of less than four hours: if you are having no complications with your pregnancy you can travel up to the end of the 40th week of your pregnancy for single pregnancies and up to the end of the 36th week for multiple pregnancies (for example, twins). Medical clearance is required if you are having complications with your pregnancy.

Medical clearance is also required for those women who wish to travel within seven days after delivery. For those wandering, neonates cannot fly within 48 hours of birth and, like mum, need a medical clearance if they wish to do so between Days 3 and 7 after delivery.

Sea Travel

Most cruise liners will carry pregnant women up to 7 months (28/40 gestation), although women would not the exacerbation of nausea and vomiting associated with pregnancy and the general risk of accidents associated with motion and imbalance.

Potential Medical Contraindications to Travel

• Chronic medical conditions requiring monitoring (asthma, diabetes, kidney, etc.)
• Valvular heart disease
• Severe anaemia (< 80 g/L)
• History of venous thromboembolic event (VTE)

Potential Obstetric Contraindications to Travel

• History of spontaneous Ab or incompetent cervix
• Threatened Ab this pregnancy
• History of pre-term labour
• Existing placental abnormalities by scan
• History of ectopic (scan before trip) Multiple gestation
• Primip over 35 or under 15 years (the unknown!)

Potential Environmental Contraindications to Travel

• Endemic area for Yellow Fever
• Endemic area for resistant falciparum .malaria
• High altitude
• Scuba diving
• Access to medical care and safe blood supply poor
• Dumb choice

Other Destination Risks

• Food and water: what medications are available for a nasty bout of traveller’s diarrhoea.
• Transportation
• Insects: is there a malaria risk? What medications are safe to use? Is travel worth the risk?
• Air pollution
• Heat
• Sports
• Altitude: women who live at high altitude (> 2,400 m) have higher rates of pregnancy-induced hypertension (PIH), pre-eclampsia, intrauterine growth retardation (IGR), and prematurity.
  • How does this risk translate to the short-term traveller?
    • remoteness implicit in an area of high altitude
    • few studies of exercise, altitude and pregnancy
    • high-altitude capacity difficult to predicted from sea-level observation and investigation in this group
    • and any exercise places further stress on oxygen delivery to foetus

Vaccinations: obviously consider both mother and foetus [1]

• ideally, complete vaccination schedule 3 months prior to conception
• if not possible, except for influenza vaccination, avoid in first trimester
• although there is no evidence that any vaccines (apart from smallpox), inactivated or live, pose a risk in pregnancy, the safety of many vaccines in pregnancy has not been established
• yet in scenarios of high-risk exposure, the benefit of vaccination may outweigh the risk to both mother and foetus
• although Yellow fever vaccination has been given to a large number of pregnant women, avoid this live virus vaccine not only until after confinement but beyond 9 months in a breastfed infant (otherwise, only administered where there is a demonstrable risk of infection).
• seek specialist travel medicine advice

Food and water safety

• Traveller’s Diarrhoea affects 30-50% of trips to less developed countries (LDC)
• Fever and dehydration reduce placental blood flow
• Pregnancy limits therapeutic options
• Avoid iodine water treatment (foetal goitre)
• Pay particular attention to the rule: “Boil, Peel, Cook, Bottle, or Forget”
• Have medication handy and use it

Toxoplasmosis

• Protozoan parasite
• Common worldwide but greater in LDC
• Hosts: cats, mice, sheep, pigs, etc. ⇒ sporulated oocysts contaminate soil, food, and water
• First Trimester (T1) transmission less common but most severe consequences
• Eat thoroughly cooked meat
• Avoid cats, cat litter, soil contact

Other serious transplacental infections

• Listeria: miscarriage, stillbirth, premature labour
  • avoid unpasteurized milk, soft cheeses, deli meats
• Leptospirosis: miscarriage, stillbirth, neonatal septicaemia
  • tropical spirochaetal infection passed from animal body fluids to water and vegetation
• Hepatitis E: maternal mortality 2% T1 to 30% T3
  • Subcontinent, China, Africa, and former USSR
  • contaminated drinking water
• Helicobacter Pylori
  • present in stool of up to 30% newborns in LDCs
• Typhoid Fever: chorioamnionitis, neonatal septicaemia

Management of Traveller’s Diarrhoea

• Oral Rehydration Solution (ORS)
• Loperamide safe in small doses
• Paracetamol +/- codeine 8 mg for cramps
• Metoclopramide or doxylamine for nausea
• Antibiotics:
  • Azithromycin 1000 mg (Pregnancy category B1) statim PO
    • good effect against Campylobacter, E.coli, Shigella, Salmonella

Other medical travel-kit items

• “Normal” annoyances of pregnancy can spoil a trip (e.g. haemorrhoids)
• Bisacodyl for constipation
• Antihistamines for allergy: cetirizine; cyproheptadine (Periactin, Australia) loratadine
• Respiratory antibiotic: penicillins, azithromycin, cephalosporins
• UTI: cephalexin, trimethoprim
• Thrush creams

VTE Risk in Pregnancy

• Venous stasis (hormonal effect)
• Coagulation and fibrinolytic system shift to hypercoagulability
• Later stages the uterus impairs venous return
• VTE risk in order of 5 x that of non-pregnant female similar age

Factor multiplicity

• Obesity
• Higher parity
• Past history thrombosis
• Thrombophilia
• Operative delivery
• Puerperium (greater risk than antepartum)

Venous Thromboembolism and Travel in Pregnancy

Relative risk ∼ 4 times within 2 weeks of arrival or 12% extra annual risk per long-haul flight:

• Immobilization
• Cramped position
• Low humidity
• Dehydration
• Hypoxia

Advice:

• Check family and past VTE history carefully and screen if indicated
• All standard-risk pregnant women should wear fitted compression stockings on long-haul flights
• Attention to hydration
• Aisle or bulk-head seat
• Exercise and walks

Mental Health

Mental health problems during the perinatal period are common. Routine screening should lead to identification, referral, and treatment. Evidence is that early intervention produces best outcomes for mothers and their families. Perinatal mental health care should be culturally responsive, and family centred. In line with the recognition by the College of the importance of reciprocal trust between practitioner and the  patients and those who support them (cultural competency), it is imperative that an awareness of systemic inadequacies (such as poor communication, or lack of continuity of care, or non-collaborative models of care) remains a high priority in order to avoid these pitfalls. Mental wellbeing is as important as physical health. Maternal anxiety and depression can have detrimental effects on fetal and infant development and on mother infant attachment. All pregnant women should be screened for psychosocial risk factors. Screening for perinatal mood disorders, in the form of a psychosocial assessment or administration of a validated tool, such as the EPDS, should be considered part of routine antenatal and postpartum care. Any treatment offered should involve collaborative decision-making with the woman and her partner including a full discussion of the potential risks and benefits. The safety of mothers and infants always needs to be considered , as well as the safety of families.

HIV Pre-Test Counselling

Without specific interventions, HIV-infected women will pass the virus to their infants during pregnancy or delivery in about 15%-25% of cases, and an additional 5%-20% of infants may acquire postnatal infection during breast-feeding, for an overall risk of 30%-45%. This means that almost one-third of children born to HIV-positive women will be infected with HIV. Reducing HIV transmission from pregnant women to their infants requires a range of interventions beginning with HIV testing and counselling and including ART for eligible pregnant women or ARV prophylaxis for women and newborns, safer obstetric practices, and counselling and support for safer infant feeding. Ideally, all women and their male partners should receive HIV testing and counselling before deciding to become parents.

HIV testing in pregnant women:

Provide essential HIV / AIDS information at the first antenatal visit to ensure women are offered and informed of the clear advantages to HIV testing. Address HIV transmission and risks associated with Mother-to-Child-Transmission (MTCT) during pregnancy, birth, and breast-feeding. Retest high-risk women in the third trimester.

Women who decline:

Spend extra time to re-examine a woman’s refusal to assist with any problems that keep her from accepting testing. Counsel women about the benefits to themselves and to their infant of knowing their HIV status to help overcome fear of stigma, discrimination, and other barriers. Allow women to express their concerns. Fear of negative outcomes is more common than actual negative outcomes, for most women: for most who disclose their HIV status report positive outcomes, support, and understanding. If a woman does not accept HIV testing at her first visit, ask again at each future visit whether she is not ready to be tested. At each clinic visit, briefly review the benefits of knowing one’s HIV status and emphasize the care that is available to HIV-positive women and their infants.

Counselling pregnant women who test positive for HIV

If a pregnant woman tests positive for HIV, discuss the following:

• the risk of being reinfected and of infecting someone else in attempting to become pregnant
• the risk of MTCT of HIV
• the need for clinical staging of HIV infection to assess eligibility for ART to benefit the woman’s health; and
• options for the prevention of MTCT

Substance-using pregnant women diagnosed HIV positive should be advised that using such substances during pregnancy can be harmful to baby and cause birth defects or neonatal dependency syndromes. Discuss also the importance to their infant’s health that the antenatal clinic doctor know that they have HIV and that they are using drugs or alcohol so that the right treatment can be offered to them and their baby. Avoid suggesting for any immediate cessation to substance use as this may place both mother and baby’s health in jeopardy. Instead, and having obtained the mother’s consent for review with a physician who can conduct the medical assessment and offer more specific medical advice applicable to her health status, indicate in a referral to the antenatal clinic that the mother is using substances.

Such counselling is intended to:

• review the client’s risk of infection
• help the client understand why the test is needed
• explain the test and clarify its meaning
• psychologically prepare the client for a potential HIV-positive result
• explain the limitations of the test and the various results that can be obtained
• obtain informed consent

Strike a balance between collecting and offering information, by listening to and meeting the client’s own needs by following this protocol:

Step 1: Introduce the service

Step 2: Clarify information on HIV/STI transmission

• HIV transmission between the husband and wife
• HIV transmission in the womb, during delivery, and during breast-feeding
• the high viral load during the period when HIV is newly acquired (seroconversion), placing the woman at greater risk of infecting the unborn child
• referral of the clients to a antenatal care physician who can offer the couple specific advice tailored to their needs and health status

Step 3: Conduct a personal HIV/STI risk assessment

• provide a private consultation area
• see each individual separately, with no other person present unless consent has been sought and given (couples should be interviewed separately; we will discuss this later in the section on the counselling of couples)
• use clear and simple language
• use models or drawings if needed
• obtain detailed information
• discuss all practices with all people
• use counselling communication micro-skills such as reflecting the client’s emotion, paraphrasing, and using open questions

Step 4: Demonstrate condom use and discuss safe injection

Step 5: Explore psychological coping resources

Step 6: Assess anticipated support from partners and family

Step 7: Discuss test procedure and obtain consent

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Specific Quoted References:

1. Travel Tips: Pregnancy. Travelex. Available at https://www.travelvax.com.au/holiday-traveller/travel-tips/pregnancy. Accessed 24 June 2020.
2. Professor Caroline Finch, of Sports Medicine Australia, chair of the National SportSafe Committee and director of the Sports Injury Research Unit at Deakin University, at the National Forum on Pregnancy and Sport.
3. Dr Simon Longstaff

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Other Works Cited

• Testing for hypothyroidism during pregnancy with serum TSH, RANZCOG C-Obs 46 (July 2015)
• Influenza vaccination during pregnancy (and in women planning pregnancy), RANZCOG C-Obs 45 (Nov 2013)
• Maternal Group B Streptococcus in Pregnancy: screening and management, RANZCOG College Statement: C-Obs 19 (Nov 2012)
• Vitamin and Mineral Supplementation and Pregnancy, RANZCOG (May 2015)
• Diagnosis of Gestational Diabetes Mellitus (GDM) and Diabetes Mellitus in Pregnancy, RANZCOG (July 2014)
• 1998 ADIPS Management Guidelines (Hoffman et al) Med J Aust. 1998 Jul 20;169(2):93-7
• Alcohol in Pregnancy, RANZCOG (July 2014)
• Guidelines for Diagnostic Imaging During Pregnancy, ACOG Committee Opinion Number 299, Sep 2004 — replaces No. 158, Sep 1995 (Reaffirmed 2014)
• Travel Issues in Pregnancy, and pregnancy issues in travel, Dr Bob Kass, Globe Medical
• Pregnancy in Sport: Guidelines for the Australian Sporting Industry, Australian Sports Commission (2002) — ISBN 1 74013 055 3
• Perinatal Anxiety and Depression, RANZCOG (March 2015)
• Epilepsy in pregnancy: A collaborative team effort of obstetricians, neurologists and primary care physicians for a successful outcome, Australian Family Physician Vol. 43, No. 3, March 2014
• Prenatal screening and diagnosis of chromosomal and genetic abnormalities in the fetus in pregnancy, RANZCOG (March 2015)
• Management of Obesity in Pregnancy, RANZCOG C-Obs 49 (Sep 2013)
• Cell-free DNA Screening for Fetal Aneuploidy, ACOG Committee Opinion Number 640, Sep 2015 — replaces No. 545
• HIV Counselling for the Asia-Pacific: A comprehensive guide to: Voluntary counselling and testing; Provider-initiated testing and counselling; Treatment and care counselling. UNICEF East Asia and Pacific Regional Office, 2009 (ISBN: 978-974-685-112-1)

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Patient Information

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