Antenatal Protocol
Content
ANTENATAL PROTOCOL
This antenatal protocol is for use in community and hospital
settings to assist doctors, midwives, Aboriginal Health Works
and Rural Area Nurses.
Confidentiality
If woman is positive for HIV, syphilis, hepatitis or other STIs,
please note this as “POSITIVE SEROLOGY” in the risk factor
section on the front of the antenatal record to maintain
patient confidentiality.
Follow up post-natally:
•
Continue maintenance dosage of 1000IU per day until
the cessation of breastfeeding.
•
Repeat level at 6 months post-partum – if deficient,
recommence treatment and continue supplementation
thereafter
•
All breastfed infants of women diagnosed with
moderate-severe vitamin D deficiency in pregnancy
should receive vitamin D supplementation with 400IU
daily (e.g. as Pentavite ®) until 12 months of age
Vitamin D
Vitamin D deficiency in pregnant women is the single
greatest risk factor for vitamin D deficiency in infants.
Vitamin D deficient rickets is easily treated once recognised
but the potential for morbidity and mortality includes
hypocalcaemia seizures, failure to thrive, bone pain,
increased susceptibility to serious infection and potential for
chronic growth problems as well as the more well known
skeletal deformities.
Screening is recommended for all Kimberley women at the
first antenatal visit.
Deficiency = 25-OH-Vitamin D level of:
41-50 nmol/L = mild deficiency
26-40 nmol/L = moderate
<26 nmol/L = severe
Treatment:
Folic Acid
All women should commence supplementation of folic acid
one month prior to conception and continue for the first 3
months of pregnancy to aid in the prevention of neural tube
defects (NTD).
The recommended dose for most women is 0.5mg daily.
The combined iron/folic acid preparations do NOT contain a
sufficient dose of folic acid, however the combined iodine/
folic acid tablets DO.
Where there is an increased risk of NTD, then prescribe 5mg
daily until 14 weeks. This includes women:
•
with a personal or family history of pregnancy/infant
with NTD
•
taking medications which may affect folic acid
absorption (eg anticonvulsants)
•
with diabetes
•
who are obese
Mild deficiency:
Cholecalciferol (D3) 1000IU – 1 tablet daily
Moderate to severe deficiency:
Cholecalciferol (D3) 1000IU: 4000IU (4 tablets)
daily. Repeat level every 6 weeks until >50nmol/L,
then continue with 1000IU (1 tablet) daily1
Iron
Iron deficiency during pregnancy affects maternal well
being, as well as being a strong predictor of iron deficiency
in infants.
Iron rich foods include red meat, liver, sardines, enriched
breakfast cereals, beans.
There is no evidence to support prescription of iron
supplements at booking antenatal visit to women who are
not anaemic (Hb >110) and low risk. Iron therapy in the
first trimester can increase side effects such as nausea and
vomiting.
Therefore:
(1) Screen all women with FBE and iron studies at the first
antenatal visit, and again at the 28 and 36 week visits, and
treat if deficient
(2) For all women, particularly those at increased risk of
iron deficiency (multiple pregnancy and known history of
anaemia), provide routine supplementation with Ferro-tabs 1
tablet daily to prevent iron deficiency
Treatment of iron deficiency:
All women at first antenatal visit with Hb 90-110g/L or
ferritin below the reference range, commence treatment
with Ferro-F® (310mg tablet) or Ferro Liquid 15ml
(30mg/5ml) daily for 4 weeks. It is recommended that
they drink a glass of orange juice (contains vitamin C)
in combination with iron supplementation to improve
absorption.
If Hb< 90, consult GP or Obstetrician.
Repeat FBE and iron levels in 4 weeks to ensure levels are
correcting. If Hb <100, consider BD oral iron or IM iron.
If unable to tolerate oral iron, not willing to take regular
iron tablets/liquid, or levels not correcting with oral iron
therapy, consider IM / parenteral iron. Discuss with GP or
Obstetrician.
Follow-up post-natally:
Check FBE and iron levels at 6 week post-natal visit.
Parasites commonly causing infection in the Kimberley
include hookworm, strongyloides, and pinworm. These may
contribute to iron deficiency.
Parasites
Routine screening for worms during pregnancy is not
recommended.
Medications used to treat parasites such as hookworm and
© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley
VC - Last Modified: December 9, 2010 9:38 AM
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ANTENATAL PROTOCOL
strongyloides, including mebendazole (category C) and
albendazole (Category D) may carry risks in pregnancy.
Pyrantel is the drug of choice for treatment of symptomatic
worm infections during pregnancy.
(eg hyperinfection with stronglyoides). Also consider
treatment of women with anaemia and eosinophilia.
Use 750mg if >45kg and 500mg if <45kg.
Iodine
Studies suggest that the Australian population is mildly
iodine deficient. There are limited studies specific to the
iodine status of pregnant women in Australia, but those
available prior to iodine fortification of bread and salt
suggest it was inadequate.
The main health concern of mild iodine deficiency during
pregnancy and breastfeeding is its negative effect on the
brain and nervous system of unborn children and infants.
Therefore, NHMRC recommends that women who are
pregnant, breastfeeding or considering pregnancy take
an iodine supplement of 150µg each day. Supplements of
150µg/d of iodine are safe and effective for pregnant and
breastfeeding women.
Iodine is currently available (in combination with folic acid)
as Blackmores I-Folic, which contains 250 µg/d of iodine.
Pregnant women should be advised to use iodised salt and
eat plenty of dairy products, seafood, eggs and vegetables,
which are high in iodine.
If a pregnant woman has a pre-existing thyroid condition,
this should be discussed with a GP or Obstetrician prior to
taking a supplement.2
Medications in pregnancy
Important phone numbers
All women on regular medications need to be reviewed by
a GP.
Kimberley Regional Obstetrician .................(08) 9194 2222
For information on the safety of medicines in pregnancy,
contact the KEMH Obstetric Drug Information Service on
9340 2723.
KEMH Obstetric Drug Info Service ..............(08) 9340 2723
KEMH ........................................................(08) 9340 2222
1 Munns C, et al. Prevention and treatment of infant and childhood vitamin D
deficiency in Australia and New Zealand: a consensus statement. MJA 2006: 185 (5)
268-272. http://www.mja.com.au/public/issues/185_05_040906/mun10153_fm.html
Exercise in pregnancy
Currently, most experts recommend that pregnant women
be encouraged to continue and maintain an active lifestyle
during their pregnancies, in the absence of medical and
obstetrical complications. Exercise may even improve some
pregnancy outcomes.
2 NHMRC Public Statement, January 2010, Iodine Supplementation for pregnant
and Breastfeeding Women http://www.nhmrc.gov.au/_files_nhmrc/file/publications/
synopses/new45_statement.pdf
3 Artal, R. Recommendations for exercise during pregnancy and the postpartum
period. Up To Date 2009 http://www.uptodate.com
The approach to exercise prescription for pregnant women
does not differ markedly from that used in non pregnant
individuals. Sedentary healthy women can safely begin
an exercise program during pregnancy. Pregnant women
who, prior to becoming pregnant, regularly participated
in strenuous recreational or competitive physical activities
may be advised to modify their exercise routines or
activity patterns. Similarly, modifications in activity may be
necessary for pregnant women with medical or obstetric
complications. Pregnant women with diabetes, severe
obesity, or hypertension, should be counseled on an
individual basis in consultation with GP or Obstetrician.3
P
R
O
T
O
C
O
L
Pregnant women should avoid becoming overheated
during exercise. Suggest exercising at the coolest time of
the day, either early in the morning, evening or in a cool
environment. Pregnant women should drink plenty of fluids
before, during and after exercising.
© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley
A
N
T
E
N
A
T
A
L
VC - Last Modified: December 9, 2010 9:38 AM
This antenatal protocol is for use in community and hospital
settings to assist doctors, midwives, Aboriginal Health Works
and Rural Area Nurses.
Confidentiality
If woman is positive for HIV, syphilis, hepatitis or other STIs,
please note this as “POSITIVE SEROLOGY” in the risk factor
section on the front of the antenatal record to maintain
patient confidentiality.
Follow up post-natally:
•
Continue maintenance dosage of 1000IU per day until
the cessation of breastfeeding.
•
Repeat level at 6 months post-partum – if deficient,
recommence treatment and continue supplementation
thereafter
•
All breastfed infants of women diagnosed with
moderate-severe vitamin D deficiency in pregnancy
should receive vitamin D supplementation with 400IU
daily (e.g. as Pentavite ®) until 12 months of age
Vitamin D
Vitamin D deficiency in pregnant women is the single
greatest risk factor for vitamin D deficiency in infants.
Vitamin D deficient rickets is easily treated once recognised
but the potential for morbidity and mortality includes
hypocalcaemia seizures, failure to thrive, bone pain,
increased susceptibility to serious infection and potential for
chronic growth problems as well as the more well known
skeletal deformities.
Screening is recommended for all Kimberley women at the
first antenatal visit.
Deficiency = 25-OH-Vitamin D level of:
41-50 nmol/L = mild deficiency
26-40 nmol/L = moderate
<26 nmol/L = severe
Treatment:
Folic Acid
All women should commence supplementation of folic acid
one month prior to conception and continue for the first 3
months of pregnancy to aid in the prevention of neural tube
defects (NTD).
The recommended dose for most women is 0.5mg daily.
The combined iron/folic acid preparations do NOT contain a
sufficient dose of folic acid, however the combined iodine/
folic acid tablets DO.
Where there is an increased risk of NTD, then prescribe 5mg
daily until 14 weeks. This includes women:
•
with a personal or family history of pregnancy/infant
with NTD
•
taking medications which may affect folic acid
absorption (eg anticonvulsants)
•
with diabetes
•
who are obese
Mild deficiency:
Cholecalciferol (D3) 1000IU – 1 tablet daily
Moderate to severe deficiency:
Cholecalciferol (D3) 1000IU: 4000IU (4 tablets)
daily. Repeat level every 6 weeks until >50nmol/L,
then continue with 1000IU (1 tablet) daily1
Iron
Iron deficiency during pregnancy affects maternal well
being, as well as being a strong predictor of iron deficiency
in infants.
Iron rich foods include red meat, liver, sardines, enriched
breakfast cereals, beans.
There is no evidence to support prescription of iron
supplements at booking antenatal visit to women who are
not anaemic (Hb >110) and low risk. Iron therapy in the
first trimester can increase side effects such as nausea and
vomiting.
Therefore:
(1) Screen all women with FBE and iron studies at the first
antenatal visit, and again at the 28 and 36 week visits, and
treat if deficient
(2) For all women, particularly those at increased risk of
iron deficiency (multiple pregnancy and known history of
anaemia), provide routine supplementation with Ferro-tabs 1
tablet daily to prevent iron deficiency
Treatment of iron deficiency:
All women at first antenatal visit with Hb 90-110g/L or
ferritin below the reference range, commence treatment
with Ferro-F® (310mg tablet) or Ferro Liquid 15ml
(30mg/5ml) daily for 4 weeks. It is recommended that
they drink a glass of orange juice (contains vitamin C)
in combination with iron supplementation to improve
absorption.
If Hb< 90, consult GP or Obstetrician.
Repeat FBE and iron levels in 4 weeks to ensure levels are
correcting. If Hb <100, consider BD oral iron or IM iron.
If unable to tolerate oral iron, not willing to take regular
iron tablets/liquid, or levels not correcting with oral iron
therapy, consider IM / parenteral iron. Discuss with GP or
Obstetrician.
Follow-up post-natally:
Check FBE and iron levels at 6 week post-natal visit.
Parasites commonly causing infection in the Kimberley
include hookworm, strongyloides, and pinworm. These may
contribute to iron deficiency.
Parasites
Routine screening for worms during pregnancy is not
recommended.
Medications used to treat parasites such as hookworm and
© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley
VC - Last Modified: December 9, 2010 9:38 AM
A
N
T
E
N
A
T
A
L
P
R
O
T
O
C
O
L
ANTENATAL PROTOCOL
strongyloides, including mebendazole (category C) and
albendazole (Category D) may carry risks in pregnancy.
Pyrantel is the drug of choice for treatment of symptomatic
worm infections during pregnancy.
(eg hyperinfection with stronglyoides). Also consider
treatment of women with anaemia and eosinophilia.
Use 750mg if >45kg and 500mg if <45kg.
Iodine
Studies suggest that the Australian population is mildly
iodine deficient. There are limited studies specific to the
iodine status of pregnant women in Australia, but those
available prior to iodine fortification of bread and salt
suggest it was inadequate.
The main health concern of mild iodine deficiency during
pregnancy and breastfeeding is its negative effect on the
brain and nervous system of unborn children and infants.
Therefore, NHMRC recommends that women who are
pregnant, breastfeeding or considering pregnancy take
an iodine supplement of 150µg each day. Supplements of
150µg/d of iodine are safe and effective for pregnant and
breastfeeding women.
Iodine is currently available (in combination with folic acid)
as Blackmores I-Folic, which contains 250 µg/d of iodine.
Pregnant women should be advised to use iodised salt and
eat plenty of dairy products, seafood, eggs and vegetables,
which are high in iodine.
If a pregnant woman has a pre-existing thyroid condition,
this should be discussed with a GP or Obstetrician prior to
taking a supplement.2
Medications in pregnancy
Important phone numbers
All women on regular medications need to be reviewed by
a GP.
Kimberley Regional Obstetrician .................(08) 9194 2222
For information on the safety of medicines in pregnancy,
contact the KEMH Obstetric Drug Information Service on
9340 2723.
KEMH Obstetric Drug Info Service ..............(08) 9340 2723
KEMH ........................................................(08) 9340 2222
1 Munns C, et al. Prevention and treatment of infant and childhood vitamin D
deficiency in Australia and New Zealand: a consensus statement. MJA 2006: 185 (5)
268-272. http://www.mja.com.au/public/issues/185_05_040906/mun10153_fm.html
Exercise in pregnancy
Currently, most experts recommend that pregnant women
be encouraged to continue and maintain an active lifestyle
during their pregnancies, in the absence of medical and
obstetrical complications. Exercise may even improve some
pregnancy outcomes.
2 NHMRC Public Statement, January 2010, Iodine Supplementation for pregnant
and Breastfeeding Women http://www.nhmrc.gov.au/_files_nhmrc/file/publications/
synopses/new45_statement.pdf
3 Artal, R. Recommendations for exercise during pregnancy and the postpartum
period. Up To Date 2009 http://www.uptodate.com
The approach to exercise prescription for pregnant women
does not differ markedly from that used in non pregnant
individuals. Sedentary healthy women can safely begin
an exercise program during pregnancy. Pregnant women
who, prior to becoming pregnant, regularly participated
in strenuous recreational or competitive physical activities
may be advised to modify their exercise routines or
activity patterns. Similarly, modifications in activity may be
necessary for pregnant women with medical or obstetric
complications. Pregnant women with diabetes, severe
obesity, or hypertension, should be counseled on an
individual basis in consultation with GP or Obstetrician.3
P
R
O
T
O
C
O
L
Pregnant women should avoid becoming overheated
during exercise. Suggest exercising at the coolest time of
the day, either early in the morning, evening or in a cool
environment. Pregnant women should drink plenty of fluids
before, during and after exercising.
© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley
A
N
T
E
N
A
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A
L
VC - Last Modified: December 9, 2010 9:38 AM
