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College Statement Statement

The Royal
College Statement
Australian and
C-Obs 3
1st Endorsed: July 1992
New Zealand
Current: November 2009
College of
Review: November 2012
Obstetricians and
Gynaecologists










C-Obs 3

Pre-pregnancy Counselling and routine Antenatal
Assessment in the absence of pregnancy complications

Pre-Pregnancy Counselling
Purpose
All women planning a pregnancy are advised to consult their general practitioner with a view
to:
1) detecting any clinical conditions that may be of relevance to the forthcoming pregnancy
but are ideally managed prior to pregnancy
2) further assessment of any conditions of relevance and optimising any treatment with
respect to the forthcoming pregnancy
3) obtaining general advice regarding personal health care in early pregnancy, in particular,
medications, alcohol, X-rays … etc
Clinical Assessment
Most important is a detailed medical history and clinical examination. The following
investigations are recommended:
1) rubella immunity status (if this is unknown)
2) varicella immunity status (if unknown and the patient does not give a clear history of
varicella)
3) cervical smear (if clinically appropriate)
General Advice
All women planning pregnancy should receive advice with respect to:
1) potential teratogens in early embryogenesis (medications, alcohol, X-rays … etc)
2) where and when to attend in early pregnancy
3) vitamin supplementation (particularly folic acid for 3 months preconception)

First Antenatal Visit in Pregnancy
All women should be advised to attend in early pregnancy with a view to:
1) confirming pregnancy and establishing an estimated date of confinement (albeit that may
alter after subsequent ultrasound examinations)
2) a comprehensive clinical assessment in order to determine any clinical conditions that
may be of relevance to the pregnancy

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RANZCOG College Statement: C-Obs 3
3) detailed assessment of any particular conditions or circumstances of relevance and
optimising management for pregnancy
4) obtaining general advice regarding common issues of concern in early pregnancy and
management of the pregnancy

Clinical Assessment
As always, of greatest importance is a careful medical history and thorough clinical
examination.
The following investigations are recommended (in the absence of specific complications):
Full blood examination
Particular note should be taken of the Mean Corpuscular Volume as a potential indicator of an
underlying Haemoglobinopathy

Blood group and antibody screen
Where the blood group has already been performed it does not need to be repeated. However,
the antibody screen should be repeated at the beginning of each pregnancy.

Rubella antibody status
All women should have their rubella antibody titre measured for each pregnancy. Although the
past antibodies titres from a previous pregnancy screens may have been used to exclude a
further antenatal test, there is evidence that levels may decline, particularly following
immunization as compared to natural infection. This is particularly so given the low level of wild
virus circulating in the community to boost women whose levels may fall below that of
protection.

Syphilis serology
Syphilis testing should be performed by screening with a specific treponema pallidum assay
for example Treponema pallidum haemaglutination assay (TPHA) or the Treponema pallidum
particle assay (TPPT). The non-specific Treponema pallidum assays, such as rapid plasma
regain (RPR) test, although cheaper, are less likely to pick up latent infection.

Midstream urine
Examination by culture, e.g. dip slide.

HIV
Before instituting screening for any viral infection in pregnancy, it is imperative that the woman
is provided with appropriate counselling as to the limitations of screening for viral infections in
pregnancy and the implications of both positive and negative findings.
All pregnant women should be recommended to have HIV screening at the first antenatal visit

Hepatitis B serology
All pregnant women should be recommended to have Hepatitis B screening in pregnancy.

Hepatitis C serology
All pregnant women should be recommended to have Hepatitis C screening in pregnancy.
However it is acknowledged that this is a contentious area of practice.

Varicella
Consideration should be given to checking varicella antibodies at the first visit where there is
no history or uncertain history of previous illness.

Cervical cytology
A cervical (Pap.) smear should be recommended at the first antenatal visit if this would fall due
during the pregnancy, according to cervical screening guidelines. There is no evidence to
suggest that a PAP smear in pregnancy is harmful.

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RANZCOG College Statement: C-Obs 3

Other tests that may be considered
1) Screening for Haemoglobinopathies
Each unit should have a defined policy for screening for haemoglobinopathies, taking into
account the ethnic mix of patients screened. As a minimum, all women should be
screened with MCV and MCHC. Haemoglobin electrophoresis and iron studies should be
performed in the event of thresholds not being reached. Consideration should also be
given to the further screening of patients with DNA analysis for alpha-thalassaemia.
Testing of normal-MCV women for haemoglobinopathies may be considered if they are
members of high-risk groups.
2) Vitamin D
Pregnant women at risk for vitamin D deficiency should be tested in early pregnancy OR
provided with vitamin D supplementation.
3) CMV
Screening for CMV infection in pregnancy is currently not recommended as a routine.
(See consensus statement on CMV in pregnancy.)

General Advice
All women in early pregnancy should be informed with respect to:
1) potential teratogens (medications, alcohol, X-rays … etc)
2) vitamin and mineral supplementation (see college statement)
3) model of care, expected visit frequency, place of booking for confinement, expected costs
for both pregnancy and confinement

Subsequent Visits during the Antenatal Care
All women should be advised to attend in early pregnancy with a view to:
1) early diagnosis of pregnancy complications
2) utilising the principles of preventative medicine to minimise the risk of problems in
pregnancy, labour and the puerperium
3) obtaining advice that will assist the woman in preparation for labour, birth and the early
puerperium
4) ongoing assessment and treatment of any particular conditions or circumstances of
relevance to the pregnancy
5) obtaining general advice regarding common issues of concern in pregnancy

Clinical Assessment
All women should have a directed clinical assessment at each antenatal visit, with a focus on
general well-being and early diagnosis of pregnancy complications. Investigations
recommended are:

1.
Obstetric Ultrasound Scan
All women should be offered an obstetric ultrasound before 20 weeks' gestation. This
will include an ultrasound for fetal morphology and placental localization usually at 18-
20 weeks gestation. Other scans may be indicated depending on individual
circumstances and to assess/confirm dates.

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RANZCOG College Statement: C-Obs 3

2.
Screening for Down syndrome
Refer to C-Obs 4 Antenatal Screening for Down syndrome and other fetal aneuploidy,
(see link below).
3.
Gestational Diabetes
Screening for Gestational Diabetes Mellitus is recommended in all pregnant women.
The original (1998) ADIPS guidelines are available at:
http://www.mja.com.au/public/issues/jul20/hoffman/hoffman.html
4.
Group B Streptococcal Disease (GBS)
Refer to C-Obs: 19 Swabbing for Group B Streptococcus, (see link below).
5.
Blood group antibody testing
Refer to C-Obs 6 Guidelines for the use of Rh-D immunoglobulin (anti-D) in
obstetrics in Australia, (see link below). Further screening is recommended for
Rh negative women at approximately 28 weeks gestation. Screening of Rh
positive women at 28 weeks gestation is at the discretion of the
clinician/managing health service.
6.
Iron deficiency
The haemoglobin level and platelet count should be repeated at 28 weeks gestation. If
anaemia is detected, further investigation is warranted.
7.
Cytomegalovirus/Toxoplasmosis
Selective testing for cytomegalovirus and toxoplasmosis is recommended only for
those women at a substantially increased risk of acquiring an infection. Ideally such
patients should be tested prior to pregnancy.
8.
Syphilis
Syphilis screening should be repeated at 28 weeks in high-risk populations.
9.
Late Pregnancy Tests of fetal well-being
Late pregnancy tests for assessment of feto-placental function should be performed
when indicated on clinical grounds – either through a suspicion of placental
insufficiency, a predisposing factor for placental insufficiency or through an inability to
clinically ascertain fetal growth (e.g. obesity). Tests of fetal wellbeing should be
considered after 41 weeks' gestation. Detailed and frequent assessment of fetal
wellbeing, including an assessment of liquor volume, is mandatory in pregnancies at or
beyond 42 weeks gestation.
10.
Chlamydia
Selective testing for Chlamydia should be considered for those who may be at
increased risk (e.g. less than 25 years).


Links to other related College Statements

C-Obs 4 Antenatal screening for Down Syndrome and other fetal aneuploidy

C-Obs 6 Guidelines for the use of RhD immunoglobulin (anti-D) in obstetrics in Australia

C-Obs 7 Diagnosis and management of gestational diabetes

C-Obs 19 Swabbing for Group B Streptococcus

C-Gen 2 Guidelines for consent and the provision of information regarding proposed treatment

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RANZCOG College Statement: C-Obs 3

C-Gen 3 Hepatitis B

C-Gen 4 Hepatitis C


Patient Resources
RANZCOG patient information pamphlets:
Antenatal care and routine tests during pregnancy - a guide for women (July 2002)
Prenatal Screening tests for Down syndrome and other conditions (July 2002)

References
1. Revision of guidelines for the management of gestational diabetes mellitus, Letter to the
Editor, J J N Oats and H D McIntyre, MJA September 2004.

http://www.mja.com.au/public/issues/181_06_200904/letters_200904_fm-2.html

2. ADIPS Gestational diabetes mellitus – management guidelines, L Hoffman, C

Nolan, J D Wilson, J J N Oats and D Simmons, MJA 1998; 169: 93-97.

http://www.mja.com.au/public/issues/jul20/hoffman/hoffman.html

3. Antenatal Care: Routine care for the healthy pregnant woman, NHS and NICE

October 2003.

http://www.rcog.org.uk/resources/Public/Antenatal_Care.pdf

4. Munns C, Zacharin MR, Rodda CP, Batch JA, Morley R, Cranswick NE, Craig ME, Wayne
S, Cutfield WS, Hofman PL, Taylor BJ, Grover SR, Pasco JA, Burgner D and Cowell CT.
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


Disclaimer
This College Statement is intended to provide general advice to Practitioners. The statement should never be relied on as a
substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient.

The statement has been prepared having regard to general circumstances. It is the responsibility of each Practitioner to have
regard to the particular circumstances of each case, and the application of this statement in each case. In particular, clinical
management must always be responsive to the needs of the individual patient and the particular circumstances of each case.

This College statement has been prepared having regard to the information available at the time of its preparation, and each
Practitioner must have regard to relevant information, research or material which may have been published or become
available subsequently.
Whilst the College endeavours to ensure that College statements are accurate and current at the time of their preparation, it takes
no responsibility for matters arising from changed circumstances or information or material that may have become available after
the date of the statements.


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RANZCOG College Statement: C-Obs 3