Antenatal Assessment & Care (Part I) PDF

Antenatal Assessment & Care (Part I) Bachelor of Science (Honours) in Nursing School of Nursing Dr Vivian Ngai 13 September 2024 Learning Outcomes By the end of this session, students will be able to: Discuss current trends of maternal & child health Describe the purposes & essential componen...

Antenatal Assessment & Care (Part I) Bachelor of Science (Honours) in Nursing School of Nursing Dr Vivian Ngai 13 September 2024 Learning Outcomes By the end of this session, students will be able to: Discuss current trends of maternal & child health Describe the purposes & essential components of prenatal care Identify critical elements of prenatal assessment, including health history, physical examination, blood & urine tests Vital Statistics Birth rate: no. of live births in one year per 1000 population Maternal mortality rate: no. of maternal deaths per 100,000 live births that occur as a direct result of pregnancy, including _________day 42 postpartum period Infant mortality rate: no. of deaths of infants under ___________ year of age per one 1000 live births Neonatal mortality rate: no. of deaths of infants younger than ____________ 28 days per 1000 live births 24 Stillbirth: the birth of baby with no signs of life after ____________weeks of pregnancy (and or weight ≥ ____________ Job gm) Perinatal mortality: no. of stillbirths & deaths in ____________ 1st week of life Maternal & Child Health Maternal mortality In 2020, almost 800 women died every day from preventable causes related to pregnancy and childbirth ~ 95% of all maternal deaths occurred in low & lower middle-income countries In 2020, maternal mortality ratio in low-income countries is 430 versus 12 per 100,000 live births in high-income countries Higher in women living in rural areas, poorer communities, adolescents Primary causes of maternal deaths worldwide Severe bleeding (mostly bleeding after childbirth) Infections (usually after childbirth) High blood pressure during pregnancy Complications from delivery e.g. obstructed labor Unsafe abortion (World Health Organization, 2023) ↓ Prenatal Care Purposes To assess health status of mothers & fetus To monitor the progress of pregnancy To have early detection of at risk mothers or fetus To promote self-care of pregnant women To provide holistic care to pregnant women & their family members Schedule First antenatal visit Subsequent visits Prenatal Assessment Health history Physical examination Blood tests Urine tests Health History Current pregnancy Reproductive history Past medical, surgical & personal history Family history Psychosocial health assessment Health History Current pregnancy Signs & symptoms of pregnancy Urine/blood test for hCG 1st day of last menstrual period (LMP) Calculate expected date of confinement (EDC) / expected date of delivery (EDD) using Nagele’s rule Example only accurate in woman with 28-day cycle Lop = 3 September 2024 EDC = LMP – (3 months) + 7 days EDC = 10 June 2025 Gestation calculator – EDC wheel Health History Reproductive history Menstrual history age at menarche, menstrual cycle, duration, regularity No. of pregnancies/abortion/living children Past experience in pregnancy, labor, puerperium Previous surgery Previous infection Date of last Pap smear, any abnormal Pap smear results Contraceptive history Gravida & Para Gravida: a pregnant woman Gravidity: the no. of times a woman has been pregnant G0 = never pregnant (Nulligravida) G1 = 1st pregnancy (Primigravida) G2 = 2nd pregnancy (Multigravida) 3rd G3 = _________________ Multigravida (________________) pregnancy G5 = _________________ 5th pregnancy (Grand multigravida) Para: a woman who has given birth to a child, alive/dead, excluding abortions Parity: _____________________________________________________________________________ P0 (Nullipara), P1 ________________, P2 _______________, P3 ________________, P5 _______________ Two digits system e.g. A woman who is pregnant for the 1st time: G 1 P 0 A woman who has had a miscarriage at 8 weeks of pregnancy & now is pregnant? G _____ 2 A P ______ Health History Past medical, surgical & personal history? · Family history? Health History Psychosocial health assessment? Physical Examination Height, weight Vital signs Head-to-toe physical examination Abdominal examination Vaginal/pelvic examination Physical Examination Height & Weight Height > ____________________ 150 indicate normal-sized pelvis Obesity Vital signs BP: normal < _____________________ 140190 mmHg Physical Examination Head-to-toe physical examination ◦ Face ◦ Abdomen ◦ Mouth, teeth ◦ Elimination ◦ Thyroid ◦ Vagina ◦ Heart ◦ Pelvic ◦ Lung ◦ Extremeties ◦ Breast Breast Examination Inspection size, shape, symmetry nipples more prominent darker pigmentation of areolae & nipples Montgomery tubercles around areola blood vessels enlarged, shinny blue colostrum secretion Inspect the breasts in various postures Seated with arms at side Arms over head Leaning over Hands pressed together Breast Examination Palpation technique Use the flat pads of 3 fingers to palpate client’s breasts Patterns for palpation Circular Wedged Vertical strip Use the bimanual technique if client has large breasts Palpation tenderness & nodular axillary lymph nodes Abdominal Examination Purpose to assess fetal size & growth to identify fetal lie, attitude, position, presentation & engagement to assess fetal health to determine no. of fetuses Preparation client - empty bladder, supine position Procedure inspection palpation auscultation Abdominal Examination Inspection size, shape skin linea nigra classical : 44 (1) striae gravidarum : lower segment (1) scars fetal movement  Abdominal Examination Palpation Fundal height – estimate period of gestation Symphysis-fundal height measure the distance between upper edge of symphysis pubis & the top of fundus 1cm = 1 week gestation from _________ 14-34 weeks Landmarks in assessing gestation Symphysis pubis __________________ 12 weeks Umbilicus _______________________ weeks 2 36 Xiphisternum ____________________ weeks Abdominal Examination Palpation Leopold’s maneuvers Fetal lie Fetal presentation Fetal attitude Fetal position Engagement Leopold’s Maneuvers First maneuver palpate upper abdomen (uterine fundus) Second maneuver right hand remains steady on one side of abdomen while left hand explores right side of woman's uterus, then repeat using the opposite side & hands Third maneuver grasp the lower portion of abdomen just above symphysis pubis with right hand Fourth maneuver face woman's feet, fingers of both hands moved gently down the sides of uterus toward pubis Abdominal Examination Palpation Fetus Description Lie Relationship between long axis of fetus & long axis of uterus # e.g. longitudinal / oblique / transverse lie Presentation The part of fetus which lies at the pelvic brim or in the lower pole of the uterus Attitude Relationship of fetal head to spine Position Relationship between the denominator of presentation part & pelvic brim Denominator Presenting part: vertex=occiput, breech=sacrum, face=mentum Engagement Occur when the widest presenting transverse diameter has passed through pelvic brim Fetal Presentation Copyright © Churchill Livingstone Fetal Attitude ‘Vertex presentation’ 12cm 13.5cm Copyright © Elsevier Fig. 1 Fig. 2 Fig. 3 Copyright © Lippincott Williams & Wilkins Fetal Position Engagement The rule of fifth Palpable fifth of fetal head is palpable above the level of symphysis pubis When 2/5 or less of fetal head is palpated above the level of symphysis pubis  the head is engaged  Abdominal Examination Auscultation Normal fetal heart rate: ______________ 110-160 /min, regular Doppler: ________________________weeks 8 17 ~ - 17-19 Fetal stethoscope: __________________weeks ~ Best heard at fetal spine near scapula Copyright © Lippincott Williams & Wilkins Abdominal Examination Example of Documentation I have examined Mrs. Chan, a 28-year-old female, who is currently at 36 weeks gestation. On inspection, the abdomen was ovoid/round in shape. The umbilicus was flattened and darkened. Linea nigra and striae gravidarum were present. No scars or fetal movements were observed. On palpation, symphyseal-fundal height was 36cm, which corresponded with her current gestation. The fetus was positioned in a longitudinal lie with a vertex presentation, and a left occipito-anterior position. The fetal head was two fifths palpable above the pelvic brim. On auscultation, fetal heart rate is 130 beat per minute and regular. Vaginal/Pelvic Examination Purpose Confirm pregnancy Assess uterine size Assess pelvic size Exclude abnormalities e.g. uterine fibroid, ovarian cyst, ca cervix, incompetent os Vaginal/Pelvic Examination Speculum examination Bimanual examination Pelvic measurement Vaginal Examination Speculum examination Characteristics of vaginal & cervical mucosa Unusual lesions Vaginal discharge 35-37 Vaginal & rectal swab culture for Group B streptococcus (___________________weeks)  Pap Smear for cervical cytology  Culture as indicated Cervix os open or close thicken Chadwick's bluish discoloration (______________________________________ sign) mucus abnormal discharge/bleeding  Vaginal Examination Bimanual examination In early pregnancy Consistency of cervix softening (________________________________ Goodell's sign) Size, shape & consistency of uterus softening of isthmus (______________________ Hegar's sign) Detect pelvic abnormality Pelvic measurement estimate of pelvic capacity detect cephelo-pelvic disproportion (CPD) ± X-ray pelvimetry AGE- An Copyright © Lippincott Williams & Wilkins  Blood Tests & Complete blood picture I ABO grouping Rhesus factor (Rh) Rubella antibody Hepatitis B surface antigen (HbsAg) Venereal disease – Syphilis Human Immunodeficiency Virus (HIV) antibody Blood Tests Complete blood picture Haemoglobin (Hb) ___________________ 211 g/dl  Anaemia Mean cell volume (MCV) haemorrhage + shock detect thalassaemia ABO grouping  Blood Tests Rhesus factor to detect Rhesus isoimmunization check blood for anti-Rh antibodies If negative: monitor during pregnancy, after amniocentesis, abortion or delivery If positive: give Rh anti-D immunoglobulin injection (Rogan) within ____________ 72 hours after delivery Copyright © Lippincott Williams & Wilkins Blood Tests FEF Fy : Rubella antibody If negative: avoid contact people suffering from Rubella Advice vaccination in puerperium with reliable contraceptive method for 3 at least _______________________ months Hepatitis B surface antigen (HbsAg) If positive Hepatitis B immunoglobulin & vaccine soon after birth to newborn Blood precaution Blood Tests Venereal disease research laboratory (VDRL) to detect any Syphilis infection confirm with Fluorescent treponemal antibody-absorption test Early treatment Human Immunodeficiency Virus (HIV) antibody Early detection of HIV infection & prompt treatment can help reduce the risk of transmitting the virus to child by two-thirds Urine Tests Glycosuria GDM Proteinuria Kidney disease UTI hypertension , , ± Ketone SlS : fever , nausea , vomiting > - dehydration Prenatal Care Subsequent prenatal assessment General condition Body weight & height Blood pressure Urine test for protein & glucose Abdominal examination Copyright © Family Health Service, Department of Health Antenatal Assessment & Care (Part II) Learning Outcomes By the end of this session, students will be able to: Discuss common antenatal tests in the assessment of fetal well-being Identify factors that contribute to high-risk pregnancy Describe nursing assessment & management for pregnant women experiencing complications: Abortion Antepartum Haemorrhage (APH) Gestational Diabetes Mellitus (GDM) Pregnancy Induced Hypertension (PIH) Assessment of Fetal Well-being Fetal heat rate (FHR) Fetal movement (Kick counts) Non-stress Test (NST) – measure response of FHR in relation to fetal movement by Cardiotocography (CTG) Ultrasonography (USG) Prenatal Diagnosis – detect congenital abnormalities or hereditary condition Biochemical Screening Amniocentesis Chorionic Villus Sampling (CVS) Cordocentesis Fetoscopy Ultrasonography Methods Transabdominal USG Transvaginal USG Clinical applications Confirm pregnancy Confirm viability of fetus Determine gestational age, assess fetal size & growth Evaluate fetal well-being e.g. movement, tone & breathing in biophysical profile Detect congenital anormalies, fetal malformation Detect multiple pregnancies Confirm fetal presentation in uncertain cases Assess placental location & function, utero-placental blood flow Detect placenta previa / abruption placenta Assess amniotic fluid volume (AFV), detect polyhydramnios & oligohydramnios Detect macrosomia, intrauterine growth restriction (IUGR) Detect uterine & pelvic abnormalities Ack: 800 < & = Confirm intrauterine death (IUD) > 2 : Ey Ultrasonography high density : bone low : blank Male Gestational Age - Female 1st trimester ND Crown-rump length (CRL) 2nd & 3rd trimester Femur length Abdominal circumference Bi-parietal diameter Head circumference Prenatal Diagnosis Non-invasive Prenatal Screening Tests in HK 7y : F Screening Tests Time Detection rate 1st tier 1st trimester Maternal age, gestation, history of T21 _____________weeks 11-137 80-90 _______% combined Nuchal translucency (NT) Result: ________week ~ ] screening Pregnancy-Associated Plasma Protein-A (PAPP-A) Free β-hCG 2nd trimester Biochemical marker: 16-19 % _____________weeks fo _______% ~ biochemical Alpha-fetalprotein (AFP) Result: _______ weeks ~ 2 screening hCG 2nd tier Non-invasive DNA test of fetal chromosomal abnormalities 7 _____________ 10 weeks 90-99 _______% ~ Prenatal Test e.g. Down syndrome (trisomy 21), Edwards syndrome Result: _________ ~ / week (NIPT) (trisomy 18), Patau syndrome (trisomy 13) neck Nuchal Translucency measure thickness of subcutaneous translucency between skin & soft tissue overlying cervical spine ↑thickness  Down’s syndrome  Prenatal Diagnosis Invasive Diagnostic Procedures: Methods Description Tests Time Complications Chorionic Chorion villi is aspirated Chromosome, perforation of membranes 11-13 villus sampling transcervically/abdominally metabolic __________weeks N maternal-fetal hemorrhage, (CVS) under USG guide disorders Rh-isoimmunization, chorioamnionitis, abortion Amniocentesis Amniotic fluid is aspirated AFP, Amniotic leakage, transabdominally Chromosome __________weeks ~16 - 20 chorioamnionitis, Rh- isoimmunization, abortion Cordocentesis Fetal blood is obtained Chromosome, fetal haemorrhage, (Percutaneous from umbilical cord, 18-24 pH, anemia, __________weeks bradycardia, perforation of umbilical transabdominally under infection, membranes, blood USG metabolic chorioamnionitis, abortion sampling) disorders Copyright © Lippincott Williams & Wilkins Pregnancy at Risk Abortion Antepartum Haemorrhage (APH) Gestational Diabetes Mellitus (GDM) Pregnancy Induced Hypertension (PIH) Abortion Definition expulsion of fetus either spontaneously or by induction, before the fetus is viable 24 < _______________ weeks’ gestation or weights < __________________gm 500 Classification Spontaneous Abortion Induced Abortion Threatened abortion Legal (Therapeutic abortion) Imminent/Inevitable abortion Illegal (Criminal abortion) Incomplete abortion Complete abortion Missed abortion  Abortion Causes Chronic maternal diseases e.g. ___________________________________________ , DM , HT chronic nephritis Kidney Hormonal deficiency Nutritional deficiency Infections ABO incompatibility Incompetent cervix Congenital abnormality of uterus Abnormality of conceptus S  Spontaneous Abortion ___________________% pregnancy end in abortion, usually of unknown cause No-15 S/S: Threatened abortion Imminent Incomplete Complete abortion Missed abortion abortion abortion Vaginal bleeding, Profuse bleeding, Bleeding is profuse Uterus is contracted Brownish vaginal lower abdominal pain, ↑abdominal pain Bleeding & pain stop discharge backache No products of May contain Part of conception is All products of Fetus dies in uterus conception are products of retained in uterus conception are & not expelled expelled conception expelled Cervix is closed, Cervix dilates, Cervix is dilated or Cervix may be closed Cervix is closed membrane intact, ±membranes partly closed Cessation of s/s placenta still attached rupture Risk of infection pregnancy to uterine wall -ve pregnancy test Threatened Abortion Nursing Care Management Bed rest Assess amount of bleeding Monitor vital signs, FHR, USG Speculum exam to exclude local lesions, stage of cervical os Vulval swabbing Gentle ambulation after bleeding stops for 48hrs Subsequent care Advice high fiber diet to prevent constipation, rest & avoid sexual activity Abdominal exam & serial USG to monitor fetal growth, note fetal movement Report when bleeding occur If contractions fail to subside, bleeding become bright red & ↑amount, abortion may become inevitable Psychological support to woman & her family Induced Abortion Legal abortion Termination of pregnancy (TOP) can be performed with woman’s consent, if 2 registered medical practitioners are of opinion that: Continuing pregnancy would involve risk to life of pregnant woman or injury to her physical/mental health, greater than if the pregnancy were terminated; or There is substantial risk if the child was born, would suffer from physical/mental abnormalities TOP can only be performed within 24 weeks of pregnancy, unless it is absolutely necessary for saving the life of pregnant woman TOP must be carried out by a registered medical practitioner in approved institutions e.g. Hospital, Family Planning Association of Hong Kong (Family Planning Association of Hong Kong, 2024) Legal Abortion Management Medical method e.g. Mifepristone, Misoprostol Complications e.g. bleeding, uterine cramping, nausea, vomiting, diarrhea, headache, dizziness Surgical method e.g. Aspiration (vacuum/suction), Dilation & Curettage (D&C) / Dilation & Evacuation (D&E) Complications e.g. Haemorrhage, infection, trauma Long-term effects e.g. Infertility, salpingitis, chronic pelvic infection, premature labor during subsequent pregnancies Antepartum Haemorrhage (APH)  24th Bleeding from genital tract after ____________ week of pregnancy & before delivery of baby  Causes Placenta praevia (PP) Abruptio placenta (AP) Marginal haemorrhage Rupture of Vasa praevia Vasa praevia – fetal blood vessel lie over internal os in front of presenting part Local conditions e.g. cervical polyp, cervical erosion, carcinoma of cervix, vaginitis APH of unknown origin  Au Placenta Praevia Copyright © Lippincott Williams & Wilkins  Placenta is situated partly/completely in lower uterine segment of uterus Types Descriptions Type I (Minor praevia / Lower placental edge encroach onto lower segment but low-lying placenta) not reaching internal os Type II (Marginal Lower margin of placenta reach but does not cover praevia) internal os Type III (Partial praevia) Placenta overlie internal os when closed, but not completely when dilated Type IV (Total praevia) Placenta lie centrally over internal os Placenta Praevia Causes Unknown Associated factors Multiple pregnancy bigger placenta : Advanced age Multiparity Smoking Previous C/S with scarring of endometrium Previous suction curettage of uterus for induced/spontaneous abortion Placenta Praevia Clinical features Painless vaginal bleeding, usually occur in 3rd trimester Bleeding can occur during rest or activity suddenly & without warning after trauma, coitus or pelvic exam Abdominal exam Uterus soft, non-tender, corresponds to date High presenting part / malpresentation Diagnosis – ultrasound scan Management depends on: amount of bleeding conditions of mother & fetus location of placenta stage of pregnancy  AG Abruptio Placenta Bleeding from premature separation of whole/part of a normally situated 24th placenta from _____________week of pregnancy until the birth of baby Risk factors Advanced maternal age, multiparity, smoking, drug abuse Pregnancy induced hypertension (PIH) Multiple pregnancy Direct trauma Rapid uterine decompression Short umbilical cord ↑ Chorioamnionitis Thrombophilitic conditions Abruptio Placenta Types Marginal (mild) Partial (concealed/apparent bleeding) Complete (massive vaginal bleeding) Copyright © Lippincott Williams & Wilkins Classification - according to type a degree of placental detainment Grade Criteria 0 Asymptomatic 1 Mild separation – minimal vaginal bleeding & changes in maternal vital signs no fetal distress or hemorrhagic shock 2 Moderate separation – fetal distress, uterus is tense & painful on palpation 3 Severe separation – maternal hypovolemic shock & may lead to fetal death Abruptio Placenta Clinical features Abdominal exam Uterus is hard, tense & tender Difficult to palpate fetal parts & auscultate fetal heart USG Placental separation with retroplacental clots Complications of APH Maternal Haemorrhagic shock, hypvolaemia  renal failure Postpartum haemorrhage (PPH) Coagulation disorder e.g. hypofibrinogenemia, thrombocytopenia Fetal Low birth weight (LBW), Intrauterine growth retardation (IUGR) Fetal hypoxia  fetal death ↓ Ov Gestational Diabetes Mellitus GDM)  Hyperglycaemia has its onset or first diagnosed during pregnancy  Risk factors  obesity, advanced age, glycosuria, macrosomia, polyhydramnios,  family or previous history of GDM, unexplained stillbirth, macrosomia, fetal abnormaly  Diagnosis  Oral glucose tolerance test (OGTT) – 75g load Test Glucose level (mmol/L) Glucose level (mg/dl) Fasting 5.1 92 1 hour 10.0 180 2 hour 8.5 153 (WHO, 2013)  Gestational Diabetes Mellitus  Management  Diet control  30 _____________ kcal/kg/day  40 45 Proportion of Carbohydrate : Protein : Fat (__________% - 12-20 : ____________% 35-40 : ___________%)  High complex carbohydrate, adequate fiber  3 meals + 3 snakes, spaced 2-3hrs interval, bed time snack  Individual meal plan according to personal lifestyle, culture food preferences, work schedule, exercise  Medication  Oral hypoglycaemic agents, e.g., metformin  Insulin  Monitor effectiveness of treatment  Blood sugar series (BSS)  Glycosylated haemoglobin (HbA1c)  Home glucose monitoring with haemoglucostix Gestational Diabetes Mellitus Maternal complications Fetal / Neonatal complications ↑Pregnancy induced hypertention (PIH) Congenital anomalies Polyhydramnios Macrosomia Preterm labor Birth trauma, shoulder dystocia ↑Operative delivery Neonatal hypoglycemia Complications of DM Neonatal Jaundice (NNJ) Recurrent of GDM in subsequent IUGR, Prematurity, ↑IUD pregnancy Hypertension in Pregnancy Classification Gestational hypertensive disorders Development of hypertension after 20 weeks of gestation Gestational hypertension – without proteinuria, ± pathological edema Pre-eclampsia (PET) – Proteinuria, ± pathological edema Eclampsia – Proteinuria, convulsion, ± pathological edema Chronic hypertensive disorders Chronic hypertension – HT preceding pregnancy Superimposed PET – Chronic HT associated with PET Hypertension in Pregnancy Diagnosis Hypertension into 190 BP ≥ ___________________mmHg 34 on 2 occasions __________hours apart OR BP ≥ ___________________mmHg 160/no at any occasion Proteinuria It Dipstick urinalysis ≥ _______ 30 Spot urine protein to creatinine ratio  __________________ mg/mmol 300 24hrs urine – Protein ≥ __________________ mg/24hrs Other features Edema, hyperuricaemia, thrombocytopenia Hypertension in Pregnancy Causes Unknown Risk factors Primigravida Advanced age Pre-existing HT, previous/family history of PET multiple preg Pelyhydramions Conditions associated with large placental site, e.g.___________________________. Obesity DM Smoking  Hypertension in Pregnancy Complications Maternal  ↑maternal mortality & morbidity rate Eclamptic seizure, cerebral haemorrhage Pulmonary edema Renal failure Liver haemorrhage / failure HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelet count) Thrombocytopenia, Disseminated intravascular coagulopathy (DIC) APH – Abruptio placenta, placental failure Fetus: IUGR, prematurity Hypertension in Pregnancy Management Depends on severity maturity fetal well-being maternal response to treatment Principles Control BP Prevent eclampsia Monitor maternal & fetal well-being References American College of Obstetricians and Gynecologists (ACOG) (2018). Gestational diabetes mellitus. ACOG practice bulletin no.190. Washington, DC: ACOG. Centre for Health Protection (2024). Infant Mortality rate and maternal mortality ratio: 1981 – 2023. Hong Kong: Department of Health. Retrieved from https://www.chp.gov.hk/en/statistics/data/10/27/113.html Cheung, K. W., Seto, M. T. Y., Wang, W., Ng, C. T., To, W. W. K., & Ng, E. H. Y. (2022). Trend and causes of maternal death, stillbirth and neonatal death over seven decades in Hong Kong. The Lancet Regional Health. Western Pacific, 26, 100523-100523. Davidson, M.R., London, M.L., & Ladewig, P.W. (2020). Old’s maternal-newborn nursing & women’s health across the lifespan (11th ed.). New York: Pearson Prentice Hall. Department of Health (2021). Healthy eating during pregnancy and breastfeeding. Retrieved from http://www.fhs.gov.hk/english/health_info/woman/ 20036.html Department of Obstetrics & Gynaecology, The Chinese University of Hong Kong (2022). Non-invasive Prenatal Test (NIPT) for chromosomal abnormality. Retrieved from https://www.obg.cuhk.edu.hk/fetal-medicine/fetal-medicine_services/nipt/ References Durham, R. F., & Chapman, L. (2023). Maternal-newborn nursing: The critical components of nursing care (4th ed.). Philadelphia: F. A. Davis Company. Family Health Service, Department of Health (2019). Prenatal screening for Down Syndrome. Retrieved from http://www.fhs.gov.hk/english/health_info/woman/20039.html Family Planning Association of Hong Kong (2024). Termination of pregnancy. Retrieved from https://www.famplan.org.hk/en/our-services/clinic-services/termination-of-pregnancy/content Hong Kong College of Obstetricians and Gynaecologists (2016). Guidelines for the management of gestational diabetes mellitus. Retrieved from http://www.hkcog.org.hk/hkcog/Download/Guidelines_on_GDM_updated.pdf LaMorte, W. W. (2021). Down Syndrome and maternal age. Boston University School of Public Health. Retrieved from https://sphweb.bumc.bu.edu/otlt/MPH-Modules/PH717-QuantCore/PH717- Module11-Confounding-EMM/PH717-Module11-Confounding-EMM3.html London, M., Ladewig, P., Davison, M. R., Ball, J., MacGillis, R. C., & Cowen, K. (2022). Maternal & child nursing care (6th ed.). Hoboken, N.J.: Pearson Education. References Lowdermilk, D. L., Perry, S. E., Cashion, K., Alden, K. R., & Olshansky, E. F. (2024). Maternity women’s health care (13th ed.). St. Louis, MO: Elsevier Inc. National Institute for Health and Care Excellence (NICE) (2019). Hypertension in pregnancy: Diagnosis and management. Retrieved from https://www.nice.org.uk/guidance/ng133/resources/hypertension-in-pregnancy-diagnosis-and- management-pdf-66141717671365 Silbert-Flagg, J., & Kennedy, C. E. (2023). Maternal & child health nursing: Care of the childbearing & childrearing family (9th ed.). Philadelphia: Wolters Kluwer. World Health Organization (2013). Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy. Retrieved from http://apps.who.int/iris/bitstream/10665/85975/1/WHO_NMH_MND_13.2_eng.pdf?ua=1 World Health Organization (2022). First trimester abortion pocket book for health care providers. Retrieved from file:///Users/vivianngai/Downloads/9789290209775-eng.pdf World Health Organization (2023). Trends in maternal mortality 2000 to 2020. Retrieved from https://www.who.int/publications/i/item/9789240068759