Med2Date — Clinical Guidelines
Home Family Medicine Basic Antenatal Care

Basic Antenatal Care

Last updated 1 Jun 2026 · Obstetrics

📋 Key Information Summary

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  • Preconception care optimises maternal and fetal outcomes — address folate (500 µg daily for ≥1 month pre-conception), iodine (150 µg daily), rubella and varicella immunity, chronic disease optimisation, teratogenic medication review, and lifestyle factors (smoking, alcohol, BMI).
  • First antenatal visit should occur before 10 weeks' gestation where possible; confirm viability and gestation by ultrasound, take a comprehensive history, and initiate baseline investigations (MBS items 16500/16501).
  • Routine booking bloods include FBE, blood group and antibody screen, rubella IgG, hepatitis B surface antigen, hepatitis C antibody (risk-based), HIV antibody, syphilis serology (RPR/TPHA), and MSU — all are Medicare-rebatable.
  • Combined First Trimester Screening (CFTS) at 11–13 weeks (NT ultrasound + serum βhCG and PAPP-A) detects ~90% of trisomy 21; NIPT (cell-free DNA) offers ≥99% sensitivity for trisomy 21 but is not currently government-funded (out-of-pocket ~0–500).
  • OGTT at 24–28 weeks is recommended universally for all pregnant women (RANZCOG 2020); earlier screening (booking or 12–16 weeks) is indicated for women with GDM risk factors (BMI ≥30, previous GDM, family history, PCOS, age ≥40, ethnicity).
  • Visit schedule follows RANZCOG guidelines: nulliparous — 7–10 visits (every 4 weeks until 28 weeks, every 2 weeks until 36 weeks, then weekly); multiparous — 6–8 visits (every 4 weeks until 32 weeks, every 2 weeks until 36 weeks, then weekly).
  • Immunisations in pregnancy include pertussis (dTaP) at 20–32 weeks each pregnancy, influenza (any trimester, in-season), and COVID-19 vaccination — all are funded under the National Immunisation Programme (NIP).
  • Aspirin 150 mg nocte from 12 weeks is recommended for women at high risk of pre-eclampsia (first pregnancy, ≥40 years, BMI ≥30, family history, pre-existing hypertension, renal disease, diabetes, autoimmune disease, multiple pregnancy).
  • Iodine supplementation of 150 µg daily is recommended throughout pregnancy and breastfeeding (NHMRC recommendation); iodised salt should be encouraged.
  • Iron deficiency is the most common nutritional deficiency in Australian pregnancy — check ferritin at booking and 28 weeks; supplement with ferrous sulfate 325 mg (105 mg elemental iron) daily–BD if deficient (PBS-listed).
  • Group B Streptococcus (GBS) screening with vaginal–rectal swab at 35–37 weeks guides intrapartum antibiotic prophylaxis; risk-based approach also accepted in some jurisdictions.
  • Aboriginal and Torres Strait Islander women have higher rates of preterm birth, low birth weight, and perinatal mortality — culturally safe care, continuity of midwifery models, early engagement, and Closing the Gap MBS items (715, 721) are essential.

Introduction & Australian Epidemiology

Antenatal care is a cornerstone of general practice in Australia, with the majority of pregnant women receiving shared care between their GP, obstetrician, and midwife. High-quality antenatal care reduces maternal and perinatal morbidity and mortality through systematic screening, risk assessment, health promotion, and timely intervention. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) provides evidence-based guidelines for routine antenatal care, which are widely adopted across Australian states and territories.

Approximately 300,000 women give birth in Australia each year. The maternal mortality rate remains low at approximately 6–8 per 100,000 births, while the perinatal mortality rate (stillbirths and neonatal deaths) is approximately 9–10 per 1,000 births. Stillbirth affects approximately 2,200 families annually — more than the national road toll — and remains a priority area for improvement under the National Stillbirth Action and Implementation Plan.

Key epidemiological trends relevant to antenatal care in Australia include:

  • Increasing maternal age (mean age 31.2 years in 2022), with associated higher rates of chromosomal abnormalities, gestational diabetes, and hypertensive disorders
  • Rising prevalence of obesity (approximately 25% of women entering pregnancy with BMI ≥30), increasing risks of GDM, pre-eclampsia, macrosomia, and caesarean section
  • Gestational diabetes mellitus (GDM) affects 12–15% of pregnancies nationally, with higher rates in women of South Asian, Southeast Asian, Aboriginal, Torres Strait Islander, Middle Eastern, and Pacific Islander backgrounds
  • Pre-eclampsia complicates 3–5% of pregnancies and remains a leading cause of maternal morbidity
  • Approximately 30% of Australian women enter pregnancy with at least one nutritional deficiency (most commonly iron and vitamin D)
  • Aboriginal and Torres Strait Islander women experience 2–3 times higher rates of preterm birth, low birth weight, and perinatal mortality compared with non-Indigenous women

General practitioners are well positioned to deliver comprehensive antenatal care, particularly in rural and remote settings where obstetric and midwifery services may be limited. The Medicare Benefits Schedule (MBS) provides specific items for antenatal care (items 16500, 16501, 16502, 16503) and Indigenous health assessments (item 715), supporting GPs in delivering high-quality, accessible pregnancy care.

Preconception Care & Initial Visit

Preconception Care

Preconception care optimises health before conception and is associated with improved maternal and neonatal outcomes. In Australian general practice, preconception counselling should be offered opportunistically during routine consultations, particularly for women of reproductive age with chronic medical conditions, previous adverse pregnancy outcomes, or those planning pregnancy.

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Folic acid supplementation: All women planning pregnancy should take 500 µg folic acid daily for at least one month before conception and continuing through the first trimester. Women at higher risk of neural tube defects (previous NTD-affected pregnancy, anti-epileptic medication [particularly valproate and carbamazepine], BMI ≥30, pre-gestational diabetes, or family history) require 5 mg daily. This is PBS-listed as Authority Required for high-risk indications.

Key Components of Preconception Care

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Folic Acid
Various generics · Vitamin supplement
Standard dose 500 µg PO daily, 1 month pre-conception → 12 weeks' gestation
High-risk dose 5 mg PO daily (previous NTD, AED use, BMI ≥30, pre-GDM)
PBS status ✔ PBS General Benefit (500 µg) ⚡ PBS Authority Required (5 mg)
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Iodine
Various · Mineral supplement
Dose 150 µg PO daily, pre-conception → throughout pregnancy and breastfeeding
Rationale NHMRC recommendation; Australian soil is iodine-deficient in many regions
PBS status ✘ Not PBS (available OTC in pregnancy multivitamins)
Domain Action
Folate & iodine 500 µg folate daily ≥1 month pre-conception; 150 µg iodine daily
Rubella & varicella immunity Check serology; vaccinate if non-immune (avoid pregnancy for 28 days post-MMR/varicella)
Teratogenic medications Review and switch: valproate → levetiracetam/lamotrigine; warfarin → LMWH; isotretinoin → cease ≥1 month pre-conception; ACE inhibitors → switch to labetalol/nifedipine
Chronic disease Optimise HbA1c to <53 mmol/mol (diabetes), ensure seizure freedom (epilepsy), disease remission (SLE, IBD)
Mental health Review psychotropic medications; risk–benefit of continuing SSRI vs relapse risk; screen for domestic violence
Lifestyle Smoking cessation, alcohol abstinence, healthy weight (BMI 18.5–29.9), regular physical activity
Genetic carrier screening Offer expanded carrier screening (CF, SMA, FXS) — now government-funded via the Mackenzie's Mission pilot; private cost ~0–500 if not eligible
Dental health Dental check-up recommended; periodontitis associated with preterm birth and pre-eclampsia

Initial (Booking) Antenatal Visit

The first antenatal visit should occur ideally before 10 weeks' gestation. In Australian general practice, this visit is typically billed under MBS item 16500 (obstetric attendance — initial visit). It is the most comprehensive consultation in the antenatal period and establishes the foundation for ongoing care.

1
Confirm pregnancy and gestation
Urine or serum βhCG, then dating ultrasound (ideally 7–8 weeks) to confirm viability, number of embryos, and estimated date of delivery (EDD) by CRL.
2
Comprehensive history
Obstetric history (gravida/parity, previous complications), medical/surgical history, medications, allergies, family history, psychosocial risk assessment (EPDS, domestic violence, alcohol/drugs).
3
Physical examination
BMI, blood pressure, urinalysis (MSU for MCS), abdominal examination, assessment for varicose veins/oedema.
4
Booking investigations
FBE, blood group & antibodies, rubella IgG, HBsAg, anti-HCV (risk-based), HIV, syphilis (RPR), MSU, ferritin, vitamin D (if risk factors), first trimester screening referral.
5
Risk stratification
Classify as low-risk (shared care/midwifery-led) or high-risk (obstetrician-led); identify psychosocial risk factors; referral to social work or specialist services as needed.
6
Health promotion & planning
Pregnancy information pack, discussion of birth options, antenatal classes, advance care directive (in some states), referral for dental care under the Child Dental Benefits Schedule (where eligible).
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MBS billing reminder: The initial antenatal visit is billed as item 16500 (pregnant woman — first attendance in a pregnancy). For shared care arrangements, ensure the shared care plan is documented and the lead maternity carer is identified. Aboriginal and Torres Strait Islander women should be offered a health check under MBS item 715, which is claimable in addition to antenatal items.

Routine Antenatal Screening

Routine antenatal screening is performed at the initial (booking) visit and at specified intervals throughout pregnancy. The following tests are recommended for all pregnant women in Australia (RANZCOG / RACGP guidelines) and are listed on the Medicare Benefits Schedule.

Booking Bloods — Complete Panel

Essential Full Blood Examination (FBE) Detects anaemia (physiological dilution vs true iron deficiency), thrombocytopenia, haemoglobinopathies. Hb <110 g/L in 1st/3rd trimester or <105 g/L in 2nd trimester warrants investigation (iron studies, B12, folate, haemoglobinopathy screen). MBS item 65060.
Essential Blood Group & Antibody Screen ABO and Rh(D) group; red cell antibody screen. Rh(D)-negative women require anti-D prophylaxis at 28 weeks (and 34 weeks if high risk). Kleihauer test at delivery if sensitising event. Anti-D 625 IU IM (Rhophylac®) — PBS Authority Required.
Essential Rubella IgG Immunity confirmation. Non-immune women should be counselled to avoid exposure during pregnancy and offered MMR vaccination postnatally (prior to discharge). MMR is contraindicated in pregnancy.
Essential Hepatitis B Surface Antigen (HBsAg) Identifies HBV carrier status. Positive HBsAg requires viral load (HBV DNA) — if >200,000 IU/mL (or >1 × 10⁶ copies/mL), tenofovir 300 mg PO daily from 28 weeks to reduce vertical transmission risk. Neonatal immunoglobulin (HBIG) + vaccination within 12 hours of birth.
Recommended Hepatitis C Antibody (anti-HCV) Risk-based testing in most jurisdictions; some states (e.g., NSW) now recommend universal screening. If positive, confirm with HCV RNA. Direct-acting antivirals (DAAs) are not currently recommended in pregnancy — treat postnatally. Neonates require follow-up testing at 12–18 months.
Essential HIV Antibody (4th-generation Ag/Ab) Universal screening recommended. Early detection allows antiretroviral therapy (ART) to reduce vertical transmission to <1%. Positive results trigger immediate referral to an infectious disease specialist with obstetric HIV expertise. PBS-listed ART regimens are available.
Essential Syphilis Serology (RPR + TPHA/EIA) Universal screening mandated in most Australian jurisdictions. Rising syphilis rates in Australia — particularly in young heterosexual individuals and Aboriginal and Torres Strait Islander communities in northern/central Australia. Positive RPR requires immediate treatment: benzathine penicillin 2.4 MU IM stat (PBS-listed) and partner notification. Repeat at 28 weeks and delivery in high-risk women.
Essential Midstream Urine (MSU) Culture Asymptomatic bacteriuria (ASB) occurs in 2–10% of pregnancies and is associated with pyelonephritis and preterm birth if untreated. Treat with antibiotics per sensitivities (e.g., cephalexin 500 mg PO BD for 5 days — PBS General Benefit). Repeat MSU post-treatment to confirm eradication.
If indicated Ferritin Check at booking and 28 weeks. Ferritin <30 µg/L suggests iron deficiency even if Hb is normal. Oral iron: ferrous sulfate 325 mg (105 mg elemental iron) PO daily–BD. IV iron (ferric carboxymaltose — Ferinject®) if oral intolerance or severe deficiency — available under PBS Authority Required, usually via hospital day-unit.
If indicated Vitamin D (25-hydroxyvitamin D) Test if risk factors: darker skin, limited sun exposure, covered clothing, BMI ≥30, liver/renal disease, anticonvulsant use. Level <50 nmol/L is insufficient; <25 nmol/L is deficient. Supplement with cholecalciferol 1000–2000 IU daily (available OTC). Not routinely PBS-listed for pregnancy.
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Rh(D)-Negative Women — Anti-D Prophylaxis: All Rh(D)-negative women with a Rh(D)-positive (or unknown) fetus should receive anti-D immunoglobulin at 28 weeks' gestation and within 72 hours of any potentially sensitising event (miscarriage, CVS, amniocentesis, ECV, vaginal bleeding, abdominal trauma, ectopic pregnancy). The dose is 625 IU IM (Rhophylac®). A second dose at 34 weeks is recommended in high-risk situations. Postnatal anti-D is given if the neonate is Rh(D)-positive.

Additional Screening by Trimester

Test Timing Purpose
CFTS / NIPT 11+0 – 13+6 weeks Trisomy 21, 18, 13 screening
Morphology ultrasound 18–20 weeks Structural anomalies, placental location, growth
OGTT 24–28 weeks Gestational diabetes mellitus (universal)
FBE + ferritin 28 weeks Iron deficiency, anaemia (high risk)
Syphilis serology (repeat) 28 weeks High-risk women (see above)
GBS vaginal–rectal swab 35–37 weeks Guides intrapartum antibiotic prophylaxis
Anti-D (Rh-neg women) 28 weeks (+ 34 weeks if high risk) Prevention of Rh alloimmunisation
Pertussis (dTaP) vaccine 20–32 weeks Neonatal passive immunity (cocooning)
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Rising syphilis in Australia: Since 2014, infectious syphilis notifications have increased dramatically, particularly among young heterosexual people and Aboriginal and Torres Strait Islander communities in northern and central Australia. RANZCOG now recommends considering repeat syphilis testing at 28 weeks for all women in high-prevalence areas, and at delivery for women at ongoing risk. Doxycycline and azithromycin are contraindicated in pregnancy — benzathine penicillin G is the only effective treatment.

Combined First Trimester Screening & NIPT

Combined First Trimester Screening (CFTS)

CFTS is the standard publicly funded aneuploidy screening test in Australia, available to all pregnant women through the Medicare Benefits Schedule (MBS item 55710 — first trimester combined screening). It is performed between 11+0 and 13+6 weeks' gestation and combines:

  • Nuchal translucency (NT) measurement — performed by accredited sonographers using FMF (Fetal Medicine Foundation) or equivalent standards
  • Maternal serum biochemistry — free βhCG and pregnancy-associated plasma protein-A (PAPP-A)
  • Additional maternal factors — age, weight, ethnicity, smoking status, IVF conception, diabetes
Feature CFTS NIPT (Cell-free DNA)
Timing 11+0 – 13+6 weeks ≥10 weeks (optimal ≥12 weeks)
Detection rate (T21) ~85–90% ≥99%
False-positive rate ~5% <0.1%
Cost Medicare-rebatable (MBS 55710); minimal out-of-pocket Not government-funded; ~0–500 out-of-pocket
Additional findings NT may identify cardiac defects, other structural anomalies Can screen for sex chromosome aneuploidies, microdeletions (optional)
Limitations Operator-dependent (NT); higher false-positive rate Not diagnostic; ~1–3% test failure rate (insufficient fetal fraction); false positives possible (especially at low prevalence); does not replace morphology scan
Confirmatory test CVS (11–13 weeks) or amniocentesis (≥15 weeks) CVS or amniocentesis required for confirmation
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NIPT is a screening test, not diagnostic. A positive NIPT result must be confirmed with invasive diagnostic testing (chorionic villus sampling or amniocentesis) before any pregnancy management decisions are made. False positives occur, particularly for rare aneuploidies and microdeletions. Counselling about the limitations and implications of NIPT should be provided before testing.

When to Offer NIPT vs CFTS

  • All women should be offered CFTS as the first-line publicly funded option
  • NIPT is recommended as first-line for women at inherently higher risk: maternal age ≥40, previous trisomy-affected pregnancy, known parental chromosomal rearrangement
  • NIPT is appropriate as second-line after an intermediate-risk CFTS result (risk 1:51 to 1:1000), allowing women to avoid unnecessary invasive testing
  • Women with a high-risk CFTS result (risk ≥1:50) should be offered direct referral for CVS or amniocentesis, though NIPT may be discussed as an interim step

Morphology Scan (18–20 Weeks)

While not technically part of first trimester screening, the mid-trimester morphology ultrasound is a critical component of antenatal screening. It assesses fetal structural anatomy, placental position, amniotic fluid volume, and cervical length. The scan is Medicare-rebatable (MBS item 55704) and should be offered to all women. A shortened cervix (<25 mm) identified at this scan may prompt further investigation (e.g., transvaginal ultrasound for cervical length measurement) and discussion of cervical cerclage or progesterone supplementation.

OGTT, Visits Schedule & Immunisations in Pregnancy

Oral Glucose Tolerance Test (OGTT)

RANZCOG (2020) recommends universal screening for gestational diabetes mellitus (GDM) with a 75 g OGTT at 24–28 weeks' gestation. Earlier testing (booking or 12–16 weeks) should be offered to women with risk factors for undiagnosed pre-existing type 2 diabetes.

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Earlier OGTT indicated if any of the following risk factors are present: BMI ≥30 kg/m², previous GDM, family history of type 2 diabetes (first-degree relative), polycystic ovarian syndrome (PCOS), maternal age ≥40 years, ethnicity (South Asian, Southeast Asian, Aboriginal, Torres Strait Islander, Middle Eastern, Pacific Islander, African), previous macrosomia (≥4500 g), corticosteroid use, or multiple pregnancy. If the early OGTT is normal, repeat at 24–28 weeks.

GDM Diagnostic Criteria (ADIPS/IADPSG — adopted by RANZCOG)

A 75 g OGTT is performed fasting. GDM is diagnosed if one or more of the following thresholds are met:

Time Point Venous Plasma Glucose
Fasting ≥5.1 mmol/L
1 hour ≥10.0 mmol/L
2 hours ≥8.5 mmol/L
ℹ️
MBS item for OGTT: 66500 (glucose tolerance test). GDM affects 12–15% of pregnancies nationally. Women diagnosed with GDM should be referred to a diabetes educator, dietitian, and obstetrician/endocrinologist. Management includes dietary modification, blood glucose monitoring, and metformin or insulin if targets are not achieved. Metformin is used off-label in pregnancy but is widely accepted; insulin is PBS-listed for GDM management.

Antenatal Visit Schedule

RANZCOG provides the following recommended visit schedule for uncomplicated pregnancies. Additional visits are arranged for high-risk pregnancies, complications, or maternal preference.

Booking (before 10 weeks) Comprehensive history, booking bloods, dating ultrasound, risk assessment, health promotion. MBS item 16500.
11–13+6 weeks Combined first trimester screening (NT scan + serum biochemistry) or NIPT. Discussion of results and next steps.
16 weeks Routine visit — review results, BP, urinalysis, fundal height assessment begins. Discuss any concerns. Offer low-dose aspirin 150 mg nocte if high risk for pre-eclampsia (continue until 36 weeks or delivery).
20 weeks Morphology ultrasound (MBS item 55704). Review results, discuss fetal movements (kick counting), vaccination planning.
24 weeks Routine visit — fundal height, BP, urinalysis. OGTT scheduling (24–28 weeks). Discuss birth plan, antenatal classes.
28 weeks OGTT results review. Repeat FBE + ferritin. Anti-D immunoglobulin for Rh(D)-negative women. Pertussis (dTaP) vaccine if not yet given. Syphilis serology repeat if high-risk. Growth assessment if indicated.
31 weeks Nulliparous women — routine visit. Review GDM management if applicable. Discuss signs of preterm labour.
34 weeks Routine visit. Second anti-D dose if high risk (e.g., external cephalic version, significant bleeding). Review birth plan. Group B Streptococcus (GBS) screening discussed.
36 weeks GBS vaginal–rectal swab (35–37 weeks). Presentation assessment (cephalic vs breech). Discussion of labour signs, when to present to hospital. Perineal massage education. Birth plan finalised.
37–41 weeks (weekly) Weekly visits — BP, urinalysis, fundal height, fetal movements, cervical assessment (if indicated), membrane sweeping discussion at ≥39–40 weeks. Post-dates management (IOL at 41+0 to 41+3 weeks per local protocol).
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Summary: Nulliparous women require 7–10 visits; multiparous women require 6–8 visits (fewer visits in early third trimester). All visits are billed under MBS items 16500 (initial), 16501 (subsequent), 16502 (28+ weeks), or 16503 (after 36+ weeks). Shared care GPs should ensure visits align with the shared care schedule agreed with the hospital.

Immunisations in Pregnancy

Vaccination in pregnancy protects both the mother and the newborn through passive transplacental antibody transfer. The Australian Immunisation Handbook (ATAGI) recommends the following vaccines during pregnancy, all of which are funded under the National Immunisation Programme (NIP).

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Pertussis (dTaP-IPV)
Boostrix® · Adacel® · Diphtheria-tetanus-acellular pertussis-inactivated polio
Timing 20–32 weeks (ideally 20–25 weeks) each pregnancy — no interval requirement from prior dose
Route IM deltoid
Rationale Transplacental IgG antibodies protect neonate before first vaccination at 6 weeks; cocooning strategy is insufficient alone
NIP funded ✔ NIP Funded (free for every pregnancy)
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Influenza (inactivated)
FluQuadri® · Fluarix Tetra® · Quadrivalent inactivated influenza vaccine
Timing Any trimester during influenza season (April–October in Australia); safe in all trimesters
Route IM deltoid
Rationale Pregnancy increases risk of severe influenza, hospitalisation, ICU admission, and death; passive neonatal protection
NIP funded ✔ NIP Funded
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COVID-19 Vaccine
Comirnaty® (Pfizer) · Spikevax® (Moderna) · Updated formulation recommended
Timing Any trimester; updated formulation annually per ATAGI advice
Route IM deltoid
Rationale Pregnancy increases risk of severe COVID-19; vaccination reduces maternal and neonatal morbidity
NIP funded ✔ NIP Funded

Vaccines NOT Recommended in Pregnancy

Vaccine Status in Pregnancy
MMR (measles-mumps-rubella) Live vaccine — contraindicated. Advise avoidance of pregnancy for 28 days post-vaccination.
Varicella Live vaccine — contraindicated. Advise avoidance of pregnancy for 28 days post-vaccination.
HPV (Gardasil 9) Not routinely recommended in pregnancy; defer until postpartum. Not an indication for pregnancy termination if inadvertently given.
Q fever Generally avoided in pregnancy unless high risk of exposure; specialist advice required.

Aspirin for Pre-eclampsia Prevention

Low-dose aspirin is recommended for women at high risk of pre-eclampsia, commencing from 12 weeks' gestation and continuing until 36 weeks or delivery. The dose is 150 mg once daily, taken at night (nocte) to maximise antiplatelet effect.

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Aspirin (low-dose)
Cartia® · Astrix® · Low-dose aspirin 100 mg tablets
Dose 150 mg PO nocte (1.5 × 100 mg tablets)
Timing Commence at 12 weeks, cease at 36 weeks or delivery
Indications First pregnancy, ≥40 years, BMI ≥30, family hx pre-eclampsia, pre-existing HTN, renal disease, diabetes, autoimmune disease (SLE/APS), multiple pregnancy
PBS status ✔ PBS General Benefit

Special Populations

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Pregnancy with Pre-existing Conditions

Type 1/2 Diabetes: HbA1c target <53 mmol/mol pre-conception and throughout. Switch statins → cease. Switch ACE/ARB → labetalol or nifedipine. Early retinal screening. Higher dose folate (5 mg). Early OGTT if T2DM risk. Insulin adjustment in pregnancy managed by endocrinology. Metformin may be continued in T2DM.
Epilepsy: Continue anti-epileptic drugs (AEDs) — uncontrolled seizures carry greater risk than medication. Lamotrigine and levetiracetam have best pregnancy safety profiles. Valproate is teratogenic (contraindicated if possible — avoid conception on valproate). Supplement with 5 mg folate. Therapeutic drug monitoring — levels drop in pregnancy due to increased volume of distribution. Referral to neurology.
Hypertension: Switch ACE inhibitors/ARBs pre-conception. First-line agents: labetalol (PBS-listed), nifedipine (long-acting). Methyldopa is used but has more side effects. Monitor for pre-eclampsia (BP, proteinuria, bloods). Refer if poorly controlled (≥160/110 mmHg).
Autoimmune Disease (SLE/APS): Multidisciplinary care (rheumatology, obstetrics). Hydroxychloroquine should be continued throughout pregnancy (PBS-listed). High-dose LMWH + aspirin if antiphospholipid syndrome. Monitor for flares.
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Adolescent & Young Pregnancies

Adolescent (<20 years): Higher risk of preterm birth, low birth weight, pre-eclampsia, and anaemia. Requires sensitive, non-judgemental care. Explore psychosocial factors (family support, education, housing, domestic violence). Referral to social work, youth health services. Multivitamin supplementation. Ensure legal reporting requirements are met (mandatory reporting for <16 years in most jurisdictions).
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Advanced Maternal Age (≥40 years)

Age ≥40: Increased risk of chromosomal abnormalities (consider NIPT as first-line), GDM, pre-eclampsia, placenta praevia, caesarean section, and stillbirth. Offer enhanced monitoring, low-dose aspirin 150 mg nocte from 12 weeks, early OGTT, and growth scans in third trimester. Higher threshold for obstetrician-led care.
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Renal Impairment

CKD Stage 1–3: High-risk pregnancy. Requires nephrology co-management. Increase frequency of renal function monitoring (eGFR, creatinine, urine PCR). Blood pressure targets: <140/90 mmHg. Labetalol and nifedipine are preferred antihypertensives (renally safe). Increase antenatal visit frequency. Growth scans from 28 weeks.
CKD Stage 4–5 / Dialysis: Referral to tertiary centre with renal-obstetric expertise. Pregnancy contraindicated in some settings — preconception counselling essential. Dose adjustments for renally cleared medications.
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Hepatic Conditions

Intrahepatic Cholestasis of Pregnancy (ICP): Presents with pruritus (especially palms/soles) from late second trimester. Diagnosed by elevated bile acids (BA ≥40 µmol/L = severe; associated with increased stillbirth risk). Treat with ursodeoxycholic acid (UDCA) 10–15 mg/kg/day — not PBS-listed for ICP specifically. Induction of labour recommended at 37–38 weeks for severe ICP.
Pre-eclampsia with HELLP: Emergency obstetric management. LFTs (AST, ALT), LDH, platelets. Magnesium sulphate for seizure prophylaxis. Definitive treatment is delivery.
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Immunocompromised

HIV-positive: Immediate ART referral — combination ART reduces vertical transmission to <1%. Mode of delivery (planned caesarean at 38 weeks if viral load >50 copies/mL) and neonatal prophylaxis (zidovudine for 4–6 weeks) discussed by multidisciplinary team. PBS-listed ART regimens available. Breastfeeding discussed — with undetectable viral load, breastfeeding may be considered in some settings (shared decision-making).
Immunosuppressive therapy: Azathioprine, hydroxychloroquine, tacrolimus can be continued. Methotrexate must be ceased ≥3 months pre-conception (teratogenic). Mycophenolate mofetil — switch to azathioprine pre-conception (teratogenic). Refer to relevant specialist.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health in Antenatal Care

Aboriginal and Torres Strait Islander women experience significantly poorer maternal and perinatal outcomes compared with non-Indigenous Australians. Addressing these disparities requires culturally safe, community-led, and strengths-based approaches to antenatal care.

Key Epidemiological Data

  • Aboriginal and Torres Strait Islander babies are 1.5–2 times more likely to be born preterm (<37 weeks) and 2 times more likely to be of low birth weight (<2500 g)
  • Perinatal mortality rates are 1.5–2 times higher for Aboriginal and Torres Strait Islander babies
  • Smoking in pregnancy affects approximately 44% of Aboriginal and Torres Strait Islander mothers (vs ~10% non-Indigenous)
  • Gestational diabetes is 1.5–2 times more prevalent
  • Syphilis rates are disproportionately high in remote and very remote communities — an ongoing outbreak since 2014 primarily affecting Aboriginal and Torres Strait Islander young people
  • Rheumatic heart disease (RHD) remains a significant concern — requiring antibiotic prophylaxis and specialist obstetric cardiology input

Barriers to Antenatal Care

Geographic access
Women in remote and very remote communities may need to travel hundreds of kilometres for birthing services, often relocating from 36–38 weeks. Aboriginal Community Controlled Health Services (ACCHS) are critical in providing local antenatal care.
Cultural safety
Mainstream services may lack cultural competency. Gender sensitivity (men may be uncomfortable with male providers for pregnancy care), avoidance protocols, and the use of Aboriginal health practitioners and interpreters improve engagement.
Systemic racism & trust
Historical and ongoing experiences of racism in healthcare lead to reluctance to engage. Building trust through continuity of carer, Aboriginal health workers, and community partnerships is essential.
Social determinants
Housing insecurity, food insecurity, family violence, substance use, and socioeconomic disadvantage contribute to delayed presentation and poorer outcomes. Holistic, wrap-around care addressing these factors is needed.
Health literacy
Use plain English, visual resources, and culturally appropriate health education materials. Involve family members in discussions where appropriate and with consent.

Recommended Actions in General Practice

Screening & Immunisation
  • Universal syphilis screening — and repeat at 28 weeks and delivery in high-prevalence regions
  • Hepatitis A and hepatitis B screening (higher prevalence)
  • Earlier OGTT (booking and 24–28 weeks) given higher GDM prevalence
  • Ensure pertussis, influenza, and COVID-19 vaccines are offered and documented
  • RHD screening — echocardiography if clinical suspicion; benzathine penicillin prophylaxis if confirmed
MBS & Funding
  • MBS item 715 (Aboriginal and Torres Strait Islander health assessment) — claimable in addition to antenatal items
  • MBS item 721 (GP Management Plan) for chronic disease management in pregnancy
  • Closing the Gap PBS co-payment — Aboriginal and Torres Strait Islander patients may access PBS medicines at reduced or no cost through CTG scripts
  • Continuity of midwifery models — funded through state/territory programs (e.g., Queensland's Midwifery Group Practice)
  • Aboriginal Maternal and Infant Health Services (AMIHS) — available in NSW and other states
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Culturally safe practice tip: Begin consultations by acknowledging Country and asking about the woman's preferences for care (who should be present, whether an Aboriginal health worker is available, gender preferences). Use the "yarning" approach — allow time for non-linear conversation before clinical questioning. Avoid deficit-framing; emphasise strengths and community supports.

📚 References

  1. 1. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Maternity care in Australia — A guide for GPs. Melbourne: RANZCOG; 2023.
  2. 2. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Diagnosis of gestational diabetes mellitus (GDM) in pregnancy — Clinical guideline. Melbourne: RANZCOG; 2020.
  3. 3. Australian Institute of Health and Welfare (AIHW). Maternal deaths in Australia 2018–2020. Canberra: AIHW; 2023.
  4. 4. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Mothers and babies. Canberra: AIHW; 2023.
  5. 5. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  6. 6. National Health and Medical Research Council (NHMRC). Iodine supplementation for pregnant and breastfeeding women — NHMRC Public Statement. Canberra: NHMRC; 2010.
  7. 7. National Health and Medical Research Council (NHMRC). Folic acid — Food Standards Australia New Zealand (FSANZ) mandatory fortification program. Canberra: NHMRC; 2016.
  8. 8. Department of Health and Aged Care. Medicare Benefits Schedule Book — Category 8: Obstetrics. Canberra: Australian Government; 2024.
  9. 9. The Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice (Red Book) — Antenatal care. 9th edn. Melbourne: RACGP; 2018.
  10. 10. Lowe SA, Bowyer L, Lust K, et al. The SOMANZ Guidelines for the Management of Hypertensive Disorders of Pregnancy 2014. Aust N Z J Obstet Gynaecol. 2015;55(1):11–16.
  11. 11. Dale S, Morgan T, Boulton T, et al. Mackenzie's Mission: Australian reproductive genetic carrier screening. Med J Aust. 2023;219(7):331–337.
  12. 12. Royal College of Obstetricians and Gynaecologists (RCOG). The Investigation and Management of the Small-for-Gestational-Age Fetus — Green-top Guideline No. 31. 2nd edn. London: RCOG; 2014 (updated 2023).
  13. 13. National Stillbirth Action and Implementation Plan. Ending preventable stillbirths in Australia by 2030. Canberra: Department of Health and Aged Care; 2020.
  14. 14. Australasian Society for Immunology and Allergy (ASCIA). Vaccination of the pregnant woman — Position statement. Sydney: ASCIA; 2023.
  15. 15. Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia — Annual Surveillance Report 2023. Sydney: Kirby Institute, UNSW; 2023.
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction
Paracetamol ± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ± calcitonin; DXA + osteoporosis Rx
6–12 weeks healing
Elderly; osteoporosis; acute onset
ACS (posterior MI)
Aspirin 300 mg, GTN, heparin; urgent PCI
Time-critical
ECG, troponin; CV risk factors
Aortic dissection
IV labetalol; urgent CT aortogram; surgery (Type A)
Time-critical
Tearing pain; BP differential >20 mmHg
Vertebral osteomyelitis
IV antibiotics (vancomycin + ceftriaxone initially); ID consult
6 weeks IV antibiotics
Fever, elevated CRP, IV drug use
Biliary colic / cholecystitis
Paracetamol ± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

📚 References

  1. 1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
  5. 5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
  6. 6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).