The first visit
this is the most important interaction point as it creates the first impression and sets the stage for a healthy doctors-patient relationship . We make sure to provide as much time as possible with the patient so that all anxieties are allayed and patient develops confidence in her doctor. Detailed history taking is done and risk stratification is done . This is followed by a thorough complete clinical examination and all the signs and symptoms of pregnancy related ailments and normal changes in body are explained to the woman. All the do’s and don’ts are explained. Wherever possible, we provide written instructions as well. Full ANC plan of management is explained and provided as a handout where all the tests required to be done are given with the dates when to be done . This makes sure that the patient does not miss out on the tests even if she misses her checkup due to any reason. Birth Plan : some fleeting idea is given and she is told to discuss this at a later stage. Medications are prescribed and instructions are provided regarding the dose and time of medication. Follow up visit dates are given.
Total number of antenatal visits
in a low risk mother with a single foetus , besides the first visit, monthly visits are recommended till 31 weeks or end of 7 months. Fortnightly visits in the 8th month or 32-36 weeks and weekly visits in the last month or 37-40 weeks are recommended. Besides these, if any emergency arises or any medical / surgical complications develop, then visits are customised.
Scans in pregnancy
in a low risk mother with a single foetus , the minimum number recommended is.
- Dating scan / NT : 11-13 weeks
- Anomaly scan 18-20 weeks
- Growth Scan : 32 weeks
- Growth cum Doppler: 34-35 weeks
Immunisation in pregnancy
in a low risk mother with a single foetus , the minimum number recommended is.
- Td Vac
- T DAP
- Fluvac
- Anti - D in Rh negative mothers
- Hep B if Anti HbS antibodies are 10 mIU per dl. Full course given
Investigations advised
All pregnant women are advised to do some blood and urine tests early in their pregnancy. These tests are collectively called Antenatal Profile
- CBC
- Blood group. If D -ve, then partners group
- RBS, HbA1C
- TSH
- HIV, HBsAg, HCV
- VDRL
- Urine: routine & ME
- Hb Electrophoresis for B Thal Trait
- Anti HbS antibodies
- ICT as required
- PAP smear
Things to Know
Screening Tests in pregnancy
Screening tests are done in a healthy population with the aim of picking up individuals with high probability of having the condition screened for . Screening for genetic disorders, gestational diabetes, pre eclampsia, Rh Isoimmunisation are the most common screening tests advised in pregnancy.
Screening for Genetic Disorders
The most common genetic disorder for which screening is advised is Down’s Syndrome. This is a condition where the affected individual has one extra Chromosome 21 , ie three chromosomes in all. For this reason this condition is also called Trisomy 21.
This is an important health problem because firstly the affected babies are usually born alive and secondly they have varying degrees of mental retardation , heart defects , musculoskeletal skeletal problems, diaphragmatic hernia and many other congenital structural deformities. The screening test involves Ultrasound scans, also known as the NT scan or Nuchal scan and blood tests. This is also called as Combined Screen. Most commonly advised at 11-13 weeks of pregnancy. In the scan , the thickness of the skin behind the baby’s neck is measured and free B-HCG and PAPP-A , two blood analytes , are measured. After putting these values and the age of the mother in a computer software, a ‘risk factor’ is calculated and reported as Low Risk or Screen Negative and High Risk or Screen Positive.
If we add the mean Systolic BP of the mother and two more analytes , PLGF and PP13, we can also screen the woman for Fetal Growth Restriction and PIH in the same test . This constitutes Screening for PIH/PE.
If this window of opportunity is missed , then a similar test called the Quad Test is advised in the second trimester. This however has lower detection rates as compared to the Combined Screen.
Proper pre test counselling is a must and it should be informed and documented.
If results are Screen positive or High Risk, then the woman is advised further diagnostic tests or Invasive tests to confirm whether her Fetus is the affected one . The options are CVS, Amniocentesis or NIPT. The procedure is explained in detail and all possible procedure related complications are discussed.
Screening for Gestational Diabetes
all Indian women are at a higher risk of developing GDM owing to our ethnicity. Other risk factors are family history of DM, higher age at pregnancy, multiple pregnancy, higher BMI, history of GDM aim previous pregnancy.
Universal Screening for GDM is advised by GOI. To be done between 24-26 weeks of pregnancy. Standard WHO 75gm oral glucose followed by blood glucose done 2 hours later , test is done. If the result is > 140mg/dl, it is diagnosed ad GDM. Less than 120 mg is normal. Between 120 and 140 mg I’d interpreted as Gestational Glucose Intolerance.
Screening for Rh Isoimmunisation
This is done when the mother is Rh Negative and the father is Rh Positive. A simple blood test is done at 28-30 weeks , called Indirect Coomb’s Test . If it is negative, it means that there is no sensitisation of the mother presuming the baby is positive. In that case the mother is given Rhogam 300mcg injection which will protect her from future sensitisation, if any, for the next 8 weeks. Finally after the delivery, baby’s cord blood is tested for Hb , ABO group and Direct Coomb’s test . If baby is positive, then 300 mcg is repeated again.
If ICT is positive or Direct Coomb’s testis positive, then no immunoglobulin is given to the mother as she is already sensitised.
Diet and nutrition
Ideally the diet should be light , nutritious, easily digestible, rich in protein, fats, and vitamins and should be of the woman’s choice. Dietary advice is given based on the socioeconomic status, food habits and tastes of the woman . Modifications are suggested keeping in mind the cultural foods consumed by the woman.
In general, a pregnant woman is advised to eat whatever she likes, whatever suits her every 2 hours. She should never eat a full stomach ; small meals every 2 hours will prevent hyper acidity and the ensuing nausea and vomiting . She should avoid outside food so as to prevent gastroenteritis and stomach upsets. Too much oily and spicy foods to be avoided to prevent acidity. In the first trimester raw papaya and pineapple are to be avoided. From the second trimester onwards, when the nausea subsides, the woman can take balanced diet
Work in pregnancy
all routine work , both inside and outside home is considered safe. Heavy strenuous work involving long hours of travel and standing may be avoided. All work to be done very gently and gradually, avoiding hurry and haste.
Rest and exercise
in a low risk woman, on an average 2 hours rest in noon and 8 hours rest at night is recommended . In the absence of any medical and obstetrics complications, 30 minutes of moderate exercise daily is recommended. Activities with risk of falling or abdominal trauma should be avoided. Continue the pre pregnancy exercise
Benefits of Rest & Exercise
- Improves posture; decrease backaches and fatigue
- Prevents GDM
- Relieves stress
- Prepares for labor & delivery
Supplements during pregnancy
- Folic Acid : 400 mcg
- Iron, Calcium, Magnesium, Zinc
- Omega-3 FA
- VIT D : 400 IU/D
- VIT A, E, K, B6; B12; C
Prescription Drugs
Almost all drugs given during pregnancy will cross the placenta and affect the fetus. Keeping this in mind the following guidelines are followed: If the benefits outweigh the potential risks , then only the drug is prescribed and that too after prior counselling. Only well tested and reputed drugs are to be prescribed and that too in a minimal effective dose for the shortest possible time.
Sex during pregnancy
Should be avoided as far as possible in first trimester and last month of pregnancy. Coitus should be gentle and preferably with woman on top position or side ways position. Potential risks of sex during pregnancy are preterm labor, pelvic inflammatory disease, antepartum bleeding esp with low lying placenta.
Alcohol and smoking
There is enough evidence to suggest that alcohol consumption and smoking in pregnancy are detrimental to the growing fetus. There is very high incidence of Sudden Infant Death Syndrome, alcohol syndrome, Fetal growth restriction and small for dates babies. It is postulated that alcohol and smoking exposure to the fetus causes autonomic disturbance in the newborn leading to SIDS.
Travel during pregnancy
long distance travel must be avoided in first trimester. Travel on bumpy roads should e avoided. After first trimester till 36 weeks it is safe to travel by road, rail or air. If travelling by air , precautions for preventing deep vein thrombosis should be kept in mind.
Management of common symptoms: the most common symptoms encountered in pregnancy are nausea , vomiting, constipation, vaginal discharge, backache heartburn, varicose veins and haemorrhoids. Dietary alterations, increased liquid intake, high fibre diet , eating frequent small meals can ease out nausea, vomiting , constipation.
Backache is relieved by local applications of analgesic gels or gentle massage. Excessive intractable vomiting must be different from a condition called Hyperemesis Gravidarum . The latter may require admission, IV infusion, VIT B6, besides dietary modifications.
Vaginal discharge is common during pregnancy. Usually it is normal physiological discharge due to high levels of hormones. But if the discharge is accompanied by itch, irritation or foul odour , then it indicates vaginal infection which needs prompt treatment. Normal discharge is usually colourless or white ; infective discharge can be grey, greenish, or thick white and curdy, and sometimes blood stained.