• Amenorrhea
• Nausea and vomiting
• Frequency of micturition
  • Due to congestion and pressure on the bladder
  • Appears from 8 to 12 weeks
  • Reappears again near the end of pregnancy when the fetal head descends into the maternal pelvis
• Breast changes
  • Discomfort
  • Enlargement
  • Pain/heaviness
• Fatigue/lassitude
• Change in appetite
  • Craving for certain foods, odors and particular objects
• Sleepiness
• Emotional changes/mood swings

   

• Appear at 6 to 8 weeks
• Enlargement with vascular engorgement
• Discomfort—fullness, heaviness and pricking sensation
• Nipple and primary areola become more pigmented and sensitivity increases
• Montgomery’s tubercles appear
• Expression of colostrum as early as 12th week
• More in primigravidae.

 

• A clinical sign of pregnancy in which there is softening in the midline of the uterus anteriorly at the junction of the uterus and cervix
• Occurs at about 6 weeks gestation.

• A significant softening of the vaginal portion of the cervix from increased vascularization of uterus in pregnancy
• Named after William Goodell
• Can be seen at 6th week.

• A clinical sign in which there is an irregular softening and enlargement of the uterine fundus during early pregnancy
• Occurs at 5 to 8 weeks gestation
• Named after Karl von Braun-Fernwald.

• Bluish discoloration of the cervix, vagina and labia resulting from increased blood flow
• Can be observed as early as 6 to 8 weeks after conception
• Discovered in 1836 by a French doctor, Étienne Joseph Jacquemin
• James Read Chadwick drew attention to it in 1886.

• Named after Ludwig Piskaçek and Kevin
• Can be observed at 7 to 8 weeks
• One half of uterus—more firm than other half (implantation site)
• Observing a soft palpable bulge at the uterine cornu.

• Its absence does not exclude pregnancy
• Bimanual examination with two fingers in the anterior fornix and the fingers of the other hand on the abdomen behind the uterus
• The internal and external fingers can be approximated due to the fact that the lower segment is soft and empty and upper part of the body of the uterus is enlarged → fingers of both the hands can be approximated against the soft uterine isthmus
• Present from 6 weeks until the 12th week of pregnancy
• Difficult to recognize in multiparous women
• Described by Ernst Ludwig Alfred Hegar, a German gynecologist, in 1895.

• Regular and rhythmic contractions of the uterus in early pregnancy
• Pregnancy should be of at least 8 weeks duration
• Method:
  • Two fingers of gloved right hand are placed into the vagina and left hand palpates the lower abdomen from above
  • Wait for 2 to 3 minutes → uterus becomes firm and then ill-defined in accordance to its contraction and relaxation.
  (In the presence of USG, Palmer’s sign and Hegar’s sign have lost their importance.)

 

• Remains a pelvic organ until 12th week
• From 12 to 14 weeks, it can be felt as suprapubic bulge.

 

• Vagina and vulva are bluish/violet in color, particularly the vestibule
• Vagina becomes moist, warm and lax
• There is an increase in the amount and acidity of the vaginal discharge.

       

• Agglutination test: Latex particles or sheep erythrocyte (tube) coated with anti-hCG
• Agglutination inhibition tests
• Dip stick test
• Rapid and simple tests based on enzyme-labeled monoclonal antibodies assay.

• Proteinuria
• Hematuria
• Done at the time of ovulation (cross-reaction with Luteinizing hormone)
• hCG injection for infertility treatment within the previous 30 days
• Thyrotoxicosis (high TSH)
• Early days after delivery or abortion
• Trophoblastic diseases
• hCG secreting tumours.
• Premature menopause (high LH and FSH)

• Missed abortion
• Ectopic pregnancy
• Too early pregnancy
• Urine stored too long at room temperature
• Interfering medications.

• Radioimmunoassay of β-subunit of hCG
• Radio receptor assay.

• Enzyme-linked immunosorbent assay (ELISA)

  	Sensitivity	Time to complete	Postconception age when first positive	Gestational age when first positive
  Radioimmunoassay	5 mIU/mL	4 hours	10–18 days	3–4 weeks
  Immunoradiometric assay (more sensitive)	150 mIU/mL	30 minutes	18–22 days	4 weeks
  Immunoradiometric assay (less sensitive)	1500 mIU/mL	2 minutes	25–28 days	5 weeks
  Enzyme-linked immunosorbent assay (more sensitive)	25 mIU/mL	80 minutes	14–17 days	3.5 weeks
  Enzyme-linked immunosorbent assay(less sensitive)	<50 mIU/mL	5–15 minutes	18–22 days	4 weeks
  Fluoroimmunoassay	1 mIU/mL	2–3 hours	14–17 days	3.5 weeks

• hCG is detectable in the serum
  • In ≈ 5% of patients, 8 days after conception and
  • In > 98% of patients, by day 11.
• At 4 weeks’ gestation (Day 18–22 postconception), the dimer and β-subunit of hCG doubling times are approximately 2.2 days (standard deviation ± 0.8 days)
• It falls to 3.5 days (standard deviation ± 1.2 d) by 9 weeks’ gestation
• Levels peak at 10 to 12 weeks’ gestation and then begin to decline rapidly until another, more gradual rise begins at 22 weeks’ gestation, which continues until term.

• 1 week after labor
• 2 weeks after abortion
• 4 weeks after evacuation of vesicular mole.

 

• Serum progesterone is a reflection of progesterone production by the corpus luteum, which is stimulated bya viable pregnancy
• Measured by radioimmunoassay and fluoroimmunoassay
• Results after 3 to 4 hours
• A dipstick ELISA that can determine a serum progesterone level of < 15 ng/mL is also available
• Serumprogesterone
  • > 25 ng/mL → viable intrauterine pregnancy (97.5% sensitivity)
  • < 5 ng/mL → a nonviable pregnancy (100% sensitivity)
  • 5 to 25 ng/mL → further testing using ultrasound, additional hormonal assays or serial examinations are warranted.

 

• Early pregnancy factor (EPF) assay may be useful in the future as an aid in diagnosing pregnancy before implantation
• It is a poorly defined immunosuppressive protein that is present in maternal serum shortly after conception
• The earliest available marker to indicate fertilization
• Detection:
  • Detectable in the serum 36–48 hours after fertilization
  • Peaks early in the first trimester
  • Almost undetectable at term
  • Also appears within 48 hours of successful IVF embryo transfers
  • Cannot be detected 24 hours after delivery or at the termination of an ectopic or intrauterine pregnancy
  • Also undetectable in many ectopic pregnancies and spontaneous abortions, indicating that if EPF is not identified, that pregnancy may represent a poor prognosis
• Today EPF has limited clinical application because the molecule is difficult to isolate
• Detection of EPF currently relies on a complex and unwieldy assay named the rosette inhibition test.

 

• These tests now use the modern immunometric assay
• Most of these tests claim ‘99% accuracy’
• The broad 99% accuracy statement is made for tests with sensitivities for hCG concentrations ranging from 25 mIU/mL (fairly sensitive) to tests with sensitivities of 100 mIU/mL (less sensitive)
• Home pregnancy tests are most commonly used in the week after the missed menstrual period (fourth completed gestational week)
• Urine hCG values are extremely variable at this time and can range from 12 mIU/mL to > 2500 mIU/mL
• This variability continues into the fifth week, when values have been shown to range from 13 mIU/mL to > 6000 mIU/mL
• Both weeks have a percentage of urine hCG values that is below the sensitivities of detection for common home pregnancy tests (range 25–100 mIU/mL)
• Therefore, during 4th and 5th weeks, they may not be highly accurate
• 8 Collection of urine for the test:
  • Try to perform first thing in the morning, though this is not mandatory
  • Collect urine in a clean, dry, plastic container
  • Wash only with water
  • Ensure that there is no detergent residue in the container
  • Take out the strip from the pack and keep it on a flat surface
  • Put about 2 to 3 drops of urine on it with a dropper (provided in the kit)
  • Do not spill urine on the reading strip
  • Wait for 3 to 5 minutes (depending on manufacturer’s instructions) and then read the test results
  • Trying to read the results before the stipulated time or waiting too long can both lead to inaccurate readings.

 

• ‘C’ indicates a control (this band must always appear because this is the comparison band)
• ‘T’ indicates the test sample
• If only one red/pink/purple band appears in the region marked ‘C’, it means that the test is negative
• If two red/pink/purple bands appear, one in the ‘C’ region and the other in the region marked ‘T’, it means that the test is positive for pregnancy
• In case no bands appear or if a faint line appears in the ‘T’ region, then the test is invalid
• Repeat the test with a new pack after 72 hours.

 

• Hemogram
• Screening for hemoglobinopathies
• Complete urine analysis (to detect asymptomatic bacteriuria, if present)
• VDRL, HIV (after pretest counseling and written consent)
• ABO Rh. If rhesus negative, check husband’s blood group
• HbsAg, Anti-HBC Ag
• Rubella susceptibility
• USG to confirm intrauterine gestation, cardiac activity, measure gestational age using CRL, to rule out multiple gestation and ectopic pregnancy
• Cervical cytology, if indicated
• A wet smear of any symptomatic vaginal discharge (i.e. itching, burning or offensive)
• Down’s syndrome screening using:
  • ‘Combined test’ (nuchal translucency, β-hCG, pregnancy-associated plasma protein-A) at 10+0 to 13+6 weeks
  • Ultrasound for nuchal translucency between 10+0 and 14+0 weeks (CRL 36–84 mm).

 

• Maternal age ≥ 35 years
• Consanguinity, ethnicity, family history of genetic disorder
• History of recurrent spontaneous abortions, stillbirths, neonatal deaths and malformations in previous babies
• Family history of a known/suspected genetic disorder, e.g. thalassemia, muscular dystrophy, cystic fibrosis, Down’s syndrome.

• Abnormal fetal USG
• Abnormal maternal serum screening
• Teratogen exposure
• Maternal infection.

Summary of prenatal genetic screening tests
Noninvasive tests
	Screen name	Markers	Possible timeframes	Best timeframes
1st trimester	USG	NT	11–13 wks 6d	12–13 wks 3d
	Combined screen	NT + PAPP A + hCG	10–13 wks 6d	10 wks 2d–11 wks 6d
2nd trimester	Triple test	MSAFP + uE3 + hCG	15–20 wks
	Quadruple test	hCG + Inhibin A + MSAFP + uE3	15–20 wks 6d	15 wks 2d–17 wks
	USG	Anomaly scan	18–22 wks
Combined 1st and 2nd trimesters	IPS (integrated prenatal screen)	PAPP + NT in 1st trimester and Quadruple in 2nd trimester	Reports given only after both the tests (by making single risk determination)
	SIPS (serum integrated prenatal screen)	PAPP A + Quad test (w/o NT)
	Stepwise sequential screening	PAPP A + NT with an age associated risk If at ↑ risk → 2 options Invasive testing in 1st trimester OR Triple or Quad test in 2nd trimester	1st trimester

 

• Oncofetal → produced by yolk sac initially and after its involution, by fetal liver (in early pregnancy)
• AFP is present in amniotic fluid initially through diffusion across immature skin and later through kidneys and fetal urination
• Amniotic fluid AFP is swallowed by fetus and recirculates with final degradation by fetal liver
• Very small amounts are present in maternal serum through diffusion across the placenta and amnion
• Levels:
  • Nonpregnancy levels → 1 μ/L
  • 16 to 18 weeks period of gestation → 18 to 40 μ/L
  • When fetal serum level is 2 μ/L and maternal serum level is 20 μ/L → amniotic fluid AFP will be 20,000 μ/L
• Fetal plasma and amniotic fluid AFP → peak in midtrimester of pregnancy
• Maternal serum AFP →↑ until 28 to 32 weeks of gestation
  10

  Elevated in	Reduced in (<0.25 mm)
  Multiple gestation Fetal demise Fetomaternal hemorrhage Placental abnormalities Uterine abnormalities Maternal ovarian or hepatic tumour Fetal congenital defects	Spontaneous abortion Preterm labor/delivery Stillbirth Infant death Macrosomia Obstetric complications (when ↑) IUGR
  Neural tube defect Spina bifida Anencephaly Encephalocele Open ventral wall defect Omphalocele Gastroschisis Congenital nephrosis (because of fetal proteinuria) Triploidy B/L renal agenesis Congenital skin disorders Aplasia cutis Epidemolysis bullosa Autosomal recessive PCKD Sacrococcygeal teratoma Cystic adenomatoid malformation of lung	APH Preterm labor/delivery Fetal death >24 weeks Spontaneous abortion Gestational hypertension and preeclampsia Polyhydramnios Low Apgar Asphyxia NICU admission

• Unexplained increase of maternal serum AFP
  • AFP>2.5 MOM in the absence of the above-mentioned causes
  • Associated with:
    • Chorionic villitis and placental vascular lesions
    • Maternal uterine malformation
• Increase AFP in amniotic fluid and maternal serum → only when NTDs are open, i.e. when neural tissue is exposed or covered by only a thin membrane
• When NTDs are skin covered, AFP does not escape from fetal circulation and there is no increase of AFP in the mother
• AFP is an important screening test because 80% of infants with NTD are born into families with no prior history of disorder
• Optimal time for screening (for NTDs)
  • 16 to 18 weeks
  • When LMP is known, dating done is according to it
  • When LMP is not known, dating is done according to BPD in the 2nd trimester (at 14 weeks)
    • BPD is usually smaller in fetuses with spina bifida and maternal serum AFP will appear higher; therefore, improved detection rate
• Other factors which affect MSAFP
  • Maternal weight → obese females have ↓ levels (because larger size results in greater dilution of fetally derived AFP)
  • Race: Black and Asian females > nonblack race
  • IDDM → levels are lower
  • Multifetal reduction in 1st trimester →↑ levels in 2nd trimester
• 11 Summary
  Increase in:
  • Neural tube defects
  • Trisomy 18
  Decrease in:
  • Down’s syndrome.

• Secreted by syncytiotrophoblasts
• Elevated hCG
  • Cut-offs varying from > 2.0 MoM to > 4.0 MoM
  • Causes:
    • Fetal chromosomal abnormalities (Down’s syndrome)
    • Placental anomalies (Molar pregnancy)
    • Multiple pregnancy
    • IUFD
    • Hypoxic cytotrophoblasts demonstrate increased proliferation and increased hCG production
    • Other placental abnormalities
      • Chorioangiosis of placenta (abnormal capillary proliferation associated with uterine hypoxia)
      • Placental mosaicism
• Obstetric complications with unexplained elevation:
  • IUGR
  • Hypertensive disorders of pregnancy
  • Preterm labor and preterm delivery
  • Stillbirth
  • Velamentous cord insertion
• Low hCG
  • Defined as a value < 0.5 MoM
  • Unexplained low hCG:
    • Normal fetal anatomy
    • Viable pregnancy
    • Normal fetal karyoptype
    • Pregnancy outcomes, when low hCG
    • In 1st trimester—miscarriage
    • In 2nd trimester—normal
• Summary
  Decrease in:
  • Trisomy 18
  No change in:
  • NTDs

• How and where is it produced?
  • Fetal adrenal glands produce DHEAS
  • Fetal liver converts DHEAS to 16 α OH-DHEAS
  • Inplacenta, 16 α OH-DHEAS is deconjugated by a sulfatase
  • Resulting molecule is aromatized to uE3
• 12 Decrease in trisomy 21 and 18
• No change in open NTDs
• High levels are not associated with adverse perinatal outcomes
• Low levels (<0.75 MoM) are associated with:
  • Fetal chromosomal abnormalities
  • Fetal death
  • Fetal metabolic conditions
    • Steroid sulfatase deficiency
    • Congenital adrenal hypoplasia/Hypocortisolism
    • Smith-Lemli-Opitz syndrome
    • Placental aromatase deficiency
    • Kallman syndrome
• Complications (when low)
  • IUGR
  • Small for gestational age
  • IUFD
  • Oligohydramnios.

• Levels are much reduced in primary antiphospholipid antibody syndrome
• Levels are much increased in:
  • Triploidy
  • HELLP syndrome
  • Following loss of 1 twin in 1st trimester
• Obstetric complications (when levels are increased → ≥ 2 MoM)
  • IUGR
  • Preterm delivery
  • IUFD
  • Hypertensive disorders
• Summary
  Increase in:
  • Down’s syndrome
  No change in:
  • Open NTDs
  • Trisomy 18.

• Produced by placenta and decidua
• Increases the bioavailability of IGF, which, in turn, mediates trophoblast invasion and modulates glucose and amino acid transport in the placenta
• Levels increased
  • No adverse outcome
• Levels decreased
  • Spontaneous abortions
  • IUGR
  • Preterm delivery
  • IUFD
  • Hypertensive disorders.
  13
  Recommendations
  • 1st trimester: Combined screening
  • 2nd trimester: Quadruple or triple test

   

Period of gestation (weeks)	Ultrasound features
Week 4	Gestational sac Gestational sac size = 3 to 6 mm Grows at the rate of 1 mm/day through the 9th week Sometimes may not appear by the end of the 5th week Initially round, anechoic structure Gestational age calculation When no structures are visible within the gestational sac: Mean sac diameter (MSD) in mm + 30 = Gestational age in days When embryo is seen inside it, MSD is no longer accurate
Week 5	Gestational sac Size = 6–12 mm Yolk sac Seen with TVS when mean sac diameter is ≈ 8 mm to 10 mm Its presence confirms the diagnosis of an intrauterine pregnancy By 5 weeks 4 days, it should definitely be present Fetal pole Adjacent to yolk sac (near the wall) Cardiac activity By the end of the 5th week Normal heart rate at this time = 60–90 bpm (In early pregnancies, the actual cardiac rate is less important than its presence or absence) Must be detected when embryo length is 5 mm Lacunar structures Cavities or spaces at the site of implantation
Week 6	Gestational sac Size = 14–25 mm Crown rump length Gestational age in the 1st trimester is calculated from the fetal CRL (± 6 days) This is the longest demonstrable length of the embryo or fetus, excluding the limbs and the yolk sac Most accurate between 7 and 10 weeks of pregnancy From 6 to 11 weeks, CRL grows at a rate of ≈ 1 mm/day CRL = 4–7 mm Fetal pole Length = 0.2–0.3 inches Grows at the rate of about 1 mm/day, from 6th week ‘Dating the fetus’ Gestational age = 6 weeks plus (CRL in days) Example: CRL 16 mm (2 wks 2 days) would have a gestational age of 8 wks and 2 days
14
Week 7	CRL (crown to rump length) 5 mm to 12 mm Length < 0.5 inch Weight < 1 g Heart rate Increases from 130–160 bpm Other features: Heart is beating with one chamber A dividing wall is formed in the heart Arm and leg buds begin to grow The lower jaw and the vocal cords are beginning to form The mouth opening is formed The inner ear is being created The digestive tract is developing The navel string is being created The following organs are being formed: the lungs, the liver, the pancreas and the thyroid gland Neural tube begins to fuse
Week 8	CRL 16 mm to 20 mm Length 0.6 to 0.9 inch Weight Approximately 1 g Fetal structures (at the end of the 8 th week): Elbows Feet buds Hands bud Even fingers are visible Initiate minor movements Stomach is being made from part of the gut Face begins to take shape Mouth and nostrils start developing Teeth begin to develop under the gums Eyes can now be seen as small hollows on each side of the head Brain cavities—seen as large ‘holes’ in the embryonic head Heart Rate—160 bpm Covers ≈ 50% of the chest area Sometimes, it is possible to recognize the fluid-filled stomach below the heart
15
Week 9	CRL → 20–30 mm Length → 0.9 to 1.2 inch Weight → 2g Other features: Fingers and toes well defined Cartilage and bones begin to form Upper lip as well as the nose tip is being formed Tongue begins to develop and the larynx is developing Eyelids are developed, although they stay closed for several months Main construction of the heart is complete Heart rate reaches a maximum of about 175 bpm
Week 10	CRL → 31–41 mm (1.2 to 1.6 inches) Weight → 2–4 g Other features: From this week until birth, the developing organism is called a fetus Size of fetus → of a small strawberry Feet are 2 mm long Neck is beginning to take shape Body muscles are almost developed Fetus has begun movement, even shifts Jaws are in place Mouth cavity and the nose are joined Ears and nose seen clearly Fingerprints are already evident in the skin Nipples and hair follicles begin to form
Week 11	CRL → 41-54 mm Length → 1.6 to 2 inches Weight → 7 g Other features: Fingers and toes have completely separated Taste buds start developing Fetus has tooth buds, the beginning of the complete set of 20 milk teeth Can swallow and stick out the tongue Whole body except the tongue is sensitive to touch Cartilage now calcifying to become bone
Week 12	Fetus is ≈ 6.5 cm long Weight → 14–20 g Other features: Fetus starts moving spontaneously Face is beginning to look like a baby’s face Fingernails and toenails appear Fetus can suck the thumb and get hiccups Nuchal translucency and nasal bone (described henceforth)

 

• Single most powerful marker for Down’s syndrome
• Refers to normal subcutaneous fluid-filled space between back of fetal neck and overlying skin
• Seen in all normal fetuses
• Called ‘translucency’ because, on ultrasound, this appears as a black space beneath the fetal skin
• Normally < 2.5 mm
• ≥ 2.5 mm → may indicate Down’s syndrome or another chromosomal abnormality
• Time: 10 to 14 weeks (CRL 36–84 mm)

  • Condition	NT
  Trisomy 21	↑
  Trisomy 18	↑
  Pregnancy loss <24 weeks	↑
  Congenital heart defect	↑

 

• Midsagittal plane with fetal spine down
• Image—magnified. Only head, neck and upper thorax should be visible
• Neck—neutral (neither hyperflexed or hyperextended)
• Skin at fetal back clearly differentiated from underlying amniotic membrane
  How?
  1. Look for separate echogenic lines
  2. Note that skin line moves with fetus
• Calipers on inner border of echolucent space and perpendicular to long axis of fetus

 

• Cardiac failure 2° to structural malformation
• Abnormality in extracellular matrix
• Abnormal or delayed development of lymphatic system.

 

• Clear association between absence of fetal nasal bone and Down’s syndrome but absent Nasal Bone (NB) is not related to NT
• It is an independent marker
• Occasionally it may not be seen at 11 weeks.

 

• Midsagittal plane
• Spine position
• Slight neck flexion
• 17Two echogenic lines at fetal nose profile should be visualized
  Superficial: Nasal skin
  Deeper: Nasal bones (should be more echolucent at its distal end)
• USG beam should not be parallel to the plane of nasal bone because this will lead to error of ABSENT nasal bone.

 

Anencephaly Spina bifida Limbs (all long bones should be measured) Hydrocephalus/microcephaly Renal (especially obstructive uropathy) Face and mouth Anterior abdominal wall

10–12 weeks 16–18 weeks 16+ weeks (serial at 4 weeks interval) 16+ weeks (serial at 4 weeks interval) 16+ weeks (serial at 4 weeks interval) 18–22 weeks (preferably 3D or 4D) 16–18 weeks

 

• Antenatal care should start at the time pregnancy is confirmed
• Booking visit should be as early as possible, preferably when the second menstrual period has been missed, i.e. at a gestational age (duration of pregnancy) of 8 weeks
• Ideally 8 to 10 antenatal appointments for nulliparous and 6 to 7 for parous women
• Basic investigations and appropriate screening tests must be done to identify high-risk patients
• Exercise (brisk walking) for 30 to 40 minutes 5 days/week seems to be appropriate
• Folic acid (400 micrograms/day, till 12 completed weeks to reduce the risk of neural tube defects) and vitamin D (10 micrograms/day) should be prescribed
• Vitamin A intake > 700 micrograms might be teratogenic and should, therefore, be avoided
• Diet, proper calorie intake and ideal weight gain should be explained at the beginning to avoid complications later in pregnancy.

     

• In general, pregnant women need between 2,200 calories and 2,900 calories a day, which should be gradually increased with the growth of the fetus
  • 1st trimester → does not require any extra calories
  • 2nd trimester → additional 340 calories a day are recommended
  • 3rd trimester → recommendation is 450 calories more a day

• Add variety to your food
• Protein sources:
  • For vegans: Nuts, peanuts, butter, legumes, soy products, quinoa and tofu
  • For nonvegans: Meat, poultry, fish, eggs or dairy products

• Choose foods high in starch and fiber, such as whole-grain breads, cereals, pasta, rice, fruits and vegetables
• Eat and drink at least four servings of calcium-rich foods a day to help ensure that you are getting 1200 mg of calcium in your daily diet. Sources of calcium include dairy products, seafood, green-leafy vegetables, dried beans or peas, and tofu
• Vitamin D helps the body absorb calcium. Adequate amounts of vitamin D can be obtained through exposure to the sun and in fortified milk, eggs and fish. Vegans should receive 10 to 15 minutes of direct sunlight to the hands, face or arms three times per week or take a supplement
• Eat at least three servings of iron-rich foods per day to ensure getting 27 mg of iron in the daily diet. Sources of iron include enriched grain products (rice), eggs, green-leafy vegetables, broccoli, Brussels sprouts, sweet potatoes, dried beans and peas, raisins, prunes and peanuts
• Choose at least one source of vitamin C everyday. Sources of vitamin C include oranges, grapefruits, strawberries, honeydew, broccoli, cauliflower, Brussels sprouts, green peppers, tomatoes and mustard greens
• Choose at least one source of folic acid everyday. Sources of folic acid include dark, green-leafy vegetables, and legumes, such as lima beans, black beans, black-eyed peas and chickpeas
• Choose at least one source of vitamin A every alternate day. Sources of vitamin A include carrots, pumpkins, sweet potatoes, spinach, squash, turnip greens, beet greens, apricots and cantaloupe
• Choose at least one source of vitamin B₁₂ a day. Vitamin B₁₂ is found in animal products including fish and shellfish, eggs and dairy products. Vegans are at risk of not consuming enough vitamin B₁₂
• Avoid:
  • Leftover food
  • Frozen and deep-frozen food
  • Cold drinks
  • Tobacco
  • Alcohol
  • Smoking
• Liver and liver products may also contain high levels of vitamin A, and, therefore, consumption of these products should also be avoided
• Tea, coffee, chocolates and ice-cream can be taken only in moderation (only 2 cups of either tea or coffee permitted/day). Chocolate contains caffeine—the amount of caffeine in a chocolate bar is equal to 1/4th cup of coffee
• Those who suffer from constipation, gas and bloating must avoid peas and other ‘heavy-to-digest’ cereals and potatoes. They must take green gram as it is easy to digest and gives protein
• Butter, clarified butter, milk, honey, fennel seeds and sweets made from jaggery rather than white sugar can be taken in small quantity
• 19 Items such as sandwich, bakery bread, bun, dhokla, pizza, khandvi, pancake, khaman dhokla, steamed rice cake, curd, tomato, tamarind and kadhi usually increase the swellings and acidity. So, try to avoid such items but if such problems do not exist, you can take in small quantity
• Most important, water intake should, by no means, be < 2.5 liters/day
• Limit fats and cholesterol
• DO NOT DIET or try to lose weight during pregnancy.

   

• Apple 56
• Avocado Pear 190
• Banana 95
• Chickoo 94
• Cherries 70
• Dates 281
• Grapes (Black) 45
• Guava 66
• Kiwi Fruit 45
• Lychees 61
• Mangoes 70
• Oranges 53
• Orange juice 100 mL 47
• Papaya 32
• Peach 50
• Pears 51
• Pineapple 46
• Plums 56
• Strawberries 77
• Watermelon 26
• Pomegranate 77

 

• Broccoli 25
• Brinjal 24
• Cabbage 45
• Carrot 48
• Cauliflower 30
• Fenugreek (Methi) 49
• French beans 26
• Lettuce 21
• Mushroom 18
• Onion 50
• Peas 93
• Potato 97
• Spinach 23
• Tomato 21
• Tomato juice 100 mL 22

 

• Bajra 360
• Maize flour 355
• Rice 325
• Wheat flour 341

 

• 1 medium chapatti 119
• 1 slice white bread 60
• 1 paratha (no filling) 280

     

Weeks	Weight gain (Pounds)	Weight gain (kg)
0–10 weeks 10–14 weeks 14–20 weeks 20–30 weeks 30–36 weeks 36–38 weeks 38–40 weeks Total	No weight gain 3–4 pounds 4–6 pounds 10–12 pounds 6 pounds 2 pounds Almost no weight gain 25–30 pounds	No weight gain 1.5 kg 2.5 kg 4.5 kg 2.7 kg 1.0 kg Almost no weight gain 12–14 kg

     

• Amenorrhea
• Morning sickness and urinary symptoms decrease
• Progressive abdominal enlargement.

 

• Breasts become engorged
• Uterus feels soft and elastic, and becomes ovoid-shaped
• Braxton-Hicks contractions are evident.

 

• Bluish discoloration of the vulva, vagina and cervix is much more evident
• Increased softening of the cervix
• Internal ballottement can be elicited between 16th–28th week. The fetus is too small before 16th week and too large to displace after 28th week.

 

• Review, discuss and record the results of all the screening tests undertaken in the 1st trimester
• Colostrum becomes thick and yellowish by 16th week
• Injection tetanus toxoid 0.5 mL IM (1st dose) should be given
• Prescribe iron and calcium.

WHO Tetanus toxoid immunization schedule
Dose	When to give	Protection %	Duration of protection
TT-1	At first contact or as early as possible in pregnancy	Nil	None
TT-2	At least 4 weeks after TT-1	80	3 years
TT-3	At least 6 months after TT-2 or during subsequent pregnancy	95	5 years
TT-4	At least 1 year after TT-3 or during subsequent pregnancy	99	10 years
TT-5	At least 1 year after TT-4 or during subsequent pregnancy	99	Throughout childbearing

1. Hemogram
   • If hemoglobin level is <10 g/100 mL, investigate and consider additional iron supplementation
   • If MCH <27 picograms, offer HPLC (high performance liquid chromatography)
   • If woman is found to be carrier of a clinically significant hemoglobinopathy, father should also be screened without delay.
2. 22 Rhesus negative blood group
   • If Rh negative blood group with husband rhesus positive, offer indirect coomb’s test
   • If ICT is negative, repeat at 28 and then at 34 weeks
   • If positive, send for anti-D antibodies titer.
3. VDRL positive
   • If either the VDRL (Venereal Disease Research Laboratory) or the RPR (Rapid Plasmin Reagin) test is negative, then the patient does not have syphilis and no further tests for syphilis are needed
   • If the titer is ≥1:16, the patient has syphilis and must be treated
   • If the titer is ≤ 1:8, the laboratory should test the same blood sample by means of the TPHA (Treponema Pallidum Hemagglutin Assay) or FTA (Fluorescent Treponemal Antibody) test:
     1. If the TPHA (or FTA) test is also positive, the patient has syphilis and must be fully treated
     2. If the TPHA (or FTA) is negative, then the patient does not have syphilis and, therefore, need not be treated
     3. If a TPHA (or FTA) cannot be done, and the patient has not been fully treated for syphilis in the past 3 months, she must be given a full course of treatment.
4. HIV positive
   • Confirm by western blot or repeat ELISA.
5. Screening for fetal anomalies
   • For women who book later in pregnancy, serum screening test (triple or quadruple test) should be offered between 15+0 and 20+0 weeks
   • If the result is screen positive for Down’s syndrome or any other abnormality, she should be given the option for amniocentesis or chorionic villus sampling.

 

• Breast → enlarged with prominent veins under the skin
• Quickening:
  • When movements made by the fetus are perceived for the first time by the mother
  • Occurs at 18–20 weeks in primigravida
  • At 16–18 weeks in multigravida
• At 20 weeks, the following can be usually observed:
  • Secondary areola
  • Prominent montgomery’s tubercles extend to the secondary areola
  • Variable degree of striae (both pink and white) may be visible in lower abdomen
  • Linea nigra
  • Palpation of fetal parts
  • Active fetal movements
  • External ballottement (fetus is relatively smaller than the volume of the amniotic fluid)
  • Fetal heart sound detected with stethoscope
  • Two other sounds confused with FHS are:
    Uterine soufflé:
    • Soft blowing and systolic
    • Synchronous with maternal pulse
    • Due to increased blood flow through the dilated uterine vessels
    Funic or fetal soufflé:
    • Due to rush of blood through the umbilical arteries
    • A soft, blowing murmur
    • Synchronous with the FHS

• Measure weight and blood pressure
• Detailed ultrasound level II (between 18 and 22 weeks)
• If any anamoly is detected, further decision accordingly
• If placenta is found extending to the internal os, repeat scan for placental localization should be offered at 32 weeks
• Continue iron and calcium
• Injection TT 0.5 mL IM (2nd dose).

 

• Face—chloasma gravidarum may appear at 24th week
• Measure weight and blood pressure
• Plot symphysis—fundal height
• Test urine for proteinuria and rule out asymptomatic bacteriuria
• OGTT with 75 g glucose
• Fetal echocardiography, if mother has heart disease or any fetal cardiac abnormality detected at the time of anamoly scan.

 

Gestational age	Fundal height
40 weeks	1–2-finger width below subcostal arch
36 weeks	At costal arch
32 weeks	Between umbilicus and xiphoid process
28 weeks	3-finger width above umbilicus
24 weeks	At umbilicus
20 weeks	3-finger width below umbilicus
16 weeks	3-finger width above symphysis

 

• To determine:
  • Period of gestation
  • Growth of the fetus
  • Multiple pregnancies
  • Complications of pregnancy, e.g. amniotic fluid disorders, hydatidiform mole and fetal growth disturbances
• Between 20 and 34 weeks gestation, the height of the uterus correlates closely with measurements in centimeter (except in obesity)

• Explain the procedure to the mother and gain verbal consent
• Wash hands
• Obtain a nonelastic measuring tape
• Ensure that the mother is comfortable in a supine position and extended legs, with an empty bladder
• Expose enough of the abdomen to allow a thorough examination.

• Ensure the abdomen is soft (not contracting)
• Perform abdominal palpation to enable accurate identification of the uterine fundus.

• Use the measuring tape with the centimeter on the underside to reduce bias
• Place the zero mark of the tape measure at the uppermost border of the symphysis pubis
• Measure from the top of symphysis pubis to the top of fundus
• The tape should stay in contact with the skin.

• Measure along the longitudinal axis without correcting to the abdominal midline
• Do not hold the tape between the fingers
• Tape should then be turned so that the numbers are visible and the value can be recorded
• Measure only once
• Measurements should be in centimeter only.

• If the bladder is full, it can increase the fundal height by 3 cm
• Supine position has the least variations in measurements
• After 34 weeks, it is not recommended as it may give erroneous readings due to descent of fetus into the pelvis
• A discrepancy of >2 cm should be reported.

   

• A scan is performed at 18 to 22 weeks when the fetus is large enough for an accurate survey of the fetal anatomy and when dates and growth can also be assessed
• Also known as—dating, anomaly or targeted scan
• Measurement of BP, FL, AC, HC, EFW is taken
• Localization of placenta and amount of liquor is determined
• Accurate dating can only be done as early in gestation as possible after 13 weeks, after which dating will not be that reliable
• Detailed Level II scan is beyond the scope of this book but few notable features are worth 25 mentioning.

Period of gestation	Ultrasound features
Weeks 13–17	Ribs appear Nose and chin well-defined Opening and closing of mouth External genitalia almost defined Ears fully developed Cheek bones appear First hair appears at 14 weeks Fetus can make a fist at 15 weeks Fat begins to form underneath the skin Baby hears external voices, sleeps and dreams by 16 weeks Umbilical cord grows thicker and stronger Retina has become sensitive to light—week 17 First stools (meconium) are now beginning to accumulate by week 17
Weeks 18–24	Vernix starts forming Genitals are distinct and recognizable by week 19 Scalp hair has sprouted Growth of hair on rest of the body Regular sleeping and waking rhythm Mother’s movements can wake her baby Eyebrows become visible by week 23 Fetus weighs around 600 g and is about 30 cm long by week 24
Weeks 25–28	Hands—fully developed Brain is growing rapidly Sexual organs are fully developed Eyes begin to open, blink and close Weight is 1000 g and length is almost 37.5 cm by week 28.

   

• During the first two trimesters:
  • Clear and yellow
• During the third trimester:
  • Colorless
• Approximately from 33 to 34 weeks onwards:
  • Cloudiness and flocculation occur, at first very slowly, then after the 36th–37th week steadily and faster.
• At term:
  • Moderately cloudy and contains a moderate number of flakes of vernix
• The appearance of the amniotic fluid, depending on the degree of cloudiness and on the number of flakes, has been expressed by means of a score system, the so-called ‘Macroscore’.

 

• Completely surrounds the embryo after the 4th week of pregnancy
• 26Main constituents are:

• Water and electrolytes only

• Water and electrolytes (99%)
• Glucose
• Lipids from the fetal lungs
• Proteins with bactericide properties
• Flaked-off fetal epithelium cells (they make a prenatal diagnosis of the infantile karyotype possible)
• Normally has a pH of 7.0 to 7.5.

 

• 20 mL in the 7th week
• 400 mL at 20th week
• 600 mL in the 25th week
• 800 mL at 28th week
• 1000 mL in the 30th to 34th weeks
• 800 mL at birth
• 400 mL in the 42nd week
• From the 5th month onwards, the fetus also begins to drink amniotic fluid (400 mL/day)
• Near to the end of pregnancy, the amniotic fluid is replaced every 3 hours.

 

• Amniotic fluid is ‘inhaled’ and ‘exhaled’ bythe fetus—essential for the development of lungs
• Swallowed amniotic fluid also forms urine and contributes to the formation of meconium
• Amniotic fluid protects the developing fetus by cushioning against blows to the mother’s abdomen
• Allowing for easier fetal movements
• Promotes muscular and skeletal development.

 

Grading system
Grades	Period of gestation	Features
‘0’	<18 weeks	Uniform echogenicity; Smooth chorionic plate
‘I’	18–29 weeks	Occasional parenchymal calcification/hyperechoic areas
‘II’	>30 weeks	Occasional basal calcification/hyperechoic areas; May also have comma-type densities at the chorionic plate
‘III’	>39 weeks	Significant basal calcification; Chorionic plate interrupted by indentations; An early progression to grade III is a matter of concern and is sometimes associated with placental insufficiency

   

• Amenorrhea continues
• As the fetus and uterus grow, the patient will complain of more and more discomfort
• Abdomen enlarges further
• There may be physiological edema of the feet
• Frequency of micturition again increases
• Fetal movements are more distinct
• Pigmentation and striae are more dark.

 

• Very important in this trimester is to distinguish lie, presentation, position and attitude of the fetus
• To know the Leopold maneuver
• To distinguish between physiological and pathological edema
• Pelvic examination
• Bishop’s scoring system.

 

• Longitudinal (resulting in either cephalic or breech presentation)
• Oblique (unstable, will eventually become either longitudinal or transverse)
• Transverse (resulting in shoulder presentation).

 

1. Cephalic presentation (96.5%)
2. Breech presentation (3%)
3. Shoulder presentation (0.5%).

 

• Vertex—the most common and associated with the fewest complications
• Sinciput
• Brow
• Face
• Chin.

 

• Flexed (this is the normal situation) → sinciput is higher than the occiput
• Neutral (‘military’) → deflexed state, when both sinciput and occiput are at the same level
• Extended.

 

Presenting part	Denominator
Vertex Face Brow Breech Shoulder	Occiput Mentum Frontal eminence Sacrum Acromion

 

• Vertex presentation with longitudinal lie:
  • Left occipitoanterior (LOA)—the occiput is close to the vagina (hence known as vertex presentation). It faces anteriorly (forward with mother standing) and towards left. This is the most common position and lie
  • Right occipitoanterior (ROA)—the occiput faces anteriorly and towards right. Less common than LOA, but not associated withlabor complications
  • Left occipitoposterior (LOP)—the occiput faces posteriorly (behind) and towards left
  • Right occipitoposterior (ROP)—the occiput faces posteriorly and towards right
  • Occipitoanterior—the occiput faces anteriorly (absolutely straight without any turning to any of the sides)
  • Occipitoposterior—the occiput faces posteriorly (absolutely straight without any turning to any of the sides).
• Breech presentation with longitudinal lie:
  • Left sacrum anterior (LSA)—the buttocks, as against the occiput of the vertex presentation, lie close to the vagina (hence known as breech presentation), anteriorly and towards the left
  • Right sacrum anterior (RSA)—the buttocks face anteriorly and towards the right
  • Left sacrum posterior (LSP)—the buttocks face posteriorly and towards the left
  • Right sacrum posterior (RSP)—the buttocks face posteriorly and towards the right
  • Sacrum anterior (SA)—the buttocks face anteriorly
  • Sacrum posterior (SP)—the buttocks face posteriorly
• Shoulder presentation with transverse lie has the following different positions, based on the location of the scapula:
  • Left scapula-anterior (LSA)
  • Right scapula-anterior (RSA)
  • Left scapula-posterior (LSP)
  • Right scapula-posterior (RSP)

 

1. Physiological
2. Preeclampsia
3. Anemia/hypoproteinemia
4. Cardiac failure
5. Chronic renal disease
6. DVT

 

1. Slight degree (ankle edema) usually confined to 1 leg (right > left)
2. Unassociated with increase in BP or proteinuria
3. Disappears on rest alone

• Over medial malleolus and anterior 1/3rd of tibia
• Press with thumb for 5 seconds

   

• Measure blood pressure and weight
• Check edema (pedal)
• Check hemoglobin
• Offer anti-D prophylaxis to all rhesus-negative women
• Measure symphysis fundal height.

 

• Measure weight, blood pressure and symphysis fundal height
• Ultrasound for fetal well-being, liquor, placental localization
• Urine routine to be done
• Repeat ICT at 34–36 weeks
• Some prefer to give anti-D again at 34 weeks (if dual dose regimen was adopted at 28 weeks) (Refer to chapter on Rh-negative pregnancy)
• Confirm the presenting part by Leopold’s maneuvers.

 

• Named after the gynecologist Christian Gerhard Leopold
• Determines position and presentation of the fetus
• Difficult to perform on obese women and women who have polyhydramnios
• The maneuvers consist of four distinct actions
• The woman is relaxed and adequately positioned
• Bladder is emptied
• The woman should lie on her back with her shoulders raised slightly on a pillow and her knees flexed
• Abdomen uncovered
• Warm the hands by rubbing prior to palpation.

 

• While facing the woman, palpate the woman’s upper abdomen with both the hands
• Determine the size, consistency, shape and mobility of the form that is felt
• Fetal head is hard, firm, round, and moves independently of the trunk while the buttocks feel softer, are symmetric, and the shoulders and limbs have small bony processes; unlike the head, they move with the trunk.

 

• Attempt to determine the location of the fetal back
• Still facing the woman, palpate the abdomen with gentle—but also deeppressure using the palm of the hands
• First the right hand remains steady on one side of the abdomen while the left hand explores the right side of the uterus
• This is then repeated using the opposite side and hands
• The fetal back will feel firm and smooth while fetal extremities (arms, legs, etc.) should feel like small irregularities and protrusions
• The fetal back, once determined, should be continuous with the part found at fundus and also to the one in the maternal inlet or lower abdomen.

 

• Face the woman’s feet
• The fingers of both the hands are moved gently down the sides of the uterus towards the pubis
• The side, where the resistance to the descent of the fingers towards the pubis is greatest, is where the brow is located
• If the head of the fetus is well-flexed, it should be on the opposite side from the fetal back
• If the fetal head is extended and the occiput is felt instead → it is located on the same side as the back.

 

• In this maneuver, attempt to determine which fetal part is lying above the inlet, or lower abdomen
• First grasp the lower portion of the abdomen just above the pubic symphysis with the thumb and fingers of the right hand
• This maneuver should yield the opposite information and validate the findings of the first maneuver
• If it is the head and is not engaged, it may be gently pushed back and forth.

 

Examination	Determined by
Lie of fetus	Inspection → uterus appears longitudinal Fundal grip 1st pelvic grip
Presentation	1st pelvic grip
Attitude	1st pelvic grip Well flexed—sinciput higher than occiput Deflexed—both sinciput and occiput at the same level
Presenting part	1st pelvic grip Sinciput on same sides as limbs
Position	Inspection—convex uterine contour Lateral grip Auscultation
Engagement	1st pelvic grip—both poles not felt per abdomen Divergence of examining fingers If the fingers converge—head is not engaged

 

• Measure weight and blood pressure
• Fetal presentation
• ‘Lightening’—when the baby has dropped down in the pelvis and the diaphragm is relieved of pressure
• If it is a breech presentation, ECV can be offered after excluding contraindications to it
• Per vaginal examination for:
  • Adequacy of pelvis
  • Any cervical changes
  • And then mode of delivery is discussed with the patient
• 32Explain the patient about the labor process in brief
• The woman is made aware of signs of onset of true labor pains and that she should report if she has the following:
  • Pain in the abdomen which is radiating
  • Intermittent and increasing in frequency, duration and intensity
  • Per vaginal leak or blood-stained discharge
  • Decreased fetal movements
• If cesarean section is to be done, indication is discussed with the woman and appropriate gestational age for it is to be decided
• Women should be made aware of the advantages of breastfeeding.

   

• Attempt should be made to tip the sacral promontory
• Try to establish the length of the diagonal conjugate
• Method:
  • Fingers are to follow anterior sacral curvature
  • In normal pelvis, it is difficult to feel sacral promontory (or felt with difficulty)
  • To reach it, elbow and wrist are to be depressed sufficiently and fingers are mobilized in an upward direction
  • Point at which bone recedes from fingers is sacral promontory
  • Fingers are then mobilized under symphysis pubis and a marking is placed over the gloved index finger by the index finger of the left hand
  • Internal fingers are removed
  • Distance between marking and tip of middle finger gives measurement of diagonal conjugate
  • Practically: If middle finger fails to reach promontory or touches it with difficulty→ conjugate is adequate for average size head to pass through
• If it is easily tipped, it should alert one to the possibility of a contracted pelvis.

 

• It is next assessed to see if it is flat or well-curved
• A well-curved sacrum allows for internal rotation of the fetal head.

 

• Assessed next to see if they are parallel or convergent
• Normally not easily palpable.

 

• These are palpated to see if they are prominent and sticking in (that is, decreasing the space in midpelvis)
• Normally these are everted.

 

• Sufficiently wide to place 2 fingers over sacrospinous ligament covering the notch
• Gives information of the capacity of posterior segment and side walls of the lower pelvis.

 

• Smooth rounded curve
• Angulation/beaking → abnormal.

 

• Normally rounded
• Should accommodate palmar aspect of 2 fingers
• Configuration more important than pubic angle.

 

• Before the fingers are removed from the vagina, the subpubic angle is assessed to see if it is acute or obtuse.

   

• Having removed the fingers, the intertuberous diameter is assessed to see if it accommodates more than four knuckles → if it does, it is adequate.

 

• A wide diagonal conjugate
• A well-curved sacrum
• Parallel side walls
• Ischial spines that are not prominent
• A wide subpubic angle; and lastly
• A wide intertuberous diameter.

 

• Measure blood pressure
• Height of uterus will be at 32 weeks due to engagement of fetal head; therefore, look at the flanks → if full, the duration of pregnancy is 40 weeks
• 34Membrane sweeping is done followed by induction of labor, if labor pains do not start on their own
• Bishop score is calculated
• Discuss about the risks associated with prolonged pregnancy (decreased liquor, meconium aspiration, etc.).

 

• Bishop score is a prelabor scoring system to assist in predicting whether induction of labor will be required
• Components included to calculate the score are (original Bishop’s score):
  • Cervical dilation
  • Cervical effacement
  • Cervical consistency
  • Cervical position
  • Fetal station
• According to the Modified Bishop’s preinduction cervical scoring system, effacement has been replaced by cervical length in cm

Score	0	1	2	3
Dilatation	Closed	1–2	3–4	5
Length	>4	3–4	1–2	0
Consistency	Firm	Medium	Soft	–
Position	Posterior	Midline	Anterior	–
Station	–3	–2	–1/0	+1, +2

 

• Total score = 13
• Favorable score = 6–13
• Unfavorable score = 0–5
• A score of ≤ 5 suggests that labor is unlikely to start without induction
• A score of ≥ 9 indicates that labor will most likely commence spontaneously.

• Existence of preeclampsia
• Every previous vaginal delivery.

• Postdated pregnancy
• Nulliparity (no previous vaginal deliveries)
• PPROM (Preterm premature rupture of membranes).

 

Period of gestation	Ultrasound features
Week 29–34	Wrinkled skin is becoming smoother now In boys, the testicles have moved down to the groin by week 30 Eyes open completely Toenails and fingernails are completely formed Eyes open when awake and close when sleeping Excellent chance of survival outside the womb

   

• 1st day of the last menstrual period + 7 days + 9 calendar months
  OR
• 1st day of LMP + 7 days – 3 calendar months + 1 year
  OR
• 1st day of LMP + 280 days (40 weeks).

       

1. Married life (years). The woman may have conceived many years after her marriage
2. Consanguinity
3. Whether ANCs were taken in each previous pregnancy
4. Complications in previous antenatal periods (preeclampsia, preterm labor, gestational diabetes, antepartum hemorrhage, etc.)
5. Grand multiparity
6. Miscarriages (to rule out bad obstetric history and its causes, which are different for each trimester)
7. Ectopic pregnancy (whether managed medically or surgically; which surgery was done; was the tube saved; any blood transfusions were done; if medically treated, any reaction to the drug used, when was the treatment ended)
8. Any h/o molar pregnancy (ask patient to get previous records in the next visit; what treatment was given; histopathology report after D and C; was chemotherapy given and for how long)
9. Any h/o twin gestation (nonidentical twins tend to recur)
10. Any perinatal deaths [at what period of gestation, cause, how was it suspected or was it an incidental finding, delivery by induction or spontaneous, how was the appearance of the baby 36(macerated, peeling of skin, skin color, any gross congenital anomalies seen, did the baby cry after birth, as the women sometimes are not able to distinguish intrauterine death or death immediately after birth); any histopathology sample of the baby was sent; if yes, ask for reports]
11. Mode of each delivery—vaginal or cesarean section; prolonged labor; birth weight of each baby; home or institutional delivery; gestational age at delivery; instrumental delivery; any complication after vaginal deliveries
12. If delivery was by cesarean section—cause, type of incision, any postoperative complications, history of blood transfusion
13. Was Anti-D taken in cases of Rh-negative pregnancy
14. Whether any baby was kept in NICU, why and for how long
15. Intervals between pregnancies
16. Whether all babies are alive and healthy
17. Whether breastfeeding done after each delivery and for how long.

 

1. Type of conception (spontaneous or after-infertility treatment)
2. Any history of fever with or without rash, vaginal bleeding, burning micturition, etc.
3. Following minor symptoms should be enquired:
   • Nausea and vomiting
   • Heart burn
   • Constipation
   • Edema of the ankles and hands.

   

1. Last menstrual period
2. Periods were regular or irregular
3. Whether the patient had any spotting after her last periods (may be implantation bleed)
4. Any history of oral or injectable contraception. These patients must have menstruated spontaneously after stopping contraception, otherwise the date of the last period should not be used to measure the duration of pregnancy.

 

1. Hypertension
2. Diabetes mellitus
3. Rheumatic or other heart diseases
4. Epilepsy
5. Asthma
6. Tuberculosis
7. Psychiatric illness
8. Any other major illness or blood transfusions in the past
9. Any past medication can be a pointer of a specific illness. Certain drugs can be teratogenic to the fetus. So, they need to be changed or stopped at all.
10. Allergies to drugs need to be mentioned clearly on antenatal card
11. Any previous (major or minor) surgeries need to be enquired.

 

1. Body mass index above 30 kg/m²
2. Previous macrosomic baby weighing ≥ 4.5 kg
3. Previous gestational diabetes
4. Family history of diabetes (first-degree relative with diabetes)
5. Family origin with a high prevalence of diabetes:
   • South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh), black Caribbean Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt).

 

1. Unemployment, poor housing (kutcha or pucca house, electricity) and overcrowding increase the risk of tuberculosis, malnutrition and intrauterine growth restriction. Patients living in poor social conditions need special support and help. Family income needs to be calculated according to Kuppuswamy scale
2. Daily calories of the patient need to be counted
3. Smoking/alcohol/tobacco consumption is enquired.

 

(A) Education: Profession or honours Graduate or postgraduate Intermediate or post-high-school diploma High-school certificate Middle-school certificate Primary-school certificate Illiterate	Score 7 6 5 4 3 2 1
(B) Occupation: Profession Semiprofession Clerical, shop-owner, farmer Skilled worker Semiskilled worker Unskilled worker Unemployed	Score 10 6 5 4 3 2 1
38
(C) Family income per month (2012): = 30375 15188-30374 11362-15187 7594-11361 4556-7593 1521-4555 =1520	Score 12 10 6 4 3 2 1
Total score 26-29 16-25 Middle 11-15 5-10 Lower <5	Socioeconomic stat Upper (I) Upper middle (II) Lower middle (III) Upper lower (IV) Lower (V)

   

1. Consciousness, orientation to time, place and person, occupation (to exclude occupational hazards or occupation as a cause of stress)
2. Built, sleep, nutrition, height, weight, BMI
3. Calories need to be calculated and proper diet needs to be explained
4. Face
   Chloasma uterinum ( gravidarum)
   • Brownish pigmentation of the bridge of the nose and the maxillae, simulating a butterfly appearance
   • Occasionally, the pigmentation is more generalized, affecting the forehead and the cheeks
   Acromegalic features
   • More manifest in the 2nd half of pregnancy
   • Ascribed to the possible increase of the growth hormone of the anterior pituitary or placenta.

 

1. Pallor, icterus, cyanosis, clubbing, lymphadenopathy (neck, axillae, inguinalareas), edema (feet, hands, face)
2. Thyroid
   • A visibly enlarged thyroid gland, a single palpable nodule or a nodular goiter is abnormal and needs further investigation
   • A slightly, diffusely enlarged thyroid gland is normal in pregnancy
3. Breasts
   • Enlargement, warmth, tenderness—in which quadrant, is generalized or isolated
     • Early pregnancy: mostly manifest in the upper and outer quadrants
     • Late pregnancy: becomes more generalized and felt all over the breasts
   • Dilated veins under the skin
   • Nipple enlargement, pigmentation, more erectile or not
   • Discharge from nipples (color, consistency, amount)
   • Inverted or flat nipples
   • 39Areola—size and pigmentation
   • Montgomery’s follicles—‘glandular tubercles’
   • Any breast lump
4. Spine (lordosis, kyphosis, scoliosis)
5. Respiratory system
   • Breath sounds, bilateral air entry, respiratory rate, dyspnea
6. Cardiovascular system
   • BP, PR
   • Functional murmurs (a soft, midsystolic, nonradiating, ejection murmur heard best over the mitral or aortic areas) are common in pregnancy.
   Blood Pressure Recording in Pregnancy—Ideal Method
   • First one should be familiar with the 5 phases of Korotkoff sounds
   • Phase I: 1st appearance of sounds marking systolic pressure
   • Phases II and III: Increasing loud sounds
   • Phase IV: Muffling of sounds
   • Phase V: Disappearance of sounds.
   Position
   • Rest—5 minutes
   • Sitting with feet supported on flat surface (avoid supine position)
   • Remove every tight clothing from the arm
   • Arm well supported at the level of the heart (different arm positions can alter the BP significantly)
   • Measure BP on both the arms at the first visit (this excludes rare vascular disorders)
   • BP of the arm giving higher reading is to be taken
   • In labor → left recumbent position.
   Cuff
   • Length—1.5 times the circumference of the arm
   • Wide enough to cover at least 2/3rd of the upper arm
   • Arm circumference >33 cm → use larger cuff
   • Smaller cuff size will overestimate BP
   • Larger cuff will underestimate BP
   • Lower edge of the cuff should be 2–3 cm above the point of brachial artery pulsation (easy access to antecubital fossa)
   • Application should be firm.
   Measurement apparatus
   • Mercury sphygmomanometer is still considered the best for measuring BP (especially in pre-eclamptic patients)
   • Automated devices may underestimate BP by 10–15 mm Hg.
   Measurement
   • Do not kink or twist the tube on the cuff
   • Inflated and deflated smoothly
   • Korotkoff V is taken for diastolic BP
   • Korotkoff IV only when sounds are audible as level approaches ‘0’ mm Hg (due to hyperdynamic circulation of pregnancy).
7. 40Abdomen (always warm your hands before abdominal palpation)
   • Pigmentation “linea nigra”
   • Striae gravidarum (color, site)
   • Any scar (any previous surgery), its site (horizontal, vertical) and present condition
   • Fetal movements
   • Fetal parts
   • External ballottement
   • Contractions
   • Fundal height
   • Symphysis fundal height (with measuring tape)
   • Tenderness, any mass palpable, organomegaly
   • Leopold maneuvers
   • Fetal heart sound.
8. Both external and internal genitalia
   • Any ulcers, purulent or excessive discharge, enlarged inguinal lymph nodes should be looked for
   • Suspicious looking cervix (cervical smear must be taken) or any growth on the cervix
   • Bimanual examination (for size of uterus, if not palpable per abdomen), condition of the internal os
   • Any tenderness in the fornices
   • Pelvic assessment (if appropriate at that gestational age).

 

1. Last normal menstrual period (if dates are sure)
2. Size of the uterus on bimanual (up to 12 weeks) examination
3. Abdominal examination from 12–22 weeks, when fundal height is still below the umbilicus, is considered very accurate
4. SFH between 24 and 36 weeks
5. The size of the fetus (rule out IUGR/SGA or large for date fetus)
6. Ultrasound measurements:
   • If the ultrasound examination is done at ≤ 14 weeks, the error in determining the gestational age is only one week
   • If patient is >24 weeks pregnant, ultrasound cannot be used to determine the gestational age
   • If still not clear, look for serial growth after 3 weeks.

• Error in calculating dates or wrong dates
• Multiple pregnancy
• Polyhydramnios
• Large for the gestational age
• Diabetes mellitus
• Complete molar pregnancy
• Hydrops
• Any mass (fibroid, ovarian tumour, etc.) with pregnancy
• Sometimes fetus in breech presentation looks bigger.

• Error in calculating dates or wrong dates
• Intrauterine growth restriction
• Oligohydramnios
• Small for gestational age
• Transverse lie
• Fetal descent into the pelvis
• Intrauterine death
• Rupture of membranes.

     

• Washing hands before handling food
• Thoroughly washing all fruits and vegetables, including ready prepared salads, before eating
• Thoroughly cooking raw meats (> 67°C/153°F)
• Wearing gloves and thoroughly washing hands after handling soil and gardening
• Avoiding cat feces in cat litter or in soil
• Freezing meat to at least −20°C/−4°F also kills T. gondii cysts
• Clean surfaces and utensils that have been in contact with raw meat
• Do not consume raw eggs or raw milk
• Do not drink water potentially contaminated with oocysts
• Be aware that:
  • The process of curing, smoking or drying meat does not necessarily result in a product free of parasite cysts
  • Refrigeration does not destroy the parasite (still viable after 68 days at +4°C)
  • Microwave oven cooking does not destroy parasites.

• Drinking only pasteurized or UHT milk
• Not eating ripened soft cheese (there is no risk with hard cheese, such as Cheddar, or cottage cheese and processed cheese)
• Not eating uncooked or undercooked ready-prepared meals.

• Avoiding raw or partially cooked eggs or food that may contain them (such as mayonnaise)
• Avoiding raw or partially cooked meat, especially poultry.

 

• Few medicines have been established as safe to use in pregnancy
• To be taken under supervision.

 

• Beginning or continuing a moderate course of exercise during pregnancy is not associated with adverse outcomes
• Contact sports, high-impact sports and vigorous racquet sports that may involve the risk of abdominal trauma, falls or excessive joint stress, and scuba diving, which may result in fetal birth defects and fetal decompression disease are to be avoided in pregnancy.

 

• Sexual intercourse in pregnancy is not known to be associated with any adverse outcomes.

 

• Pregnant women and women planning a pregnancy should be adviced to avoid drinking alcohol in the first 3 months of pregnancy if possible because it may be associated with an increased risk of miscarriage
• If women choose to drink alcohol during pregnancy, they should be adviced to drink no more than one small (125 mL) glass of wine
• Although there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level, there is no evidence of harm to the unborn baby.

 

• Ask about active or even passive smoking (in case the husband is a smoker)
• Risks associated—low birth weight and preterm birth
• The benefits of quitting at any stage should be emphasized.

 

• Pregnant women should be informed that long-haul air travel is associated with an increased risk of venous thrombosis, although the fact that whether or not there is additional risk during pregnancy is unclear
• Wearing correctly fitted compression stockings is effective at reducing the risk.

 

• Correct use of seat belts (that is, three-point seat belts ‘above and below the bump, not over it’) should be explained.

 

• Pregnant women should be informed that if they are planning to travel abroad, they should discuss about considerations such as flying conditions, vaccinations and travel insurance.

   

• Women should be informed that most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks and that nausea and vomiting are not usually associated with a poor pregnancy outcome
• 43The following interventions appear to be effective in reducing symptoms:
  • Nonpharmacological: ginger, P6 (wrist) acupressure
  • Pharmacological: antihistamines.

 

• Lifestyle and diet modification
• Antacids may be offered to women whose heartburn remains troublesome despite lifestyle and diet modification.

 

• Diet modification, such as bran or wheat fiber supplementation
• Increase water intake.

 

• Diet modification
• If clinical symptoms remain troublesome, standard hemorrhoid creams should be considered.

 

• Varicose veins are a common symptom of pregnancy that will not cause harm
• Compression stockings can improve the symptoms but will not prevent varicose veins from emerging.

 

• Administration of adequate calcium and vitamin D3
• Gentle massage of the legs
• Local application of topical analgesics.

 

• Increase in vaginal discharge is a common physiological change that occurs during pregnancy
• If it is associated with itch, soreness, offensive smell or pain on passing urine, there may be an infective cause and so investigation should be considered
• A 1-week course of a topical imidazole is an effective treatment and should be considered for vaginal candidiasis infections in pregnant women
• The effectiveness and safety of oral treatments for vaginal candidiasis in pregnancy are uncertain and these treatments should not be offered.

 

• Women should be informed that exercising in water, massage therapy and group or individual back care classes might help to ease backache during pregnancy.

 

• Maintain cleanliness
• Massage the breasts
• Try to express the discharge (colostrum).

   

1. Healthy eating
2. Danger symptoms and signs
3. Dangerous habits, e.g. smoking or drinking alcohol
4. Description of the onset and process of labor must be included, especially when the patient is a primigravida
5. HIV counseling of both the partners
6. Breastfeeding
7. Care of the newborn infant
8. Family planning.

       

1. Risk factors for numerical chromosomal abnormalities and new mutations
   • Maternal age
   • Paternal age (≥ 40 years, r/o child having new gene mutations)
   • Radiation/chemicals/drugs
2. Risk factors for inherited mutations
   • Presence of such an illness in either parent, in his or her family or in a previous child
   • Couple’s ethnic background:
     • Cystic fibrosis in Europe, the Mediterranean region and Middle East
     • Sickle cell anemia and thalassemia (where prevalence of malaria is ↑)
     • Tay-Sachs disease and several other rare disorders in Ashkenazi Jewish background
     • Neural tube defects
   • Consanguinity—risk of autosomal recessive disorders increases.

   

• Muscular dystrophy
• Hemophilia
• Cystic fibrosis
• Fragile X syndrome
• Congenital heart disease
• Phenyl ketonuria
• Dwarfism
• Sickle cell anemia
• Tay-Sachs disease.

 

• Spina bifida
• Anencephaly
• Cleft palate and cleft lip
• Hypospadias
• Congenital heart disease.

 

• Developmental disability
• Premature atherosclerosis
• Diabetes mellitus
• Psychosis
• Epileptic disorders
• Hypertension
• Rheumatoid arthritis
• Deafness
• Severe refractive disorders of the eye.

 

• Women < 20 or > 35 years carry increased risks.

   

• Diabetes mellitus
• Anemia
• Thyroid disorders
• Gynecological disorders
• Asthma
• STDs
• Heart disease
• Hypertension
• Deep venous thrombosis
• Kidney disease
• SLE
• Epilepsy
• Hemoglobinopathies
• Cancer
• Seizure disorders
• Tuberculosis
• Rheumatoid arthritis
• Mental health/psychiatric disorders.

 

• Rubella or varicella susceptible—offer vaccination if not vaccinated
• Hepatitis B and C—routine preconception testing is not currently recommended
• 46Routine serologic testing for toxoplasmosis is not recommended
• Evaluate (woman and her partner) for sexually transmitted disease (e.g. Chlamydia, HIV, gonorrhea, syphilis)
• Periodontal screening
• Nonpregnant women immunized with a live or live-attenuated vaccine should be counseled to delay pregnancy by at least four weeks.

 

• Menstrual history (regularity, duration and amount of flow, length of cycle, clots, dysmenorrhea)
• Contraceptive
• Sexual history
• Infertility
• Abnormal Pap smear
• In utero exposure to diethylstilbestrol
• Past obstetric history
  • Early/late miscarriages/stillbirths
  • Number of pregnancies and live issues
  • Mode of previous deliveries
  • Length/course of labor
  • Complications (preterm labor or delivery, gestational diabetes mellitus, hypertension in pregnancy, postpartum depression).

 

• BMI
• Nutrition
• Physical activity
• Sufficient sleep
• Minimum stress
• Prescription and over-the-counter drug use
• Other substance abuse
• Environmental exposures (current and past).

 

1. Ideal BMI—19.6–26.0 kg/mt²
2. Laboratory testing:
   • CBC
   • Urinalysis
   • ABO Rh
   • VDRL
   • HIV
   • HbsAg
   • Rubella antibody titer
     
3. 47Folic acid or folate (vitamin B₉)
   The recommended strategy(ies) for primary prevention or to decrease the incidence of fetal congenital anomalies include(s) various options:
   Option A:
   Patients with no personal health risks, planned pregnancy and good compliance require:
   • Folate-rich foods—fortified grains, spinach, lentils, chickpeas, asparagus, broccoli, peas, Brussels sprouts, corn and oranges
   • A multivitamin with folic acid (0.4–1.0 mg) × 2–3 months before conception and throughout pregnancy and postpartum period (4–6 weeks and as long as breastfeeding continues).
   Option B:
   Patients with health risks (previous child with neural tube defects, epilepsy, Type I DM, use of folate antagonists, obesity with BMI >35 kg/m², family history of neural tube defects, belonging to a high-risk ethnic group, e.g. Sikhs) require:
   • Increased dietary intake of folate-rich foods
   • A multivitamin with 5 mg folic acid, beginning at least three months before conception and continuing until 10 to 12 weeks postconception. From 12 weeks postconception and continuing throughout pregnancy and the postpartum period (4–6 weeks or as long as breastfeeding continues), supplementation should consist of a multivitamin with folic acid (0.4–1.0 mg).
4. Vitamin D intake of minimum 5 μg/day for nonpregnant women with limited exposure to sunlight (i.e. those whose hands and face are exposed to the open air for < 15 minutes/day) and 10 μg/day for pregnant women
5. Avoid exposure to cat feces, raw/undercooked meats and unpasteurized milk
6. Smoking and alcohol cessation
7. Consumption of vitamin A to < 3000 μg/day
8. Polytherapy changed to monotherapy in case of epilepsy with prior consultation with a neurologist
9. Adequate glycemic control in a patient of pregestational diabetes
10. Consultation with cardiologist if having cardiac disease
11. ACE inhibitors should be changed to a different drug.