Pregnancy

Prepregnancy Counselling

To clarify quantify . minimize

risk of pregnancy from any pre-existing medical condition or lifestyle pattern of either partners that affect reproductive outcome.

Prepregnancy Visit

• Optimize maternal health.
• Identify and treat or optimize any pre-existing disease.

Who Will Do Prepregnancy Counselling?

MDT (Multi-Disciplinary Team) consisting of:

• Obstetrician.
• Nurse.
• Midwife.
• Anesthetist.
• Others according to needs.

Plan

I. Revise

• Patient history.
• Lifestyle.
• Medications. Vit A … ↝ lead to congenital Anomaly

II. Optimize Optimize the previous points.

III. Do Examination

IV. Investigation Basic investigations according to need.

V. Medication We give “Folic Acid” 400 microgram/day only ↝ give Folic acid. high doses in some studies showed association with Autism

• In high doses:
  • Hx of Congenital Anomaly ‘spinal Bifida’
    • Diabetic delivery
    • Epilepsy “liver drugs” “Folic Acid consuming drugs” / methotrexate “chelating - consuming”
  • Rheumatic disease
  • Malabsorption

Guidelines for Treating Women with Respect and Dignity

• Treat women with kindness and dignity.
• Respect her cultural and religious beliefs.
• Services should be accessible & continuous.
• Appropriate, verbal and written information on which women can base their choices & decisions.

Who Will Provide Care

• Community-based team of:
  • Midwives
  • And family practitioners (such as GPs)
  • A hospital consultant team.
  • Or a combination of the two.
• Hospital-based obstetric team:
  • For complex pregnancies.
  • They are said to have consultant care.

Primary components

• early registration and first checkup within first trimester (12 wk)
• Minimum 4 antenatal check ups; at least one ANC by M.O (Preferably 3rd ANC)
• Vaccination

Essential components

• History taking
• physical examination (Weight, BP, Pallor, Respiratory rate, Edema)
• Abdominal examination
• Laboratory investigation
  • (Hb % Urine for sugar and proteins)

Desirable components

• Blood‑group & Rh typing
• Screenings: HIV, hepatitis, blood‑sugar

Counselling – key points

• Discuss delivery & birth preparedness
• Recognise danger signs & symptoms during pregnancy, labour, and the post‑natal period
• Outline a plan for complicated management
• Emphasise diet, rest, and family‑planning

New‑born care

• Initiation of exclusive breast‑feeding (EBF)
• Guidelines for supplementary feeding when needed
• Schedule of immunisations

How to Diagnose Pregnancy

From:

• History. Amenorrhea, N/V
• Examinations. Distended abdomen
• Investigations. BhCG in urine but blood accurate

History

• Amenorrhea.
• Symptoms & signs of pregnancy. as a first presentation, N/V
• Quickening. 16-20wk usually In 4 months “In lactating or women with irregular menses”

Examinations

Signs of pregnancy in face, neck & breast. Abdominal examination:

• inspection.
• palpation of Fetal parts & fundal height:
  • At symphysis pubis 12 weeks
  • At umbilicus 22 weeks.
  • At xiphisternum 36 weeks.
  • Auscultation FHS.

Investigations

A. Lab Investigations

• Urinary pregnancy test.
  • most accurate
• Serum bHCG test.
• Quantitative bHCG.
  • when to do?
  • in Miscarriage susceptibility + ectopic pregnancy
  • “normally” should double every 48h
  • but ‘in this case’ will be less !!!
  • or Molar pregnancy
  • L will be more than the double

B. Images

• Ultrasound (AUS & TVUS).

Pregnancy Symptoms

Pregnancy is a time of great uncertainty and stress and physical changes experienced by the woman.

• Common symptoms include:
  • Nausea.
  • Heartburn.
  • Constipation.
  • Abdominal Discomfort.
  • Shortness of breath.
  • Dizziness.
  • Swelling.
  • Backache.
  • Headaches.

Generally these reflect physiological adaptation to pregnanc ;… .CCFile

Pregnancy Trimesters

Pregnancy is divided into three trimesters:

• First trimester: 0-13 weeks
• Second trimester: 14-26 weeks
• Third trimester: 27-40 weeks

Why Divide Pregnancy into Trimesters?

• For the purpose of good follow-up as any trimester has its own features and changes.

Visits Schedule

• Two times in the first trimester

• Two times in the 2nd trimester

• Monthly in the 3rd trimester till 36 weeks, then every two weeks till delivery.

  Pregnancy Trimester & Visit Schedule Integrated Pregnancy Trimester & Care Table

Trimester	Weeks (gestation)	Visit Frequency / Timing	Core Care Components
First	0 – 13	2 visits (including the booking visit)	• Detailed maternal history • Physical examination • Routine investigations (blood work, urine, etc.) • Dating scan; age of baby • Folic‑acid supplementation • Identify risk factors → referral to obstetric consultant or other specialists as needed (medical/psychosocial support)
Second	14 – 26	2 visits (mid‑pregnancy)	• Anomaly scan (done at 18‑20wks) – fetal anatomy assessment • Iron Supplementation - • Vaccination • Ask about quicknening • Routine investigations each visit:  – Full Blood Count (FBC)  – Urinary analysis (UG) • Thyroid screening if prior history (each trimester) • Gestational diabetes (DM) screening – performed at each visit when indicated -Z
Third (early)	27 – 36	Monthly visits	(Follow up) • Maternal clinical assessment • Routine investigations (e.g., hemoglobin, glucose, urine) • Routine obstetric examinations • Ultrasound to reassess fetal growth & well‑being • Discuss mode of delivery & develop a written delivery plan
Third (late)	37 – 40	Every 2 weeks until delivery	• Continued maternal clinical assessment • Same routine investigations as early third trimester • Focused ultrasound if indicated • Finalize delivery plan & mode of delivery • Breast‑feeding education and postpartum preparation

First Trimester

• First interactions booking visit:

  • Detailed history.

  • Examine the woman.

  • Routine investigations.

• If risk factors are identified specialized services:

  • This may mean referral to a hospital consultant obstetrician** or other specialist services as appropriate.

  • Medical or psychosocial issues offered.

    • Dating scan

    • Give folic acid.

Examinations in Booking Visit

• Height and weight should be measured at the booking visit.
• Body mass index (BMI) calculated and assessed.
• General pregnancy dietary advice (balanced meals).
• Blood pressure assessment.

Booking Tests

1. Full blood count (FBC)

   • To identify women with anemia,
   • to allow early initiation of treatment.
   • Also to identify low platelets. (low platelet in the 1st trimester warrants further investigation).

2. Blood group & Rh status.

Antenatal Screening

• Gestational diabetes screening.
• Thalassemia Sickle cell screening.
• Infections screening:
  • Rubella
  • Syphilis
  • Hepatitis B & C HIV
• Ultrasound for first trimester dating.
• Vitamin D deficiency

Second Trimester Care

Very Important

• Anomaly scan Between 20 and 22 weeks’ gestation it is recommended that fetal anatomy be assessed.

Every visitz

• Routine investigations:
  • FBC Full blood Count
  • UG.

If indicated: → each trimester

• Thyroid screening. Each trimester if there’s a history
• DM screening. Each visit

Third Trimester

• Assess the mother clinically.
• Routine investigations.
• Routine examinations.
• US to assess the baby.
• Discuss mode of delivery.
• Written plan for delivery.
• Breastfeeding education.