For a safe, trouble free pregnancy, antenatal care ideally should start even before conception.
A newly married couple came to my clinic for a prenatal checkup a few days back. And as it turned out, the resident on call did not have a clue as to what to do with them.
A lot of people including doctors seem to think that pregnancy consultation with a medical professional should be 6 to 7 months into a pregnancy. This actually is a big misconception. During this time, major changes have taken place and the baby has matured. Therefore not much can be done at this stage to help the baby or the mother in case a complication has arisen. To take the best possible care of a pregnancy, the couple should visit the clinic at the time they start to plan for a baby.
At a pre-pregnancy stage the health of the couple is assessed. The family and medical history is appraised carefully and habits such as smoking, alcohol, drugs use if present, are strongly discouraged. The woman’s complete blood count is done to check her hemoglobin and platelet levels. Her blood sugar and blood pressure is also controlled if not at optimum levels. Her rubella immunity is checked, and if negative she is given a rubella vaccine and advised to avoid pregnancy for 3 months, due to theoretical risk of abnormalities in the fetus. She can also be vaccinated for Hepatitis-B during this period although it can be safely done during pregnancy as well. General health, hygiene and lifestyle advice is given which includes a healthy diet plan and an exercise regime. Exercise is not contraindicated before or during pregnancy but care should be taken that it is not overdone.
When a woman suspects pregnancy she can confirm her status by utilizing a home pregnancy test. After confirmation of pregnancy an early ultrasound is important for the viability of the fetus. It confirms the exact date of pregnancy (especially valid in our community as women are not sure of dates), and viability, which is the cardiac activity of the fetus. It usually is visible by 6 weeks of pregnancy and is reassuring for both the mother and the obstetrician. An early ultrasound is also important to establish whether it is a twin or singleton and also an intrauterine or ectopic pregnancy. In case a cardiac flicker is not present then a serial beta HCG (blood test) is advised to confirm the well being of pregnancy.
Once pregnancy is confirmed and its viability established, a complete evaluation at a clinic is mandatory. This includes checking up on the history especially in the case of marriage of cousins, congenital abnormalities in the family, history of thalessemia, diabetes, blood pressure, epilepsy, thyroid disease, asthma etc.
If the patient is on medication such as antidepressants, antihypertensives or antiallergics, sometimes these medications cannot be withdrawn. However the dosage may be tapered or alternatives can be suggested which are safer in pregnancy. Luckily pregnancy occurs at the prime of age when one is young and healthy therefore most of these problems are not very frequent.
The workup in addition to history requires examination and investigations. These include blood group/Rh factor, complete blood picture, urine detail report and culture/sensitivity, hepatitis B and C and rubella . The blood sugar test is done at 20 weeks.
In routine, low risk pregnancies (80 percent of the cases), the usual follow up for pregnant female are the monthly visits till 30 weeks, fortnightly visits till 36 weeks and then weekly visits till delivery. On these routine visits themother’s BP and weight are checked; a physical checkup is carried out to see the growth of fetus by measuring the height of fundus (distended womb), fetal heat and movements are checked and maternal well being is established.
The mother is usually advised routine activity and told to avoid exertion. Supplements such as iron/calcium are advised and foods rich in iron are encouraged. These include spinach, dates, apples, red meat and liver. The concept of garam/thanda doesn’t exist in medical science so from a medical viewpoint she can eat whatever she likes. Fish, cheese, nuts, milk and yogurt are encouraged as well. Only in case of diabetes or in morbidly obese patients is the diet restricted.
The mother-to-be is advised to continue her routine job/work. Minor aches and pains are to be expected during pregnancy and they can be corrected by posture, rest, occupational therapy (being busy) with the last option being pain killers. Light relaxing massage on the back and legs helps especially in the third trimester when blood circulation in the legs is stagnant because of mechanical pressure of the womb.
Another important test which is carried out mid pregnancy (20 weeks) is the detailed anomaly scan, which is a comprehensive visualization of the 4 chambers of the heart, lungs, stomach, bowels, bladder, kidneys and liver of the fetus. The skeletal normality is also established on this scan. This, however, has to be done from a tertiary center.
In families where the index of suspicion for abnormalities is high or the maternal age is above 35 years, other sophisticated hi-tech tests such as amniocentesis are advised at 16-17 weeks. These are invasive and will have the slight risk of miscarriage.
The tetanus toxoid shot is advised at the 28th and 32nd week, 2 doses only. In women who have completed their 5 shots, the additional dosage in pregnancy is not recommended. Growth scans are advised in the third trimester to monitor the growth of the fetus, these can be serial or just one depending on the need. Hemoglobin checks can be repeated in every trimester.
This is the basic pattern of antenatal care. The laboratory work up, medicines and supplements are at their most effective when they are tailored specifically according to the needs of the patient. The plan can be simplified according to the means of the patient, the setting and the availability of facilities. For example in under developed communities, it is the midwife who can conduct visits to the mother and monitor whether the mother is in a high risk situation and requires hospital delivery. The important thing is to always remember that the best prenatal care happens even before conception. Getting in touch with medical professionals from the very beginning ensures a safe and trouble free pregnancy for you and your baby.
