The following information is based on the guidelines of the Royal College of Obstetricians and Gynaecologists of Great Britain (revised 2008) and forms the basis of monitoring a pregnant woman.
However, this can be individualised so that the pregnant woman has the monitoring that suits her lifestyle, personal and family history, and physical and mental condition.
At the first contact (4-6 wk) with a healthcare professional:
folic acid supplementation, food hygiene, including how to reduce the risk of a food-acquired infection, lifestyle advice, including smoking cessation, and the implications of recreational drug use and alcohol consumption in pregnancy, all antenatal screening, including screening for haemoglobinopathies, the anomaly scan
and screening for Down’s syndrome, as well as risks and benefits of the screening tests.
At booking (ideally by 10 weeks): how the baby develops during pregnancy
nutrition and diet, including vitamin D supplementation for women at risk of vitamin D deficiency, exercise, including pelvic floor exercises, pregnancy care pathway, breastfeeding, including workshops, participant-led antenatal classes, further discussion of all antenatal screening, discussion of mental health issues
Before or at 36 weeks:
breastfeeding information, including technique and good management practices that would help a woman succeed preparation for labour and birth, including information about coping with pain in labour and the birth plan recognition of active labour care of the new baby, vitamin K prophylaxis, newborn screening tests, postnatal self-care, awareness of ‘baby blues’ and postnatal depression.
At 38 weeks:
Options for management of prolonged pregnancy.
Frequency of antenatal appointments
A schedule of antenatal appointments should be determined by the function of the appointments.
For a woman who is nulliparous with an uncomplicated pregnancy, a schedule of ten appointments should be adequate. For a woman who is parous with an uncomplicated pregnancy, a schedule of seven appointments should be adequate.
Early in pregnancy, all women should receive appropriate written information about the likely number, timing and content of antenatal appointments associated with different options of care
Gestational age assessment: LMP and ultrasound
Pregnant women should be offered an early ultrasound scan between 10 weeks 0 days and 14 weeks to determine gestational age and to detect multiple pregnancies. This will ensure consistency of gestational age assessment and reduce the incidence of induction of labour for prolonged pregnancy.
Crown–rump length measurement should be used to determine gestational age. If the crown–rump length is above 84 mm, the gestational age should be estimated using head circumference.
Good fetal development
Pregnant women should be informed of their maternity rights and benefits. The majority of women can be reassured that it is safe to continue working during pregnancy. Further information about possible occupational hazards during pregnancy is available from the increased risk through occupational exposure.
Pregnant women (and those intending to become pregnant) should be informed that dietary supplementation with folic acid, before conception and up to 12 weeks of gestation, reduces the risk of having a baby with neural tube defects (anencephaly, spina bifida). The recommended dose is 400 micrograms per day. Iron supplementation should not be offered routinely to all pregnant women. It does not benefit the mother’s or the fetus’s health and may have unpleasant maternal side effects. Pregnant women should be informed that vitamin A supplementation (intake greater than 700 micrograms) might be teratogenic and therefore it should be avoided. Pregnant women should be informed that as liver and liver products may also contain high levels of vitamin A, consumption of these products should also be avoided. All women should be informed at the booking appointment about the importance for their own and their baby’s health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding. In order to achieve this, women may choose to take 10 micrograms of vitamin D per day, as found in the Healthy Start multivitamin supplement. Particular care should be taken to enquire as to whether women at greatest risk are following advice to take this daily supplement.
Pregnant women should be offered information on how to reduce the risk of listeriosis by: drinking only pasteurised or UHT milk not eating ripened soft cheese such as Camembert, Brie and blue-veined cheese (there is nο risk with hard cheeses, such as Cheddar, or cottage cheese and processed cheese) not eating pate (of any sort, including vegetable) not eating uncooked or undercooked ready-prepared meals.
Pregnant women should be offered information on how to reduce the risk of salmonella infection by: 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. Prescription medicines should be used as little as possible during pregnancy and should be limited to circumstances where the benefit outweighs the risk.
Pregnant women should be informed that beginning or continuing a moderate course of exercise during pregnancy is not associated with adverse outcomes. Pregnant women should be informed of the potential dangers of certain activities during pregnancy, for example, 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.
Pregnant woman should be informed that sexual intercourse in pregnancy is not known to be associated with any adverse outcomes.
The direct effects of cannabis on the fetus are uncertain but may be harmful. Cannabis use is associated with smoking, which is known to be harmful; therefore women should be discouraged from using cannabis during pregnancy.
Pregnant women should be informed that long-haul air travel is associated with an increased risk of venous thrombosis, although whether or not there is additional risk during pregnancy is unclear. In the general population, wearing correctly fitted compression stockings is effective at reducing the risk.
Pregnant women should be informed about the correct use of seatbelts (that is, three-point seatbelts ‘above and below the bump, not over it’).
Women should be informed that most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks of gestation and that nausea and vomiting are not usually associated with a poor pregnancy outcome. If a woman requests or would like to consider treatment, the following interventions appear to be effective in reducing symptoms:
non pharmacological: ginger, P6 (wrist) acupressure
pharmacological: antihistamines.
Information about all forms of self-help and non-pharmacological treatments should be made available for pregnant women who have nausea and vomiting.
Women who present with symptoms of heartburn in pregnancy should be offered information regarding lifestyle and diet modification.
Antacids may be offered to women whose heartburn remains troublesome despite lifestyle and diet modification.
Women who present with constipation in pregnancy should be offered information regarding diet modification, such as bran or wheat fibre supplementation.
In the absence of evidence of the effectiveness of treatments for haemorrhoids in pregnancy, women should be offered information concerning diet modification. If clinical symptoms remain troublesome, standard haemorrhoid creams should be considered.
Women should be informed that varicose veins are a common symptom of pregnancy that will not cause harm and that compression stockings can improve the symptoms but will not prevent varicose veins from emerging.
Women should be informed that an increase in vaginal discharge is a common physiological change that occurs during pregnancy. If this is associated with itch, soreness, offensive smell or pain on passing urine there may be an infective cause and investigation should be considered.
Pregnant women and women planning a pregnancy should be advised 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 advised to drink no more than 1 to 2 UK units once or twice a week (1 unit equals half a pint of ordinary strength lager or beer, or one shot [25 ml] of spirits. One small [125 ml] glass of wine is equal to 1.5 UK units).
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.
Women should be informed that getting drunk or binge drinking during pregnancy (defined as more than 5 standard drinks or 7.5 UK units on a single occasion) may be harmful to the unborn baby.
Women should be informed that exercising in water, massage therapy and group or individual back care classes might help to ease backache during pregnancy.
Pregnant women should be offered screening for anaemia. Screening should take place early in pregnancy (at the booking appointment) and at 28 weeks when other blood screening tests are being performed. This allows enough time for treatment if anaemia is detected. Haemoglobin levels outside the normal UK range for pregnancy (that is, 11 g/100 ml at first contact and 10.5 g/100 ml at 28 weeks) should be investigated and iron supplementation considered if indicated.
Women should be offered testing for blood group and rhesus D status in early pregnancy. It is recommended that routine antenatal anti-D prophylaxis is offered to all non-sensitised pregnant women who are rhesus D-negative. Women should be screened for atypical red cell alloantibodies in early pregnancy and again at 28 weeks, regardless of their rhesus D status. This recommendation is from the NICE clinical guideline on antenatal and postnatal mental health. Pregnant women with clinically significant atypical red cell alloantibodies should be offered referral to a specialist centre for further investigation and advice on subsequent antenatal management. If a pregnant woman is rhesus D-negative, consideration should be given to offering partner testing to determine whether the administration of anti-D prophylaxis is necessary.
Preconception counseling (supportive listening, advice giving and information) and carrier testing should be available to all women who are identified as being at higher risk of haemoglobinopathies, using the Family Origin Questionnaire from the NHS.
Information about screening for sickle cell diseases and thalassaemias, including carrier status and the implications of these, should be given to pregnant women at the first contact with a healthcare professional. Screening for sickle cell diseases and thalassaemias should be offered to all women as early as possible in pregnancy (ideally by 10 weeks). The type of screening depends upon the prevalence and can be carried out in either primary or secondary care.
Where prevalence of sickle cell disease is high (fetal prevalence above 1.5 cases per 10 000 pregnancies), laboratory screening (preferably high-performance liquid chromatography) should be offered to all pregnant women to identify carriers of sickle cell disease and/or thalassaemia.
Where prevalence of sickle cell disease is low (fetal prevalence 1.5 cases per 10 000 pregnancies or below), all pregnant women should be offered screening for haemoglobinopathies using the Family Origin Questionnaire.
If the Family Origin Questionnaire indicates a high risk of sickle cell disorders, laboratory screening (preferably high-performance liquid chromatography) should be offered.
If the mean corpuscular haemoglobin is below 27 picograms, laboratory screening
(Preferably high-performance liquid chromatography) should be offered.
If the woman is identified as a carrier of a clinically significant haemoglobinopathy then the father of the baby should be offered counseling and appropriate screening without delay.
This includes a thorough examination of the fetus’s anatomy. Furthermore, if an anatomical defect is discovered, the parents are informed about its severity, whether it is treatable or not, and where the fetus should be born in order to receive the best treatment. A thorough examination of the fetus’s heart is recommended only in cases where there is an indication.
All pregnant women should be screened for Down syndrome between 11-14 weeks of pregnancy. For women who found out about their pregnancy later, the test should not be done after 20 weeks of pregnancy. The combined test, which includes the test of nuchal translucency, β-HCG and PAPP-A, is the right choice. The triple test is also good for women over 15 weeks of pregnancy. Women should also be informed that the test must be performed by specialized personnel, so that it does not lose its diagnostic value and the options that they have in case of abnormal results. Finally, they should be informed about the CVS and amniocentesis techniques, as diagnostic tools for abnormal results.wn between 11-14 weeks of pregnancy. For women who realized their pregnancy later, the test should not be performed beyond 20 weeks of pregnancy. The combined test, which includes the test of nuchal translucency, β-HCG and PAPP-A, is the right choice. The triple test is equally good for women over 15 weeks of pregnancy. Also, women should be informed that the test must be performed by specialized personnel, so that it does not lose its diagnostic value and the options that she has, in case of pathological results. Finally, they should be informed about the CVS and amniocentesis techniques, as diagnostic tools for pathological results.
The pregnant woman should be informed that most cases of gestational diabetes are treated with diet and exercise, while 10-20% require oral medication or insulin. If diabetes is not diagnosed or treated, there is a small risk of complications during delivery, such as shoulder dystocia. However, its diagnosis requires increased monitoring during pregnancy and delivery.
Blood Pressure measurement and proteinuria testing should be performed at every examination. At the first visit to the obstetrician, risk factors for preeclampsia should be determined, which are age >40 years, primiparity, distance from previous pregnancy more than 10 years, personal or family history of preeclampsia, BMI >30Kg/m2, some pre-existing vascular disease, such as hypertension, kidney disease and multiple gestation.
In addition to monthly BP measurements, it is recommended, in the presence of the above factors, that these be performed more frequently. BP measurement should be performed as follows: Remove tight clothing, place the arm at heart level and use the appropriate cuff size. Inflate the cuff 20-30mmHg above the palpable systolic pressure and lower the pointer slowly, at a speed of 2mmHg /sec. Read the systolic and diastolic pressure (disappearance of the sound).
Arterial hypertension is defined as diastolic pressure in a single measurement above 110mmHg or two consecutive measurements, with an interval of at least 4 hours between them. The combination or not with proteinuria (1+) requires close monitoring. When there is an increase in systolic pressure above 160mmHg in two consecutive measurements with an interval of 4 hours between them, then the pregnant woman should receive treatment.
Also, all pregnant women should be concerned if they experience symptoms of preeclampsia, such as severe headache, vision problems (flashes), pain behind the ribs, vomiting, sudden swelling of the face/hands/feet.
Routine screening for preterm labour should not be offered.
Because most low-lying placentas detected at the routine anomaly scan will have resolved by the time the baby is born, only a woman whose placenta extends over the internal cervical os should be offered another transabdominal scan at 32 weeks. If the transabdominal scan is unclear, a transvaginal scan should be offered.
High-quality medical services from Obstetrician-Gynecologist Alexandros Mainas, in Komotini.