Maternal Physiological Adaptation to Pregnancy

CHANGES IN GENITAL ORGANS

1. Vulva
• Oedematous - More Vascular, Superficial varicosities may appear
• Labia minora are pigmented and hypertrophied
2. Vagina
• Vaginal walls become hypertrophied, oedematous and more vascular.
• Increased blood supply of the venous plexus surrounding the walls
• Secretion becomes copious, thin and curdy white, pH acidic (3.5-6)
3. Uterus
• Non-pregnant state weighs about 60gm, with a cavity of 5-10 ml and measures
about 7.5 cm in length.
• At term, weighs 900-1000 gm and measures 35cm in length
1. Changes in the muscles
• Hypertrophy and hyperplasia-occur under the influence of the hormones-
oestrogen and progesterone
• Stretching: The muscle fibres further elongate beyond 20 weeks due to
distension by the growing foetus.
• Arrangement of the muscle fibres of upper uterine segment
• Formation of lower uterine segment
2. Vascular system of the uterus:
• Uterine artery diameter becomes double
• Blood flow increases by eight fold at 20 weeks of pregnancy.
• The vessels that supply the uterine corpus widen and elongate yet preserve
their contractile function
• The spiral arteries, which directly supply the placenta, vasodilate but
completely lose contractility from endovascular trophoblast invasion that
destroys the intramural muscular elements - this vasodilation allows
maternal–placental blood flow to progressively rise during gestation.
• Normal pregnancy is also characterized by vascular refractoriness to the
pressor effects of infused angiotensin II.
• Vasodilatation is mainly due to several hormones and growth factors all
augment endothelial nitric oxide production (potent VD).
• Veins become dilated and are valveless.
• Numerous lymphatic channels open up.
3. Consistency Softer than cervix (Hegar sign)
4. Shape
• Non pregnant pyriform shape is maintained in early months. Becomes
globular at 12 weeks.
• As the uterus enlarge, the shape once more becomes pyriform or
ovoid by 28 weeks
• Changes to spherical beyond 36th week
 Maternal Physiological Adaptation to Pregnancy

CHANGES IN GENITAL ORGANS

5. Position
• Normal anteverted positions exaggerated up to 8 weeks
• The enlarged uterus may lie on the bladder
• Afterwards, it becomes erect, the long axis of the uterus conforms more is
a tendency of ante version
• Primigravidae with good tone of the abdominal muscles, it is held firmly
against the maternal spine.
6. Contractions (Braxton-Hicks) : Irregular, infrequent, spasmodic and painless without
any effect on dilatation of the cervix.
7. Endometrium : changes to decidua
8. Isthmus
During the first trimester isthmus hypertrophies and elongates to share in the
formation of LUS
9. Cervix
i. Hypertrophy and hyperplasia of the elastic and connective tissues
ii. Vascularity is increased
iii. Softening of the cervix (Goodell’s sign)
iv. Squamous cells also become hyperactive
v. Mucosal changes simulate basal cell hyperplasia or cervical intraepithelial
neoplasia (CIN)
vi. Secretion is copious and tenacious – physiological leucorrhoea of pregnancy
4. Fallopian Tube
• Total length is increased - becomes congested
• Muscles undergo hypertrophy
5. Ovary
• Growth and function of the corpus luteum reaches its maximum at 8th week -
Hormones-oestrogen and progesterone secreted by the corpus luteum maintain
the environment for the growing ovum
• Initial recruitment of follicles continues but the are not rescued by FSH and thus
ovulation ceases all through pregnancy.
 Maternal Physiological Adaptation to Pregnancy

CHANGES IN GENITAL ORGANS

UPPER UTERINE SEGMENT LOWER UTERINE SEGMENT
Formed by Enlargement of Uterine body Enlargment of isthmus (4mm) and
lower 1.2 cm of uterine body –
Starts to form from 12 weeks
gradually till it become about 10
cm at term.
Covering Adherent Loose
peritoneum
Muscle layers Thick Thinner
3 layers: 2 layers
1)Outer longitudinal 1)Outer longitudinal
2) Inner circular 2) Inner circular
3) Intermediate – It is the thickest and
strongest layer arranged in criss-cross
fashion through which the blood
vessels run. Muscle fibres give the
figure of ‘8’ form, it called as living
ligature.
Decidua Well Developed Poorly developed
Efficient limitation of placental trophoblast May allow pathological adherence
invasion of placenta in placenta previa
Fetal More firmly attached Less firmly attached
membranes
Role in labor Active contraction and retraction in labor and Passive stretch in labor Passive
and puerperium peurperium involution in puerperium
Efficient control of bleeding from placental Inefficient control of bleeding
bed from placental bed in cases of
placenta previa
In Cesarean Inefficient healing and more prone to rupture Better healing and less prone to
Section in subsequent pregnancy 5% rupture in subsequent pregnancy
0.5%
 Maternal Physiological Adaptation to Pregnancy

1. BREAST CHANGES
1. Increased size of the breasts
2. Marked hypertrophy and proliferation of the ducts (oestrogen and progesterone)
3. Vascularity is increased
4. The nipples become larger, erectile and deeply pigmented
5. Sebaceous glands become hypertrophied and are called Montgomery’s tubercles
6. Outer zone of less marked and irregular pigmented area appears in the second
trimester and is called secondary areola
7. Secretion (colostrum) can be squeezed out of the breast at about 12th week
2. CUTANEOUS CHANGES
Face (cholasma gravidarum or pregnancy mask) an extreme form of pigmentation
around the cheek, forehead and around the eyes
Abdomen
1. Linea nigra : a brownish black pigmented area in the midline stretching from the
xiphisternum to the symphysis pubis
2. Straie graviderum :slightly depressed linear marks with varying length and
breadth found in pregnancy
3. HEMATOLOGICAL CHANGES
Blood volume
• Due to increased vascularity of the enlarging uterus, Blood volume is markedly
raised during pregnancy
• The blood volume starts to increase from about 6th week, expends rapidly
thereafter to maximum 40-50% above the nonpregnant level at 30-32 weeks
Plasma Volume
• Starts to increase by 6 weeks
• Rate of increase almost parallels to that of blood volume
• Reached to the extent of 50%
• Total plasma volume increases to the extent of 1.25 litters
RBC And Haemoglobin
The RBC mass is increased to the extent of 20- 30%
Increase demand of oxygen transport during pregnancy
Disproportionate increase in plasma and RBC volume produces state of
haemodilution (fall in haemocrit)
Leucocytes And Immune System In the second and third trimester, the action of the
polymorphoneuclear leukocytes may be depressed, perhaps accounting for the
increased susceptibility of pregnant women to infection
Total plasma protein
• Increases from the normal 180 gm in non-pregnant to 230 gm
• Due to haemodilution (increase plasma volume), the plasma protein
concentration falls from 7 gm% to 6 gm%
Blood Coagulation Factor Pregnancy is a hypercoagulable state with increase in
major clotting factors – fibrinogen (reached 600mg%.
 Maternal Physiological Adaptation to Pregnancy
5. METABOLIC CHANGES
• Total metabolism is increased due to the needs of the growing fetus and the uterus
• Basal metabolic rate is increased to the extent of 30% higher than non- pregnant.
Protein Metabolism
• Positive nitrogenous balance throughout pregnancy
Carbohydrate Metabolism
Insulin secretion is increased in response to glucose and amino acids.
Hyperplasia and hypertrophy of beta cells of pancreas.
Increased insulin level favours lipogenesis (fat storage).
Fat Metabolism
An average of 3-4 kg of fat is stored during pregnancy mostly in the abdominal wall,
breasts, hips and thighs
Iron Metabolism
Total iron requirement during pregnancy is estimated approximately 1000mg. In the
absence of iron supplementation, there is drop in haemoglobin, serum iron and ferritin.
6. Weight Gain
• In early weeks, the patient may lose weight because of nausea and vomiting
• During subsequent months, the weight gain is progressive until the last one or two
weeks, when the weight remains static
• The total weight gain during the course of a singleton pregnancy for a healthy
woman averages 11 kg (250mg – 500mg per weeks)
• The total weight gain at term is distributed approximately as :
• Fetus – 3.3 kg,
• Placenta – 0.6 kg and
• Liquor – 0.8 kg
• Uterus – 0.9 kg and
• Breast -0.4 kg,
• Accumulation of the fat and protein – 3.5 kg
• Increases in blood volume – 1.3 kg
• Increases in extracellular fluid – 1.2 kg
7. LOCOMOTOR SYSTEM
• Relaxation of pelvic ligaments and muscles (influence of estrogen and relaxin)
reaches maximum during last weeks of the pregnancy (Pelvic give)
• Increased lumber lordosis during later months of the pregnancy due to enlarged
uterus backache and wadding gait
8. RESPIRATORY SYSTEM
• Shape of the chest and the circumference increases in pregnancy by 6 cm
with wide subcostal angle
• Progressive increase in oxygen consumption (20%), which is caused by the
increased metabolic needs of the mother and fetus
• The mucosa of the nasopharynx becomes hyperaemic and oedematous
• A state of hyperventilation occurs during pregnancy leading to increase
tidal volume by 40%
• The woman feels shortness of breath (due to stimulation of respiratory
center which is more sensitive to CO2)
• Pregnancy is a state of respiratory alkalosis
 Maternal Physiological Adaptation to Pregnancy

7. CARDIOVASCULAR CHANGES
The Heart :
• Muscle, hypertrophies leading to enlargement of the heart
• The growing uterus pushes the heart upward and to the left
• During pregnancy the heart rate and stroke volume increases
Cardiac Output :
• Increases markedly by the end of the first trimester about 40% reaching 6.5 L/min
(COP = Stroke volume x heart rate - both increase). Pulse increases 10 to 15 bpm
• Circulation is hyperdynamic with sometimes water-hammer pulse
• Heart sounds show split S1 – soft systolic murmer in 90% of cases – audible S3 and
diastolic murmer in 20% of cases. ECG changes reflect change in postiion (discussed
in cardiac disease in pregnancy)
• The pressure of gravid uterus compresses the vena cava, reducing the venous return
and Cardiac output is reduced by 25-30 percent thus COP is Lowest in the sitting or
supine position and highest in the right or left lateral or knee chest position.
10. BLOOD PRESSURE
Arterial Pressure
• Arteries dilate due to the effect of progesterone.
• Reduced sensitivity to vasopressors.
• Hypotension may occur in 10% of women in unsupported supine position. This
termed as “supine hypotensive syndrome”
Venous pressure
• Increases in lower limbs due to pressure of gravid uterus, → predisposes to varicose
veins and lower limb edema may also occur (other contributing factors as
hypoalbuminema, sodium retension, increased capillary permeability).
Regional Distribution Of The Blood Flow
• Uterine blood flow is increased from 50 ml per minute in non-pregnant state
about 750 ml near term
• Pulmonary blood flow (normal 6000ml/min) is increased by 2500 ml per minute
• Renal blood flow (normal 800 ml) increases by 400 ml per minute at 16th week
remains at this level till term
11. URINARY SYSTEM
Kidney
• Dilatation of the ureter, renal pelvis and calyces. The kidneys enlarge in length by 1
cm.
• Glomerular filtration rate (GFR) is increased by 50% all through pregnancy
Ureters
• Ureters become hypotonic due to high progesterone level.
• Dilatation of the ureter above the pelvic brim with stasis is marked on the right side
specially in primigravidae.
Bladder
• Increased frequency of micturition is noticed at 6-8 weeks of pregnancy which
subside after 12 weeks and In late pregnancy, and once more reappears due to
pressure on the bladder as the presenting part descends down the pelvis.
• Stress incontinence may observe in late pregnancy due to urethral sphincter
weakness
 Maternal Physiological Adaptation to Pregnancy

12. ALIMENTARY SYSTEM

• Gums become congested and spongy and may bleed to touch
• Risk of peptic ulcer disease is reduced.
• Hypotonicity of the gut leads to heart burn and constipation
Liver and gall bladder
• Liver functions are depressed
• High blood cholesterol level during pregnancy, favour stone formation
13. NERVOUS SYSTEM
• Temperamental changes are found during pregnancy and in the puerperium
• Nausea, vomiting, mental irritability and sleeplessness are probably due to
some psychological background
• Postpartum blues, depression or psychosis may develop in a susceptible
individual
14. CHANGES IN THE ENDOCRINE SYSTEM
Placental Hormones
• Placenta produces several hormones
• The high levels of estrogen and progesterone produced by the placenta are
responsible for breast changes, skin pigmentations and uterine enlargement
in the first trimester
• Chorinonic gonadotrophin is the basis for the immunologic pregnancy tests
• Human placental lactogen stimulates the growth of the breasts
Pituitary Hormones
• The secretion of prolactin, adrenocorticotrophic hormone, thyrotrophic
hormone and melanocyte-stimulating hormone increases
• Follicle stimulating hormone and luteinzing hormone secretion is greatly
inhibited by placental progesterone and estrogen.
• The effects of prolactin secretion are suppressed by estrogen
• Posterior pituitary gland releases oxytocin in low-frequency pulses
throughout pregnancy. At term the frequency of pulses increases which
stimulates uterine contractions
Thyroid Function
• Gland increases in size by about 13 percent due to hyperplasia of glandular
tissue and increased vascularity
• Increased uptake of iodine during pregnancy
• Pregnancy can give the impression of hyperthyroidism, thyroid function is
basically normal
• The basal metabolic rate is increased mainly because of increased oxygen
consumption by the fetus and the work of the maternal heart and lungs
Maternal Physiological Adaptation to Pregnancy
 PRECONCEPTIONAL CARE

Definition: Couple planning for conception are provided care and counseled about pregnancy,
its course and outcome before the time of actual conception.

Objective: to ensure that, a woman enters pregnancy with an optimal state of health which
would be safe both to herself and the fetus by.

1. Basal level health status including BP recording

2. Folic acid supplementation
3. Maternal health is optimized preconceptionally such as overweight anemia
4. General screening including Rubella, varicella serology & Hepatitis
5. Offer immunization
6. Advise the woman and her partner on general healthcare (e.g. on
nutrition/diet/folate, smoking, alcohol and drugs) Advise to stop smoking, alcohol
and drug abuse
7. Proper counseling to those with history of recurrent fetal loss or family history of
congenital abnormalities
8. Identification of high risk factor – If present:
1. Assess and advise on the effects of existing disease and its management on
the pregnancy, and the effects of pregnancy on the disease in addition to
problems that may recur from previous pregnancies and deliveries.
2. Treat preexisting diseases to minimise the problems that may arise in
pregnancy. Patient with medical disease like hypertension, diabetes are
stabilized in an optimal state by intervention
3. Provide genetic counselling with full genetic history, especially in high-risk
groups.
9. Female genital mutilation should be identified preconception or early in antenatal
care through sensitive enquiry. Antenatal examination will then allow planning of
intrapartum care.
10. Domestic violence Healthcare professionals need to be alert to the symptoms or
signs of domestic violence and women should be given the opportunity to disclose
domestic violence.
11. Drugs used before pregnancy are verified and changed if required to prevent any
adverse effect of the fetus; e.g., warfarin is replaced with heparin, oral anti-diabetic
drug with insulin
12. Counseling regarding health care cost
 ANTENATAL (PRENATAL) CARE
Diagnosis of pregnancy
Initial prenatal evaluation OBJECTIVES OF ANTENATAL CARE
Subsequent prenatal visits
Lifestyle counseling
Common complaints

1. Detect and manage any pre-existing maternal disorders that may affect pregnancy
outcome
2. Prevent or detect and manage maternal complications of pregnancy
3. Prevent or detect and manage foetal complications of pregnancy
4. Detect congenital foetal problemsif requested by parents
5. Plan with the mother- the circumstances of birth to ensure maximum safety for the
mother and baby and the maximum parental satisfaction
6. Provide advice regarding lifestyle and ‘minor’ disorders of pregnancy

Provision and organization of care

1. Provider of Antenatal Care:

- Professional health care giver with adequate experience, according to national
guidelines this may be Midwife, General Practioner or obstetricians in all cases involving
obstetricians is mandatory when complications arise.
2. Continuity of care
• There should be continuity of care throughout the antenatal period.
• A system of clear referral paths should be established so that pregnant women who
require additional care are managed and treated by the appropriate specialist teams
when problems are identified.
3. Documentation of care
• Structured maternity records should be used for antenatal care. It is recommended
that women carry their own case notes. Antenatal cards may be standardized by
health authorities or health providers, either way they should include all points
relevant and all care provided including tests and advise.
4. Frequency of antenatal appointments
• RCOG: Low risk pregnancies
• NP: schedule of 10 appointments should be adequate.
• MP: schedule of 7 appointments should be adequate.
• WHO - ACOG: Visits for low risk pregnancies are schedules every 4 weeks till 28
weeks then every 2 weeks till 36 weeks then every week till birth.
• WHO minimum requirement for low risk pregnancies: Four visits —first at 16th
week; second at 24–28 weeks; third at 32 weeks and fourth at 36 weeks (No
disadvantages were attributed to this regimen with fewer visits).
Each antenatal appointment should be structured and have focused content. Longer
appointments are needed early in pregnancy to allow comprehensive assessment and
discussion.
 ANTENATAL (PRENATAL) CARE
Diagnosis of pregnancy
Diagnosis of pregnancy
Initial prenatal evaluation
Subsequent prenatal visits
Lifestyle counseling
Common complaints First trimester

Symptoms:
• Missed Period
• Morning sickness and urinary symptoms.
Signs
• Breast signs
• Pelvic signs
• Jacquemier’s: purplish discoloration of the mucous membrane of the vagina
• Chadowick: bluish discoloration of the cervix, vagina, and labia
• Osiander; pulsation can be felt through the lateral vaginal fornix.
• Goodell; significant softening of the vaginal portion of the cervix from
increased vascularization
• Heger: Softened lower uterine segment on bimanual exam.
Investigations:
1- Measurement of HCG
• hCG is present in the maternal circulation as either an intact heterodimer,with two
dissimilar sunbunits alpha or beta subunit, and the degraded form, or beta core fragment
• Detection of HCG in maternal serum and urine is evident 8- 10 days after conception
• hCG is detectable in the serum of approximately 5% of patients 8 days after conception and
in more than 98% of patients by day 11 (2-3 days before the period that will be missed).
• Diagnostic levels in Urine seen only about weeks 5. Levels peak at 10-12 weeks' gestation
and then plateau before falling
• HCG level will double every 1.2 to 2 days in normal early pregnancy
False-positive hCG test results are rare. It may be due to:
1. A few women have circulating serum factors that may bind erroneously with the
test antibody directed to hCG in a given assay. The most common factors are
heterophilic antibodies. Women who have worked closely with animals are more
likely to develop these antibodies
2. Exogenous hCG injection used
3. Renal failure with impaired hCG clearance,
4. hCG-producing tumors that most commonly originate from gastrointestinal sites,
ovary, bladder, or lung.
ULTRASOUND
< 5w empty uterus + increased endometrial thickness.
5-6w gestational sac with yolk sac seen
6-7w fetal pole,
6-8w fetal pulse detection,
7- 11w Fetal structure and crown-rump length
 ANTENATAL (PRENATAL) CARE
✓ Diagnosis of pregnancy
Diagnosis of pregnancy
Initial prenatal evaluation
Subsequent prenatal visits
Lifestyle counseling
Common complaints Second trimester

Symptoms:
• Amenorrhea continues
• Morning sickness and urinary symptoms gradually decrease .
• “Quickening “ occurs : First perception of fetal movements by the pregnant
woman: a. 18-20 weeks in primigravida, 16-18 week s in multipara.
• Abdominal enlargement.
ABDOMINAL EXAMINATION…
• INSPECTION:
– Linea nigra extending from symphysis in the midline
- STRIAE ( both pink and white) visible in the lower abdomen flanks
• PALPATION:
• Fundal height – increased with progressive enlargement of the uterus.
• The uterus is abdominally felt (ovoid). The uterus feels soft and elastic
• Braxton Hicks contractions; intermittent painless contractions
detected by abdominal examination.
• Active fetal movements can be felt at intervals by placing the hand over the
uterus as early as 20th week.
• External ballottement : elicited at 20 week.
• Palpation of the fetal parts and palpation of fetal movements by the
obstetrician at 20 weeks.
• Auscultation:
• • Auscultation of FHS as early as 20-24 weeks by Pinard stethoscope
• • Auscultation of funic/fetal souffle due to rush of blood through the
umblical artery
• • Auscultation of uterine souffle (soft blowing and systolic murmur heard low
own at the sides of the uterus) synchronous with the maternal pulse
INVESTIGATION
• SONOGRAPHY: – Routine sonography at 18 – 20 weeks permits a detailed survey of
fetal viability, fetal anatomy, placental localization.
ANTENATAL (PRENATAL) CARE

Diagnosis of pregnancy

✓ Diagnosis of pregnancy
✓ Initial prenatal evaluation
Subsequent prenatal visits
Lifestyle counseling
Common complaints
ANTENATAL (PRENATAL) CARE
Booking Visit (8 and 14 weeks)
A thorough history and general physical examination
Pelvic examination is performed as part of this evaluation
including speculum examination and bimanual palpation.

1- Confirm dates and estimated due dates.

Reliability of the expected date of delivery
Excellent dates
1. Patients with adequate clinical information (known, normal LMP; 28–30-day cycles; no
recent use of oral contraceptives; uterine size in agreement with dates) plus ultrasound
examination between 16 and 24 weeks indicating that the fetal measurements are in
agreement with the clinical estimation of gestational age.
2. Patients with inadequate or incomplete clinical information but with two ultrasound exams
between 16 and 24 weeks showing linear fetal growth and similar EDD.
Good dates
1. Patients with adequate clinical information (as defined above) and one confirming
ultrasound examination obtained after 24 weeks of gestation.
2. Patients with inadequate or incomplete clinical information and two or more ultrasound
exams showing adequate growth and similar EDD.
Poor dates
Any clinical situation different from those listed above.

2- Provide information of booking visit

• All women should receive appropriate written information about the likely number, timing
and content of antenatal appointments associated with different options of care and be
given an opportunity to discuss this schedule with their midwife or doctor.
• 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.
• Domestic violence if at risk should include seeking help and disclosure
• Nutrition and diet, including vitamin D supplementation for women at risk of vitamin D
deficiency, and details of the Healthy Start programme
• Exercise, including pelvic floor exercises
• Place of birth
• Breastfeeding, including workshops
• Antenatal classes availability
• Discussion of mental health issues (depression – nervousness..etc)

✓ Diagnosis of pregnancy
✓ Initial prenatal evaluation
Subsequent prenatal visits
Lifestyle counseling
Common complaints
ANTENATAL (PRENATAL) CARE
Booking Visit (8 and 14 weeks)
A thorough history and general physical examination
Pelvic examination is performed as part of this evaluation
including speculum examination and bimanual palpation.

3- Routine investigations/screening to be done during the first antenatal visit

1. First trimester ultrasound scan for gestational age assessment
2. Determination of the patient’s blood group (ABO and Rh)
3. Hemoglobin estimation
4. Blood sugar (random)
5. Urine test for proteins, glucose and pus cells
6. Serological screening test for syphilis (VDRL)
7. A rapid HIV screening test after pretest counseling and written consent
8. Screening for HbsAg and hepatitis C virus
9. Wet smear of any symptomatic vaginal discharge
10. Screening for asymptomatic bacteriuria
11. Screening for Down syndrome
12. Ultrasound screening for structural anomalies (20 weeks)

4- Identification of High-Risk Pregnancy condition

Some conditions that place
pregnancy at high risk for a
poor outcome
# Presence of medical disorder
with pregnancy: Anemia -
Chronic hypertension – Diabetes
– Asthma – Thrombophilia
(history of DVT or PE) - Cardiac
disease - Hemoglobinopathy -
Renal disease - Autoimmune
disordees as Lupus
erythematosus and
Antiphospholipid syndrome..etc
# Rh alloimmunization
# Family history of genetic
disease
# Life style risks: Drug and
alcohol abuse, Smoking
# Infectious disease:
- Hepatitis B carrier – HIV
infection- Syphilis,
asymptomatic bacteriuria..etc.
Some Obstetrical high-risk factors
# History of previous prolonged labor,
instrumental assisted delivery, obstructed
labor/rupture uterus/traumatic delivery
# History of postpartum hemorrhage (high
parity status)/obstetric shock
# History of puerperal sepsis
# Prior preterm birth
# History of birth asphyxia/neonatal
convulsions/birth injuries
# Prior stillbirth or neonatal death
# Prior fetal growth restricted infant
# Prior Second trimester pregnancy loss
# Prior infant with cerebral palsy
# Prior cesarean delivery
# Diagnosis of incompetent cervix in prior
pregnancy or History of cervical trauma
# History of preeclampsia before 32 weeks in
prior pregnancy
# Prior fetus with chromosomal disorder or
congenital anatomic abnormalities
# Anatomic abnormality of the uterus
 ANTENATAL (PRENATAL) CARE
✓ Diagnosis of pregnancy
✓ Initial prenatal evaluation
✓ Subsequent prenatal visits
Lifestyle counseling
Common complaints Follow-up visits

1- Follow-up prenatal surveillance

At each return visit, the well-being of mother and fetus are assessed:
• History update is obtained and high risk symptoms are inquired such as headache, altered
vision, abdominal pain, nausea and vomiting, bleeding, vaginal fluid leakage, and dysuria.
• General examination done and maternal blood pressure and weight recorded.
• Fetal growth and well being are evaluated (see next section).
• Pelvic examination in return visits is not recommended till late pregnancy, as it does not
accurately assess gestational age, nor does it accurately predict preterm birth or
cephalopelvic disproportion.
• In late pregnancy, vaginal examination often provides valuable information that includes
confirmation of the presenting part and its station, clinical estimation of pelvic
configuration, and cervical consistency, effacement, and dilatation

2- Provide information
Before or at 36 weeks:
• Breastfeeding information, including technique and good management practices.
• 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.

3- Repeat investigations/screening
1. If initial results were normal, most tests need not be repeated.
2. Hematocrit or hemoglobin determination is repeated at 28 to 32 weeks.
3. For women at increased risk for HIV acquisition during pregnancy, repeat testing is
recommended in the third trimester, preferably before 36 weeks.
4. Women who are at high risk for hepatitis B virus infection are retested at the time of
hospitalization for delivery.
5. Women who are D (Rh) negative and are unsensitized should have an antibody screening
test repeated at 28 to 29 weeks, and anti-D immunoglobulin is given if they remain
unsensitized
 ANTENATAL (PRENATAL) CARE
Diagnosis of pregnancy
Initial prenatal evaluation
Subsequent prenatal visits
Lifestyle counseling
Common complaints Follow-up visits

4- Investigations/screening at repeat visits

1. Group B Streptococcal Infection
The CDC (2010b) and the American College of Obstetricians and Gynecologists (2016g)
recommends that vaginal and rectal group B streptococcal (GBS) cultures be obtained in
all women between 35 and 37 weeks’ gestation
- Women with GBS bacteriuria or a previous infant with invasive disease are given
empirical intrapartum prophylaxis. Described further in Chapter: Obstetric infections –
GBS screening and prophylaxis.
2- Gestational Diabetes
All pregnant women are screened for gestational diabetes mellitus. Laboratory testing
between 24 and 28 weeks’ gestation is the most sensitive approach, Gestational
diabetes is discussed in Chapter Diabetes Mellitus in Pregnancy.
3- Neural-Tube Defect
Serum screening for neural-tube defects is offered at 15 to 20 weeks. Fetal aneuploidy
screening may be performed at 11 to 14 weeks’ gestation and/or at 15 to 20 weeks,
depending on the protocol selected.
4- Genetic Screening
Screening for certain genetic abnormalities is offered to women at increased risk based
on family history, ethnic or racial background, or age e.g trisomy 21 for those with
advanced maternal age, β-thalassemia for Mediterraneans, α-thalassemia for Asian or
African ancestry; sickle-cell anemia for people of African, Mediterranean, Middle
Eastern, Caribbean, Latin American, or Indian descent.
5- Ultrasound

Sonography provides invaluable information regarding fetal anatomy, growth, and

well-being.
Pregnant women with low risk should be offered
- An early ultrasound scan between 10 weeks 0 days and 13 weeks 6 days to determine
gestational age and to detect multiple pregnancies and markers for Downs syndrome
screen.
- An anomaly scan at 18-22 weeks
- If risk arise or if indicated subsequent scans are individualized.
Continuing trends suggest that the number of these examinations performed per
pregnancy is increasing. The American College of Obstetricians and Gynecologists
(2016h) has concluded that sonography should be performed only when there is a valid
medical indication in a low-risk patient, but that if she requests sonographic screening,
it is reasonable to honor her request.
6- Continued identification of High-Risk Pregnancy conditions
 ANTENATAL (PRENATAL) CARE
✓ Diagnosis of pregnancy
✓ Initial prenatal evaluation GENERAL LIFESTYLE CONSIDERATIONS FOR LOW-RISK
✓ Subsequent prenatal visits PREGNANCIES
✓ Lifestyle counseling
Common complaints

NUTRITION
1. CALORIES: Pregnant women require 15% more kilocalories than nonpregnant women,
usually 100–300 kcal more per day, depending on the patient’s weight and activity.
2. SUPPLEMENTATION: iron, folic acid, protein and calcium is required during pregnancy.
•IRON: WHO recommends supplementation with 30-60 mg of elemental iron daily
throughout the pregnancy for all pregnant women. Howerer RCOG states “Iron
supplementation should not be offered routinely to all pregnant women”
• FOLIC ACID, 400 μg/day before conception and up to 12 weeks of gestation, helps in
reducing the risk of neural tube defects
• CALCIUM: The recommended dose of calcium supplementation in pregnancy is 1.5–
2.0 g elemental calcium/day (WHO, 2013). Calcium supplementation is recommended
for all pregnant women, particularly those at higher risk of gestational hypertension.
3. VITAMINS:
Vitamin A: vitamin A supplementation (intake above 700 micrograms) might be
teratogenic and should therefore be avoided. Liver and liver products may also
contain high levels of vitamin A, and therefore consumption of these products should
also be avoided.
Vitamin D: 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. Particular care should be taken to
women at greatest risk. These include:
• women with darker skin
• women who have limited exposure to sunlight, such as women who are
housebound or confined indoors for long periods, or who cover their skin for
cultural reasons.
4. Avoiding food-acquired infections by:
• Drinking only pasteurised or UHT milk
• Not eating ripened soft cheese such as (there is no risk with hard cheeses, such as
Cheddar, or cottage cheese and processed cheese)
• Not eating pâté (of any sort, including vegetable)
• Not eating uncooked or undercooked ready-prepared meals.
• Avoiding raw or partially cooked eggs (avoid as mayonnaise)
• Avoiding raw or partially cooked meat, especially poultry.

WEIGHT GAIN
Presently the focus is on lower weight gain during pregnancy because of concerns
regarding the epidemic of obesity. The physiological average weight gain in a healthy
primigravid woman eating without restriction is expected to be about 12.5 kg, of which
1 kg is gained during the first trimester. Approximately 3.2 kg (7 lbs) is gained at 10–20
weeks and approximately 4.6 kg (10 lbs) at 20–30 weeks. It has been found that the
woman who gained less than 15 lbs during pregnancy are associated with lower rate of
preeclampsia, large for gestational age infants and cesarean delivery.
 ANTENATAL (PRENATAL) CARE
✓ Diagnosis of pregnancy
✓ Initial prenatal evaluation GENERAL LIFESTYLE CONSIDERATIONS FOR LOW-RISK
✓ Subsequent prenatal visits PREGNANCIES
✓ Lifestyle counseling
Common complaints

The total weight gain recommended during pregnancy based on the pre-pregnancy body mass
index.

ACOG 2017 Category BMI Recommended weight gain

Low <19.8 12.5−18 kg (28−40 lbs)
Normal 19.8−26 11.5−16 kg (25−35 lbs)
High 26−29 7−11.5 kg (15−25 lbs)
Obese >29 ≤7 kg (<15 lbs)

ALCOHOL CONSUMPTION IN PREGNANCY

Due to increased fetal risks, women should avoid or limit their alcohol consumption to no more
than a single measure of spirits, one small glass of wine, or a half pint of ordinary strength
beer, lager or cider.
TOBACCO USE AND SMOKING IN PREGNANCY
• Specific risks related to smoking/tobacco exist (low birthweight, IUGR or preterm birth) and
therefore pregnant women should be encouraged to quit.
• Provide information about the hazards of exposure to secondhand smoke.
• Discuss the risks and benefits of nicotine replacement therapy (NRT) with pregnant women
who smoke
• Advise women using nicotine patches to remove them before going to bed.
• Benefits of quitting at any stage should be emphasized.
CANNABIS USE IN PREGNANCY
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

SEXUAL INTERCOURSE
No restriction of sexual activity is necessary for low risk pregnant women. Avoidance of
sexual activity is recommended for women at risk of preterm labor, placenta previa or
women with previous history of pregnancy loss.
EXERCISE IN PREGNANCY
• Beginning or continuing a moderate course of exercise during pregnancy is not
associated with adverse outcomes.
• Potential dangers of certain activities during pregnancy involves for example, contact
sports, and vigorous racquet sports that may involve the risk of abdominal trauma,
falls or excessive joint stress, and scuba diving.
WORKING DURING PREGNANCY
• 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.
• A woman's occupation during pregnancy should be ascertained to identify those who
are at increased risk through occupational exposure e.g nursery teachers.
 ANTENATAL (PRENATAL) CARE
✓ Diagnosis of pregnancy
✓ Initial prenatal evaluation GENERAL LIFESTYLE CONSIDERATIONS FOR LOW-RISK
✓ Subsequent prenatal visits PREGNANCIES
✓ Lifestyle counseling
Common complaints

TRAVEL DURING PREGNANCY

Air travel during pregnancy
• Long air travel is associated with an increased risk of venous thrombosis. In general,
wearing fitted compression stockings is effective at reducing the risk.
Car travel during pregnancy
• Pregnant women should be informed about the correct use of seatbelts (that is,
three-point seatbelts 'above and below the bump, not over it’).
Travelling abroad during pregnancy
Pregnant women should be informed that, if they are planning to travel abroad, they
should discuss considerations with their midwife or doctor such as flying, vaccinations,
travel insurance, ease and availability of medical services at destination.
MEDICINES:
Prescribed medicines
Prescription medicines should be used as little as possible during pregnancy and should
be limited to circumstances in which the benefit outweighs the risk.
Over-the-counter medicines
Over-the-counter medicines should be used as little as possible during pregnancy.
Pregnant women should be informed that few over-the-counter medicines have been
established as being safe to take in pregnancy.

Vaccination in Pregnancy information:

 ANTENATAL (PRENATAL) CARE
✓ Diagnosis of pregnancy
✓ Initial prenatal evaluation MANAGEMENT OF COMMON SYMPTOMS OF
✓ Subsequent prenatal visits PREGNANCY
✓ Lifestyle counseling
✓ Common complaints
Nausea and vomiting in early pregnancy
• Women should be informed that most cases of nausea and vomiting in pregnancy will
resolve spontaneously within 16 to 20 weeks. If a woman requests or would like to
consider treatment, interventions effective in reducing symptoms may be:
• Non-pharmacological: ginger - P6 (wrist) acupressure
• Pharmacological: antihistamines.
Heartburn
• Lifestyle and diet modification.
• Antacids may be offered to women whose heartburn remains troublesome despite
lifestyle and diet modification.
Constipation
• Diet modification, such as bran or wheat fibre supplementation.
Haemorrhoids
• Diet modification.
• If clinical symptoms remain troublesome, standard haemorrhoid creams should be
considered.
Varicose veins
• 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.
Vaginal discharge
• 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 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.
Backache
Women should be informed that exercising in water, massage therapy and group or
individual back care classes might help to ease backache during pregnancy.
Decreased fetal movement
(see next section)
ANTENATAL (PRENATAL) CARE