Obstetric Topic 10. Pregnancy care, pregnancy counseling

I. Aim and Visit Schedule

Basic Components

• Pregnancy care: organized follow-up of mother and fetus from early pregnancy until delivery.
• Aims: confirm pregnancy, date pregnancy, assess risk, screen complications, educate patient.
• Starts ideally before conception.
• Risk logic: low-risk pregnancy → routine schedule; high-risk pregnancy → individualized, more frequent visits and specialist care.

Traditional Visit Schedule

• First antenatal visit: GW6-8.
• Until GW28: every 4 weeks.
• GW28-36: every 2 weeks.
• From GW36 until delivery: weekly.
• Minimum: at least 4 visits, but follow-up is tailored to risk and local protocol.

Preconception / Early Pregnancy Counseling

• Folic acid: 400 microgram/day preconception and early pregnancy.
• Optimize chronic disease: diabetes, hypertension, thyroid disease, epilepsy, renal/cardiac disease.
• Medication review: stop/replace teratogenic drugs if possible.
• Assess genetic risk, infection risk, psychosocial safety and substance use.

II. First Antenatal Visit

Confirm Pregnancy and Location

• hCG: confirms biochemical pregnancy; serum hCG helps if US is uncertain.
• Zero ultrasound: confirms intrauterine pregnancy, viability and fetal heart activity.
• Dating: LMP + 1st-trimester ultrasound when needed.

History

• Medical, obstetric, gynecologic and surgical history.
• Medication, allergy, transfusion and chronic disease history.
• Family/social history: genetic disease, thrombosis, diabetes, HT, smoking, alcohol/drugs, support.

Physical Examination

• General examination: body weight, height/BMI, HR/pulse, general status.
• BP measurement at every visit.
• Pelvic examination: bimanual/speculum if indicated; Pap smear if due.
• Colposcopy: if abnormal screening or clinical indication.
• Breast examination when indicated.

Initial Laboratory Tests

• CBC, Hb, platelets.
• Blood group, Rh typing and antibody screen.
• Blood sugar; liver/kidney function if protocol or risk indicates.
• hCG level if needed.
• Urinalysis and urine culture: asymptomatic bacteriuria is common and increases pyelonephritis/preterm birth risk.
• Serology: syphilis, HIV, HBV, rubella immunity; other infection tests by risk/local protocol.
• Patient advice and education.

III. Screening by Trimester

First Trimester

• Timing: GW0-12/13.
• 1st ultrasound screening: dating, viability, multiple pregnancy, nuchal translucency.
• Genetic screening: combined test or NIPT depending on protocol/patient choice.
• High-risk result or abnormal US → genetic counseling + diagnostic option.
• CVS: diagnostic test in high-risk cases, usually 10-13 weeks.

Second Trimester

• Timing: GW13-27.
• 2nd ultrasound screening: detailed malformation/anatomy scan, usually 18-22 weeks.
• Triple/quad test: AFP, hCG, estriol ± inhibin A.
• Down pattern: low AFP + low estriol + high hCG/inhibin.
• High AFP → neural tube defect or abdominal wall defect.
• Amniocentesis: diagnostic option in high-risk cases, usually from 15 weeks.

Third Trimester

• Timing: GW28-delivery.
• Routine checks: BP, weight, fundal height, fetal HR, fetal movement.
• DM screening: 75 g OGTT usually at 24-28 weeks.
• 3rd ultrasound: fetal growth, presentation, placenta, amniotic fluid; Doppler if indicated.
• BPP = ultrasound fetal wellbeing assessment + NST/CTG elements according to protocol.
• GBS screening: vaginal-rectal culture late in pregnancy; positive result → intrapartum antibiotics.
• Tdap: one dose in each pregnancy, usually GW27-36; not routinely two doses unless primary tetanus immunization is incomplete.

IV. Subsequent Visits and Fetal Assessment

Maternal Surveillance at Each Visit

• BP, pulse/HR, weight, edema and symptoms.
• Urine check: protein, glucose, infection signs according to protocol.
• Ask warning symptoms: bleeding, fluid leakage, contractions, headache/visual symptoms/RUQ pain, fever, dysuria, reduced fetal movement.
• Fundal height: screening for fetal growth abnormality.
• Repeat labs/imaging according to trimester, symptoms and risk.

Fetal Surveillance

• Fetal heart rate at visits once detectable.
• Fetal movement later in pregnancy; reduced movement requires evaluation.
• US: growth, amniotic fluid, placenta and presentation when scheduled or indicated.
• NST/CTG, BPP and Doppler: for fetal wellbeing when risk or indication exists.
• Leopold maneuvers late pregnancy → lie, presentation, position and engagement.

V. Counseling, Prevention and Practical Points

Patient Advice

• No alcohol, smoking or illicit drugs.
• Proper diet, hydration and appropriate weight gain.
• Exercise is recommended if there is no obstetric contraindication.
• Seatbelt: lap belt below abdomen + shoulder belt between breasts.
• Supplements: folic acid early; iron/iodine according to trimester, diet and local protocol.
• Vaccines: Tdap, influenza/COVID/RSV according to timing, season and local protocol; avoid live vaccines during pregnancy.
• Medication safety: review all drugs; avoid known teratogens.
• Warning signs: bleeding, fluid leakage, severe pain/contractions, preeclampsia symptoms, fever/UTI symptoms, dyspnea/chest pain, reduced fetal movement.