Introduction
Prenatal visits help the doctor to keep on top of the upcoming delivery. The doctor may already know a fair amount about the pregnant woman, if she was referred to a specialist for an infertility treatment to help her to get pregnant. In many cases this might be an older first pregnancy (primigravida), perhaps older than 30 years of age, which would mean that this would be considered to be a high risk pregnancy warranting closer monitoring, particularly towards the end of the pregnancy.
The reduction of mortality rates among newborns is due to a large extent on advising women during prenatal check-ups what to eat and not to eat, to avoid noxious substances and drugs, and by the physician checking for little problems that can be corrected when diagnosed early thus avoiding big problems later.
For instance, when the weight in a primigravida goes up in the last four weeks of her pregnancy, this is very suspicious for pre-eclampsia. By ordering bedrest for a few days this condition will correct itself, the edema and protein leakage into the urine will stop and her blood pressure that was starting to get elevated will normalize. By monitoring for these simple things eclampsia has literally been wiped out as one of the main reasons why mothers used to die during child birth. Still in 1955 about 1 in 150 pregnancies ended up with eclampsia as a complication.
At that time maternal deaths among published cases with eclampsia were in the 35% range on average. Now this illness is confined to patients with high risk conditions such as liver and kidney diseases, diabetes and high blood pressure problems, and occurs with a frequency of about 1 in 500. If treated with sedation and magnesium intravenously, the death rate is about 10% now in this high risk group. (see Ref. 18, p. 956). The child death rate has gone from 85 to 100% in the 1950’s to about 30% now with intervention in the hospital setting. The good news is that about 70% of all eclampsia cases can be prevented by looking out for signs and symptoms of pre-eclampsia.
These 70% of patients are picked up by family physicians and midwives throughout the prenatal visits by doing blood pressure checks, testing urine for protein and checking for excessive weight gain.
Also, they are investigated to see whether or not there are any hidden triggering factors such as diabetes, liver disease, neurological disorder, kidney disease, high blood pressure problems etc. If any of these problems are identified, appropriate specialist referrals are made and each problem is closely monitored. High risk pregnancies are referred immediately to the obstetrician specialist for follow-up. Using this approach many unnecessary deaths of unborn babies and of mothers have been avoided over the years.
Frequency of prenatal visits
On the 1st prenatal visit the physician will usually ask the pregnant patient when the period has been missed and the first day of the last period will be established. The expected due date (also “expected date of confinement” or pregnancy EDC) is established, which is the date when the baby likely will be born. A pelvic examination is done in order to determine that the pregnancy is in the body of the womb and not in the tube (tubal pregnancy has to be excluded). About 2% of all pregnancies are due to tubal pregnancies and when undiagnosed this accounts for 50% of all of the death rates in early pregnancies (Ref. 15, p. 351).
Prenatal visits: what they are all about
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The EDC (= expected date of confinement or expected due date): There are 40 weeks ± 2 weeks from the first day of the last period for more than 95% of all pregnancies until the baby gets born. A pregnant woman who gets into labor before week 38 is in prematurity, a 42 week pregnancy or later is in post-maturity. Pre- and post-maturity are associated with considerable risks for mother and child. It requires intervention by the health professional.
The frequency of visits are monthly until week 32 from the first day of the last period. From week 32 to 36 she sees her physician or midwife every 2 weeks and from week 36 onwards,weekly visits are needed until the baby is born.
During each visit the health professional will weigh the pregnant woman, measure the height of the uterus, listen to the fetal heart from week 10 to 12 onwards (with Doppler ultrasonography), measure the blood pressure and check the urine for protein and sugar (=glucose). Questions about substance abuse, smoking habit etc. are asked and concerns regarding any topic surrounding pregnancy are answered.
Ultrasonography is done often routinely once or more often. It can be used for timing of the pregnancy, if there are questions about the reliability of the EDC. This is most accurate between week 8 to 12 of the pregnancy (always measured from the first day of the last menstrual period).
Amniocentesis is offered to women who are over 35 years of age to rule out genetic abnormalities. However, respect is shown to those who for religious reasons do not want this done as the next step could imply a therapeutic abortion. Others will not want it done as there is a certain risk that the needle would injure the unborn fetus even under ultrasonic control.
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Nutritional counselling
Many physicians will refer a pregnant lady to see a dietician, if she seems unsure about proper nutrition. It is important to avoid sugar and too much starchy foods as this could lead to a gestational diabetes. A zone type iet, DASH diet or Mediterranean type diet is best. On the pother hand vegetarian food can be a problem, if there are not enough essential amino acids present, in other words, if she is not experienced in proper vegetarian food. Some fish and lean meats like chicken, lean pork, the occasional grass fed beef or bison is a good source of protein, which contains all of the essential amino acids. Read more about healthy food intake and a nutritional study that measured the outcome in children who had 80% less asthma and 40% less allergies.
Minimizing risk
The health care professional will concentrate on attempting to minimize risk whenever possible. If, for instance, a tubal pregnancy should be suspected because of the findings during the initial pelvic examination at 6 to 8 weeks into the pregnancy, a swift referral would be done to seek the advice of a gynecologist/obstetrician after ultrasonography has confirmed the suspicion.
Mostly this pregnancy has to be terminated with emergency surgery as the life of the woman would be at stake. Typically a tubal pregnancy, if left alone, leads to massive internal bleeding and a high risk of death from shock at 10 to 12 weeks into the tubal pregnancy. Once one fallopian tube has been removed,or the pregnancy has been evacuated with a fallopian tube sparing microsurgery, the woman is at a higher risk for further complications with future pregnancies. She needs to be followed by a specialist regarding plans for another pregnancy as well.
Counselling about refraining from factors that damage the fetus
During prenatal visits very early on the physician/midwife will want to inquire carefully about any potential exposure of the pregnancy to drugs or noxious substances. Here is a list of such common agents (modified from Ref. 15, p. 353).
Factors affecting fetal growth
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alcohol : mental retardation, fetal alcohol syndrome, stunted growth, heart malformations
angiotensin converting inhibitors : these antihypertensives cause fetal death, stunted growth, poor development of skull and lungs
cocaine : malformations of genitals and urinary tract
iodine deficiency : fetal goiter, mental retardation, deafness
isotretinoin (Accutane, Isotrex) : abnormalities of the central nervous system, ears and heart
nicotine(smoking or patches) : stunted growth, sudden infant death syndrome
radiation : small skull, abnormalities of internal organs, brain, eyes
tetracycline : tooth and bone staining; higher doses lead to deformed teeth
thalidomide : defects of limbs; heart, kidney and ear deformities; can lead to absence of esophagus and duodenum in fetus
valproic acid (an anti-seizure medication) : defects of neural tube; face and heart deformities; stunted growth
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Historically, one of the landmark disasters were the thalidomide babies. Thalidomide was once prescribed as a sleeping medication in the 1950’s. It led to limb and other deformities (thanks to www.bbc.com for this image) and was banned for years.
Other important factors are lifestyles such as consumption of alcohol and smoking. Exposure to alcohol during pregnancy leads to the effects of fetal alcohol syndrome. This is a cause of mental retardation and can be prevented by ovoiding alcohol entirely during the pregnancy. Prenatal classes emphasize how poisonous these substances are for the fetus and unfortunately some women use these substances only to learn later that they should not have done this. Cocaine use is another problem. But as the table above shows (and it is incomplete) many other medical drugs used in hypertension therapy and in the control of epileptic seizures are potentially toxic factors for the fetus and can be detrimental to a pregnancy.
Viruses and other infections can also be very dangerous to a pregnancy. Herpes simplex virus, which commonly can cause herpes lesions in the genital area, can be so detrimental to the fetus in the last days before delivery or when infected during labor that many physicians will do an elective Caesarean section when there is a history of this as the virus persists in the ganglia in the pelvic depth. Rubella can lead to mental retardation, development of a small head and brain, deafness, glaucoma, liver disease and heart abnormalities. Toxoplasmosis in pregnancy can lead to a missing head, liver and spleen disease, encephalitis, seizures and blindness. It comes from too close contact with the house cat or the litter box of an infected cat. Ask your doctor for preventative measures and for more details.
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