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JukkaUotila

Antenatal Clinics: Care and Examinations

Tasks of antenatal clinics Antenatal Lower Genital Tract Infection Screening and Treatment Programs for Preventing Preterm Delivery

  • The tasks of antenatal clinics are listed below.
    • Provide the expectant mother with information and guidance regarding the pregnancy, childbirth and care of the newborn.
    • Offer a wide range of psychosocial support and identify the need of such support; attention should be paid to
      • the life situation and well-being of the parents and the whole family, as well as factors contributing to or possibly decreasing the quality of life
      • the changes in family relations and resources brought about by the baby.
    • Identify any health risks to the foetus or mother so that any problems can be duly attended to, either at the antenatal clinic or by specialist intervention.
    • Provide routine care of various illnesses and complaints.
    • Identify situations which require specialist health care.
  • See also Antenatal Clinics and Specialist Care: Consultations, Referrals, Treatment Guidelines.
  • Co-operation between the physician and midwife/nurse, and a mutually agreed workload division, is important in the provision of antenatal care. When appropriate, the following tasks associated with medical examinations can be carried out by the nurse.
  • Visits to an antenatal clinic are divided into scheduled periodic visits (basic visits) and discretionary additional visits.
    • The basic schedule of periodic health examinations includes a minimum amount of check-up visits that are planned for normally progressing low-risk pregnancies.
    • Two of the basic visits should be to a doctor, one in early and one in late pregnancy.
    • Additional visits are appointed either to a nurse or a doctor as needed. About one quarter of the resources of an antenatal clinic are estimated to be needed for the additional visits.

Periodic medical examination during weeks 13-18 (extensive examination)

Gynaecological examination

  • A speculum examination and a bimanual pelvic examination are carried out as needed (routine examinations are of no benefit Repeat Digital Cervical Assessment in Pregnancy for Identifying Women at Risk of Preterm Labour). The main objective in early pregnancy is to identify possible infections Antenatal Lower Genital Tract Infection Screening and Treatment Programs for Preventing Preterm Delivery. A pelvic examination can be conducted during later pregnancy in order to detect threatened premature labour if the patient complains of contractions or feeling of pressure. The examination must be carried out carefully and without irritating the cervix. Possible dilatation of the cervix and membrane bulging can also be detected during speculum examination.
    • At the beginning of pregnancy the vaginal membranes swell, and it might be more difficult than usual to see the external uterine orifice. The amount of physiological vaginal discharge is increased throughout pregnancy.
    • The vagina and the cervix are examined for signs of infection Vulvovaginitis. Findings suggestive of infection include erosions and offensive or otherwise abnormal discharge. In addition to the clinical picture, a sample of vaginal discharge may be tested for the release of fishy odour on adding alkali. The sample may also be tested for yeasts, Trichomonas or clue cells, either microscopically or by culture. If there is discharge from the cervical canal or the patient's history so indicates, samples should be taken for chlamydial infection Chlamydial Urethritis and Cervicitis and gonorrhoea Gonorrhoea.
    • Should a suspicion of uterine or ovarian tumour arise during the pelvic examination, the patient must be referred for an ultrasound scan within primary care or for a specialist consultation.
    • Size of the uterus during pregnancy: see table T1.

Size of the uterus during pregnancy

Weeks of gestationSize of the uterus
6No noticeable growth
89 cm
1212 cm
16Halfway between symphysis and umbilicus
20Up to umbilicus

Periodic medical examination of late pregnancy during weeks 35-36

  • The objectives are to identify mothers who require planning of the delivery at a hospital prenatal clinic (abnormal presentation, suspected foetopelvic disproportion, other risk factors associated with the delivery), and to assess the post-pregnancy significance, follow-up and management of health problems detected during the pregnancy.
  • Ask the mother about
    • foetal movements
    • possible contractions, feeling of pressure
    • oedema
    • pruritus - if hepatic cholestasis of pregnancy is suspected, blood is taken for ALT and fasting bile acids.
  • Physical examination
    • Body weight, blood pressure, heart rate; evaluation of swellings
    • Size of the uterus and foetus
    • Foetal presentation and pelvic positioning
    • Status of the cervix is examined as needed.
    • External genital organs are examined as needed (e.g. herpes suspicion, see later in this chapter).
  • During late pregnancy, in the weeks 35-37, a sample to screen for Streptococcus B (GBS) is also collected from the vaginal orifice and from the anus (unless the local policy favours PCR detection test for GBS carried out at the hospital when the labour starts). If the result is positive, the mother is given a course of antimicrobials in association with delivery in order to prevent septicaemia in the newborn Intrapartum Antibiotics for Known Maternal Group B Streptococcal Colonization.

Discretionary additional medical examinations

  • Discretionary visits are appointed if
    • the pregnant mother has a chronic illness requiring evaluation by a physician
    • periodic visits reveal health problems that require evaluation or management by a physician
    • the mother has symptoms suggesting pregnancy problems
    • the mother has symptoms that she herself worries about, or she has a need to see a doctor.
  • The objectives include e.g. the identification of the risk of preterm birth, disturbances in the uterine growth, gestational diabetes and early pre-eclampsia.
  • The forthcoming childbirth often occupies the mother's mind and she may wish to obtain information regarding the rest of the pregnancy and the delivery. Possible fear of childbirth should be assessed and managed.
  • Ask how the mother is coping at work. Sick notes should be issued whenever necessary, even for short time periods.
  • Status
    • The size of the uterus (a deviation of over 2 cm from the reference curve or from patient's own curve)
    • Cervix: the presenting part deep within the pelvis and the softening, shortening and opening of the cervix as well as the alignment of the cervix in relation to the vagina are signs of impending delivery. See also table T2.
    • The amount of amniotic fluid is estimated, i.e. normal, excessive or small amount. Large size and tightness of the uterus suggest a large amount of amniotic fluid whereas particularly easy palpability of the foetal body parts may be due to scantiness of the fluid.
    • Abnormal weight gain (does the patient have pre-eclampsia, abnormal foetal growth, excessive amniotic fluid, gestational diabetes?)

Cervical assessment by the modified Bishop score. A ripe cervix (score > 4) predicts labour.

ParameterScore
012
Cervical dilation (cm)Closed1-23-4
Cervical length (cm)>42-41-2
Foetal station1 -3-2-1 or 0
ConsistencyFirmIntermediateSoft
Cervical positionPosteriorIntermediateAnterior
1 Position of the presenting part in relation to the level of the ischial spines (cm); negative above, positive below, 0 = at level with the spines
Postnatal examination 5-12 weeks after delivery Schedules for Home Visits in the Early Postpartum Period, Telephone Support for Women during Pregnancy and the First Six Weeks Postpartum
  • How is the mother managing with breast feeding and caring for the infant?
  • How does she feel about her pregnancy and delivery?
  • How is her mood? How is she coping? Note any signs of depression. Should the mother have negative feelings about her delivery or if some relevant issues are not clear to her a referral could be written for the relevant obstetric team.
  • Gynaecological examination at discretion
    • Mucous membranes are often thin and erythematous before the return of hormonal activity and the menstrual cycle. The situation will correct itself, but, should the patient complain of discomfort, topical oestrogen may be prescribed in the form of pessaries or creams.
    • The episiotomy wound may be tight and tender, but will heal by itself with time. Even wounds that have opened, as well as thick scars, become as a rule symptomless within a year.
    • Cervical ectopy is common and does not need treatment at the postnatal appointment. If the ectopy is later associated with excessive mucous discharge, which the patient finds uncomfortable, the area can be treated with electrocoagulation.
    • Any infections are to be diagnosed and treated. Fever, abnormal discharge and a tender uterus are suggestive of endometritis Pelvic Inflammatory Disease (Pid) which is treated with a course of antimicrobials (e.g. cephalexin for 7 days + metronidazole for 5 days). If offensive discharge is the only symptom anaerobic bacteria are likely to be the causative agent, and metronidazole alone will suffice for the treatment.
    • Postnatal discharge (lochia) will usually persist for 4-6 weeks after the delivery. In those mothers who choose exclusive breastfeeding the discharge often persists a little longer. If the discharge remains heavy the possibility of retained placental fragments, poor contractility of the uterus and infection should be borne in mind Postpartum Haemorrhage and Endometritis.
    • Are there any problems with urinary, fecal or flatal incontinence? The required follow-up visits or a consultation within specialized care are planned. Pelvic floor muscle exercises are instructed to all.
    • In some rare cases the linea alba (white line) may be considerably distended (diastasis recti or abdominal separation). The condition is not dangerous, but if it causes a lot of trouble, a referral is made to a physiotherapist and, as necessary, even for consideration of surgical treatment Hernias in Adults.
  • Important points to be checked
    • The need and method of contraception Contraception: Initiation, Choice of Method and Follow-Up. An intrauterine device (regular or hormone-releasing) can be inserted in a normal-sized uterus already within a follow-up checkup, usually however only after 3-4 months after delivery. Progestin pills, capsules or injections may be started right away. Combined oral contraceptives or a vaginal ring can be introduced 3 months after delivery for mothers who do not breastfeed and 6 months after delivery for mothers who apply exclusive breastfeeding. Sterilization is an option for women aged over 30 years who already have a number of children and who are eligible for sterilization according to legislation.
    • If blood pressure was elevated, has it now been normalised and has proteinuria disappeared? If risk factors relevant to the patient's future health (high blood pressure, obesity, gestational diabetes) were noted during the pregnancy, possible life style changes and other measures to prevent morbidity in later life are discussed. Follow-up appointments are agreed on.
      • Pre-eclampsia is a risk factor for coronary artery disease and, if severe, poses a risk for glomerulopathy.
      • Deep venous thrombosis may suggest a hereditary trombophilia.
      • Gestational diabetes mellitus (GDM) increases significantly the risk of type 2 diabetes Gestational Diabetes Mellitus and Future Risk of Diabetes. It is advisable to control the glucose tolerance test about 6-12 months after delivery (6-12 weeks after delivery if treated with medication). The body weight, blood pressure, waist circumference and blood lipids are controlled at the same visit. Subsequently, these or HbA1c instead of glucose tolerance are controlled e.g. every (1-)3 years. A repeated or early GDM requires a more frequent follow-up.
    • Any signs of postnatal depression (EPDS Edinburgh Postnatal Depression Scale (Epds)) Postpartum Psychosis and other Postpartum Mental Disorders?

Antenatal screening programmes

Blood group antibodies Intramuscular Versus Intravenous Anti-D for Preventing Rhesus Alloimmunization during Pregnancy, Anti-D Administration in Pregnancy for Preventing Rhesus Alloimmunisation, Anti-D after Childbirth for Preventing Rhesus Alloimmunisation

  • Each mother's blood is grouped during the first trimester, and tested for blood group antibodies http://www.dynamed.com/management/routine-prenatal-care-36#SCREENING__ANC_306830338, at a transfusion laboratory. If antibodies are present the concentrations are measured every 4 weeks.
  • Even if RhD-negative mothers have no antibodies during the first trimester their blood is tested again during weeks 24-26 and 36 for the presence of antibodies.
  • The presence of antibodies is reported both to the antenatal clinic and to the appropriate maternity hospital. If the presence of antibodies is significant the hospital will invite the patient for follow-up studies and plan the delivery accordingly Antenatal Clinics and Specialist Care: Consultations, Referrals, Treatment Guidelines.
  • Despite post-delivery and risk-based anti-D immunoglobulin prophylaxis, a proportion of RhD-negative mothers become immunized due to symptomless minor foetomaternal haemorrhage during pregnancy. In order to prevent these immunizations anti-D immunoglobulin prophylaxis (1 250-1 500 IU or 250-300 μg) is recommended to be given at the antenatal clinic during weeks 28-30 either to all RhD-negative mothers or only to those RhD-negative mothers whose foetus has been determined as RhD-positive. In order to avoid unwarranted use of anti-D immunoglobulin and for the planning of prophylactic measures, it is recommended to determine the RhD blood type of the foetus within the maternal screening blood tests at weeks 24-26.

Screening for syphilis, HIV and hepatitis B

  • If the result of syphilis http://www.dynamed.com/management/routine-prenatal-care-36#SEXUALLY_TRANSMITTED_INFECTIONS screening is positive, the patient is referred to specialist care.
  • Drug treatment of a confirmed HIV infection HIV Infection considerably reduces the risk of the foetus or newborn contracting the virus http://www.dynamed.com/condition/hiv-in-pregnancy#GUID-4574671F-D3D2-4C0D-BC9B-ED8A0CBCC08C.
  • If the expectant mother is HBsAg-positive, the newborn is to be offered protection immediately after birth with hepatitis B immunoglobulin and by vaccination. HBV nucleic acid testing is performed on HBsAg-positive mothers. If the result is > 200 000 IU/ml, the mother is referred to specialized care for consideration of hepatitis treatment.
  • The incidence of hepatitis C has increased lately, particularly among drug abusers. The mother-to-child transmission of hepatitis C cannot be prevented by medical measures. The medical staff should be alert for blood born contamination Viral Hepatitis when caring for patients with hepatitis B and C and HIV. Patients with a history of drug abuse should have their blood tested for hepatitis C.

Screening for foetal abnormalities

  • Chromosomal abnormalities http://www.dynamed.com/management/routine-prenatal-care-36#TOPIC_HM4_5DC_QNB
    • Combined screening is the primary choice: serum screening during weeks 9+0 - 11+6 and ultrasonography to determine nuchal translucency and the expected date of delivery during weeks 11+0 - 13+6
    • Those who have not made it to combined screening may have been offered serum screening during weeks 15-17 or noninvasive prenatal testing (NIPT).
  • Ultrasonography for the detection of severe structural abnormalities during weeks 18-21 or after week 24
  • Screening is voluntary, and the pregnant mother decides her participation independently.
  • Those with positive screening results are referred to specialized care. Further investigations may include more specific ultrasonography, invasive chorionic villus sampling or amniocentesis, or NIPT using mother's blood sample in order to reveal the most common trisomies in the foetus.
  • See also Screening for Fetal Chromosomal Abnormalities Ultrasound Scanning during Pregnancy.

Blood pressure monitoring Maternal Obesity as a Risk Factor for Complications in Pregnancy, Altered Dietary Salt for Preventing Pre-Eclampsia, Planned Early Delivery Versus Expectant Management for Hypertensive Disorders from 34 Weeks Gestation to Term

Starting low-dose ASA at an antenatal clinic (source: Finnish Current Care Guideline [Elevated blood pressure in pregnancy and pre-eclampsia], 2021, modified)

Even one of the following:At least two of the following:
Chronic hypertensionPrimigravida
SLE or positive antiphospholipid antibodiesAge > 40 yrs
Chronic renal diseaseBMI > 30 kg/m2
Type 1 or 2 diabetesMother's or sister's pre-eclampsia
Previously:Pregnancy achieved with donated eggs
Pre-eclampsia>10 yrs between pregnancies
Placental insufficiency with foetal growth disturbanceMultiple pregnancy
Foetal intrauterine death associated with placental causesPregnancy-associated plasma protein A MoM < 0.4 in the first trimester screening

Screening for diabetes mellitus Insulin Versus Oral Anti-Diabetic Pharmacological Therapies for Gestational Diabetes, Gestational Diabetes Mellitus and Pregnancy Outcomes, Diet and/or Exercise for Pregnant Women for Preventing Gestational Diabetes Mellitus, Treatments for Gestational Diabetes, Dietary Advice in Pregnancy for Preventing Gestational Diabetes Mellitus, Abnormal Screening Glucose Challenge Test in Pregnancy and Future Risk of Diabetes, Lifestyle Interventions for the Treatment of Women with Gestational Diabetes, Gestational Diabetes Mellitus and Future Risk of Diabetes, Metformin for Gestational Diabetes, Maternal Obesity and Infant Outcomes, Maternal Obesity as a Risk Factor for Complications in Pregnancy, Interventions for Preventing Excessive Weight Gain during Pregnancy, Energy and Protein Intake in Pregnancy,

  • Gestational diabetes mellitus (GDM) is diagnosed by a 75 grams glucose tolerance test (GTT; see Gestational Diabetes Mellitus (Gdm)) http://www.dynamed.com/condition/gestational-diabetes-mellitus-gdm#MAKING_THE_DIAGNOSIS. See also table T4.
  • GTT is carried out between weeks 24 and 28.
  • GTT is not needed for
    • a nulliparous woman under 25 years of age with BMI under 25 kg/m² and no type 2 diabetes in near relatives
    • a multiparous woman under 40 years of age with BMI under 25 kg/m² who has previously not given birth to a macrosomic child.
  • GTT should be carried out already between weeks 12-16 if the patient has
    • a history of gestational diabetes
    • BMI over 35 kg/m²
    • glucosuria in early pregnancy
    • near relatives with type 2 diabetes
    • oral glucocorticoid medication.
  • If the GTT is normal during the early pregnancy, it must be repeated between weeks 24 and 28.
  • If gestational diabetes is confirmed with the GTT (one or more blood glucose values above the upper limit) the patient is to be given lifestyle advice at the antenatal clinic.
  • Self-monitoring of blood glucose is instructed at the antenatal clinic.
  • Targets for capillary plasma glucose concentrations in self-monitoring are
    • fasting concentration under 5.5 mmol/l
    • under 7.8 mmol/l 1 hour after meal.
  • Insulin or other antidiabetic medication is started in specialized care in case the targets are not reached with dietary treatment.
  • Foetal macrosomia must be detected early enough and appropriate delivery plans put into action.
  • The dietary treatment of gestational diabetes aims to reduce big fluctuations in blood glucose levels. Therefore, regular, small and fairly frequent meals are recommended and the consumption of quickly absorbed carbohydrates is to be avoided Dietary Advice in Pregnancy for Preventing Gestational Diabetes Mellitus.
  • The risk of developing type 2 diabetes later in life is high Gestational Diabetes Mellitus and Future Risk of Diabetes, concerning up to one half of women with gestational diabetes, so life-style counselling is essential.

Pathological threshold concentrations in glucose tolerance test (mmol/l)

Sample0 h1 h2 h
Capillary whole blood or venous plasma5.310.08.6

Screening and treatment of anaemia Daily Oral Iron Supplementation during Pregnancy, Treatments for Iron-Deficiency Anaemia in Pregnancy, Intermittent Oral Iron Supplementation during Pregnancy, Effects and Safety of Periconceptional Folate Supplementation for Preventing Birth Defects, Folic Acid Supplementation during Pregnancy for Pregnancy Outcomes other Than Neural Tube Defects, Iron Status and Gestational Diabetes

  • Up to 50 percent increase in the plasma volume of the mother without a respective increase in the red blood cell mass leads to physiological anaemia.
  • Mild maternal anaemia does not in general cause problems to the foetus. Haemoglobin concentrations below 80 g/l are harmful both for the foetus and the mother.
  • The WHO criterion for maternal anaemia is Hb concentration < 110 g/l.
  • Iron deficiency http://www.dynamed.com/management/treatment-of-iron-deficiency-anemia-in-adults#PREGNANT_WOMEN is the most common cause of anaemia in pregnancy. This is suggested by low mean corpuscular volume (MCV) of the red blood cells and small plasma ferritin concentration (< 30 µg/l) Iron Deficiency Anaemia.
  • The cause may also be a deficiency of other nutrients
    • Most commonly of folic acid or vitamin B12 Megaloblastic Anaemia.
    • Vitamin B12 deficiency may be associated with an autoimmune condition of the stomach, i.e. atrophic gastritis.
    • Treatable gastrointestinal absorptive disorders, particularly coeliac disease Coeliac Disease, may possibly be found behind a deficiency of iron or other nutrients.
  • Sometimes anaemia is associated with other chronic diseases Anaemia of Chronic Disease (Acd) or infections (e.g. malaria Diagnosis and Treatment of Malaria), more rarely with diseases of the bone marrow Acute Leukaemias in Adults Myelodysplastic Syndromes (MDS) Chronic Lymphocytic Leukaemia (CLL), haemolysis Haemolytic Anaemia or hereditary conditions, e.g. thalassaemias Thalassaemias.
  • The diet should be well-balanced. Plain vegetarian food does not necessarily guarantee sufficient intake of iron. The dietary situation and needs are individually assessed.
  • Routine iron supplementation for all pregnant women is not recommended Daily Oral Iron Supplementation during Pregnancy.
  • Mild anaemia can be treated and prevented at the antenatal clinic.
    • If the Hb concentration is below 110 g/l, a therapeutic trial with 100 mg of iron per day is initiated, because iron deficiency is by far the most common cause of anaemia.
    • The diagnosis of anaemia is further specified, as required, by determination of plasma ferritin concentration Iron Deficiency Anaemia.
  • If the Hb concentration remains remarkably low (below 100 g/l) despite iron supplementation or if the patient suffers from symptoms compatible with anaemia, further investigations are performed in specialized care.
    • In this situation, intravenous iron is often administered.

Group B streptococcus (GBS), Streptococcus agalactiae

  • See Infections during pregnancy below.

Growth of the uterus

  • A normal growth of the uterus mirrors a normal size of the foetus and a normal amount of amniotic fluid.
  • The measurement of symphysis-fundal height (SFH) is carried out with the patient in a gynaecological position. The urinary bladder must be empty.
  • A deviation of over 2 cm from the reference curve, or from the patient's own sequential SFH measurements, warrants further investigations but only after technical errors have been excluded.
  • Foetal size and the amount of amniotic fluid should also be assessed by abdominal palpation. The results must be adjusted for maternal height and weight.

Monitoring of foetal movements

  • Whilst resting, the mother counts the number of foetal movements in one hour Fetal Movement Counting for Assessment of Fetal Wellbeing. The counting should be carried out whilst the foetus is particularly active.
  • If the number of movements is less than 10, counting is continued for a further hour.
  • If the mother's recognition of foetal movements remains less than 10 it is recommended that, during the following 24 hours, she visits an obstetric outpatients' clinic for further investigations.

Foetal heart auscultation

  • Hearing the foetal heartbeat confirms that the foetus is alive. Auscultation of foetal heartbeat during a routine antenatal visit will not yield much information regarding possible foetal distress, but foetal arrhythmias can be detected.
  • Isolated ectopic beats are common and harmless.
  • Should ectopic beats occur frequently and be regular (every third beat or more) a non-urgent referral should be considered for further investigations of the foetal heart and its functioning.
  • Persistent tachycardia (over 160-180/min) and bradycardia (less than 110/min) are rare. These situations may be indicative of obstetric complications requiring immediate intervention and an urgent referral for a specialist team might be warranted.

Infections during pregnancy

Infections of vagina and cervix

  • See also Vulvovaginitis.
  • Yeasts are the most common causative agents of vaginitis. Vaginal thrush has not been shown to be harmful to the foetus. Symptomatic thrush is treated with topical medication.
  • Signs and symptoms of bacterial vaginosis (BV) are greyish, malodorous discharge and the release of fishy odour on adding alkali, or clue cells on direct microscopy.
  • BV is associated with preterm birth. However, due to modest treatment outcomes routine screening for BV is not recommended http://www.dynamed.com/management/routine-prenatal-care-36#BV.
  • Antimicrobial treatment of BV effectively relieves symptoms but does not prevent preterm birth Antibiotics for Treating Bacterial Vaginosis in Pregnancy. However, after previous preterm birth treatment may reduce the risk of preterm prelabour rupture of membranes and low weight of the foetus Antibiotics for Treating Bacterial Vaginosis in Pregnancy in Women with Previous Preterm Birth. A mother attending an antenatal clinic should therefore be asked about the presence of offensive discharge, and during a speculum investigation attention should be paid to signs of BV.
  • If signs suggestive of BV are present the infection should be treated in those belonging to risk groups, for example with topical metronidazole. No follow-up is necessary after the treatment. However, the treatment may be repeated should the symptoms recur.
  • Cervicitis caused by gonorrhoea or chlamydial infection, or an asymptomatic carrier status, increase the risk of preterm birth, premature rupture of the membranes and infections of the newborn. Should the signs, symptoms or the patient's history suggest the presence of these infections, they should be diagnosed or excluded, for example with a urine test ( Chlamydial Urethritis and Cervicitis and Gonorrhoea). A diagnosed infection must be treated.
  • Recurrent, symptomatic genital herpes Genital Herpes should be treated with oral aciclovir (200 mg, 5 times daily for 5 days) or valaciclovir (500 mg twice daily for 5 days).
  • If the episodes of herpes are frequent, prophylactic medication with aciclovir is recommended, 400 mg b.d., towards the end of the pregnancy, starting during weeks 36-38, or the patient should at least be recommended to start medication immediately on the occurrence of symptoms.
  • In cases of primary gestational genital herpes the diagnosis must be confirmed (demonstration of the virus and antibody tests) and medication with aciclovir commenced. Specialist consultation should also be considered (Caesarean section is usually chosen as the method of delivery if less than 6 weeks have elapsed since the primary herpes infection).

Urinary tract infections

  • See also Urinary Tract Infections http://www.dynamed.com/management/routine-prenatal-care-36#ASYMPTOMATIC_BACTERIURIA.
  • Asymptomatic bacteriuria during pregnancy leads to pyelonephritis in 40% of the cases and is a risk factor for preterm birth.
  • Treatment of asymptomatic bacteriuria reduces the risk of pyelonephritis and preterm birth Antibiotics Vs. No Treatment for Asymptomatic Bacteriuria in Pregnancy.
  • Urine is tested with a strip test during antenatal appointments. Urine is sent for bacterial culture if infection is suspected.
  • If the patient complains of premature contractions, the possibility of urinary tract and vaginal infections should be borne in mind.
  • The treatment of asymptomatic bacteriuria is the same as that for symptomatic urinary tract infection, i.e. antimicrobials for 5-7 days.
  • Follow-up after treatment
  • Should the patient suffer from two infections during the pregnancy, prophylactic treatment should be considered for the rest of the pregnancy, usually with nitrofurantoin.

Listeria

  • See also Listeriosis.
  • Listeria may cause a serious uterine and foetal infection, which is strongly associated with a risk of losing the foetus (miscarriage, death of the foetus or newborn).
  • Even though Listeria is a common bacteria of the soil, epidemics caused by contaminated foodstuffs comprise the most significant health threat.
  • Listeriosis, which poses a hazard to the foetus, is very unlikely without a maternal, symptomatic infection. In practice, listeriosis should be considered in patients with pyrexia of unknown origin or in febrile patients with intestinal or uterine complaints. These febrile patients must be sent urgently to a hospital for further investigations and treatment.
  • There is no need to carry out antibody assays at the antenatal clinic.

Group B streptococcus, Streptococcus agalactiae

  • Group B streptococcus (GBS) can be isolated from the normal flora of the vagina and rectum in some women.
  • Screening programmes to detect GBS carriers http://www.dynamed.com/management/routine-prenatal-care-36#GROUP_B_STREPTOCOCCAL_GBS_COLONIZATION have led to a significant decrease in the incidence of GBS disease in the newborn.
  • At the antenatal clinic, it is recommended to collect a sample for GBS culture from the vulval orifice, perineum and anus (on the same swab) in all pregnant women during weeks 35-37. The result is recorded in the maternal health card. At the maternity hospital, GBS-positive mothers are given antimicrobial prophylaxis in association with the delivery Intrapartum Antibiotics for Known Maternal Group B Streptococcal Colonization.
  • An alternative for the late pregnancy GBS culture is testing the mother by a PCR test for GBS in the maternity hospital. Use of different screening methods varies.
  • The "treatment" of GBS colonisation during pregnancy does not reduce the incidence of perinatal exposure or improve the outcome of the pregnancy.

Other infections

Pregnancy nausea Acupressure and Acupuncture for Treating Nausea and Vomiting in Early Pregnancy, Interventions for Nausea and Vomiting in Early Pregnancy

  • A feeling of nausea and mild vomiting is considered part of pregnancy.
    • 70-90% of pregnant women suffer from at least mild nausea; only less than 2% have severe symptoms.
    • It usually starts between weeks 5 and 7 of pregnancy, is at its worst between weeks 8 and 12 and stops shortly after the beginning of the 2nd trimester. Symptoms very rarely persist throughout pregnancy.
    • More common in primigravidas and in multiple pregnancy and hydatidiform mole.
      • It may recur in 20-40% in subsequent pregnancy, but usually in less severe form.
    • The diagnosis is based on symptoms.
      • Mornings are usually the most difficult.
      • Vomiting does not endanger the foetus or the pregnancy.
      • Weight is monitored at the antenatal clinic more frequently, as necessary.
    • In most cases, dietary treatment is sufficient. Provide the patient with appropriate patient education materials.
      • A small snack in the morning before getting up may help.
      • Small meals and fluids frequently, even every 1-2 hours.
      • Cold foods, snacks and fruit may be more suitable than warm food.
      • Avoid coffee and acidic drinks.
      • Avoid fatty and strongly flavoured foods.
      • Carbohydrate-rich foods (porridge, breads, potatoes, rusks) are easier to digest.
      • Any iron supplements are temporarily paused.
      • Pregnant women usually know what is best for themselves.
      • Avoid irritating/offensive smells and tastes.
      • Rest can relieve discomfort.
    • Drug treatment can be safely tried, but there is no good evidence of effectiveness.
    • Sometimes 1-2 l intravenous fluids given at the health centre can make the situation easier if the patient cannot keep any fluids down.
      • For example, initially Ringer 2 l within 2-4 hours
      • If necessary, continue with 500 ml of glucose 5% solution, but before starting it, thiamine 250 mg i.v. should be given slowly to avoid Wernicke's syndrome.
    • Hyperemesis gravidarum is the most difficult form.
      • The severity is assessed clinically.
      • Vomiting is profuse and may cause upper abdominal pain and blood streaks in the vomited material.
      • Can lead to dehydration and weight loss of more than 5% (compared to pre-pregnancy weight).
      • Measure blood pressure and heart rate.
      • An ultrasound scan should be performed (number of foetuses and exclusion of hydatidiform mole).
      • Electrolyte and liver enzyme concentrations may be abnormal.
        • Basic blood count with platelet count, potassium, sodium, urinalysis (ketones), ALT, plasma glucose, free T4 and TSH
      • Hospitalisation with fluid therapy may be required.

Treatment guidelines for other common ailments of pregnancy

  • Appropriate medication: see also Use of Medication during Pregnancy and locally available databases or other information sources for pharmacotherapy during pregnancy and breastfeeding.

Heartburn

Constipation Interventions for Treating Constipation in Pregnancy

Cramps

Headache and migraine

  • As is the case with most ailments in pregnancy, the first-line recommendation should be a non-pharmacological intervention: rest, healthy life style, avoidance of irritants, neck and shoulder massage and other measures offered by physiotherapy.
  • In severe cases, medication should be considered. Paracetamol, either alone or combined with codeine, is the first-line analgesic. Ibuprofen and ketoprofen can also be used temporarily. However, large doses should be avoided in late pregnancy.
  • Sumatriptan in the treatment of severe migraine attacks can be used occasionally.
  • Ergotamine products are contraindicated.
  • Drugs used for the treatment of nausea, such as metoclopramide and vitamin B6, may also alleviate migraine. The use of metoprolol, nifedipine or magnesium can be considered for migraine prophylaxis.

Depression Psychosocial and Psychological Interventions for Treating Antenatal Depression

  • During the development of a normal pregnancy the mother often also experiences fear, worry and low spirits. However, pathological anxiety, panic disorders or depression during pregnancy must be identified, and appropriate therapy offered Psychosocial and Psychological Interventions for Treating Antenatal Depression; see Mental Disorders during Pregnancy.
  • The warning signs include sleep disturbances with early waking up, consistent lack of appetite and nausea, excessive pessimism and feelings of guilt as well as an inappropriately nonchalant attitude or impaired orientation.
  • If medication is needed to treat depression, citalopram is the most used medication during pregnancy. Because withdrawal symptoms in the newborn are common, cessation of the medication or reduction of the dose is recommended a few weeks before the estimated date of delivery, if feasible.

Allergic rhinitis

  • Topical preparations which are applied to eyes or nostrils can be used during pregnancy.
  • Of the conventional antihistamines, hydroxyzine has been used widely without any reported serious adverse events. It does, however, cause tiredness.
  • Of the new antihistamines, cetirizine or loratadine may be used.

Backache Interventions for Preventing and Treating Backache in Pregnancy

  • Physiotherapy and ergonomic counselling is beneficial for the treatment and prevention of backache.
  • Women with lower back pain have sometimes been treated successfully with stability enhancing support belts.
  • If the pain is worse at night, a wedged pillow, which gives support to the abdomen, could be tried.

Visual acuity

  • During pregnancy, fluid collects in the body. This can cause a temporary change in the refractive power of the lens. Perceived visual acuity deteriorates, often towards minus refraction.
  • The situation gradually rights itself after pregnancy.

Nutrition, lifestyle, smoking and substance abuse

Nutrition Vitamin D Supplementation for Women during Pregnancy, , Multiple-Micronutrient Supplementation (Mms) during Pregnancy, Pyridoxine (Vitamin B6) Supplementation in Pregnancy, Interventions for Preventing Excessive Weight Gain during Pregnancy, Folic Acid Supplementation during Pregnancy for Pregnancy Outcomes other Than Neural Tube Defects, Effects and Safety of Periconceptional Folate Supplementation for Preventing Birth Defects, Daily Oral Iron Supplementation during Pregnancy, Magnesium Sulphate for Women at Risk of Preterm Birth for Neuroprotection of the Foetus, Effects of Restricted Caffeine Intake by Mother on Pregnancy Outcome

  • Energy requirements are usually met by eating a normal balanced diet. Attention should be paid to the nutritional value of the diet to ensure an adequate intake of trace elements.
  • Special attention and dietary advice should be given to women whose diet is restricted or who are undernourished, who follow a special diet or are overweight.
  • The mother should not put herself on an antigen avoidance diet in an attempt to prevent an allergy from occurring in her child.
  • Conflicting opinions prevail regarding prophylactic iron supplementation. Routinely administered iron supplementation during pregnancy reduces the incidence of low Hb perinatally and 6 weeks postnatally, but there is no data regarding the well being of the mother and child Daily Oral Iron Supplementation during Pregnancy.
  • Iron stores of approximately one third of pregnant women are significantly low, and iron supplementation should be considered at least for this patient group.
  • Folic acid supplementation of 0.4 mg daily is recommended for all women who plan to become pregnant and all pregnant women (until the end of the 12th week of pregnancy) Folic Acid Supplementation during Pregnancy for Pregnancy Outcomes other Than Neural Tube Defects.
  • Additional folic acid supplementation is required for the prevention of neural tube defects Effects and Safety of Periconceptional Folate Supplementation for Preventing Birth Defects, starting from the contemplation of pregnancy and lasting until the end of the first trimester, in the following cases:
    • Daily folic acid supplementation of 1 mg (tablets) if the mother
      • has epilepsy, coeliac disease or a chronic inflammatory bowel disease
      • consumes excessive amounts of alcohol or her diet is very unbalanced.
    • Daily folic acid supplementation of 4-5 mg (tablets) if
      • the risk of having a child with neural tube defects is higher than average
      • the mother has type 1 or type 2 diabetes
      • there is a close family history (an affected child of the parents or an affected child of one of the parents with another partner or the mother or father affected themselves) of neural tube defects.
    • Supplementation must occur under medical supervision. The patient must be checked for vitamin B12 deficiency before and, as necessary, during the supplementation.
  • Vitamin D supplementation (cholecalciferol, i.e. vitamin D3) 10 µg/day is recommended for all pregnant mothers throughout the year Vitamin D Supplementation for Women during Pregnancy, particularly in sunless climates.
  • The recommended daily intake of calcium is 900 mg. Calcium supplementation may reduce pre-eclampsia if dietary intake is low Calcium Supplementation during Pregnancy for Preventing Hypertensive Disorders.
    • Low consumption of dairy products or calcium-fortified foods: calcium 500 mg/day
    • No dairy products or calcium-fortified foods: calcium 1 000 mg/day
  • Check also local recommendations on diet as well as on iron, vitamin and calcium supplementation.

Exercise Interventions for Preventing Excessive Weight Gain during Pregnancy, Diet and/or Exercise for Pregnant Women for Preventing Gestational Diabetes Mellitus, Aerobic Exercise for Women during Pregnancy

  • Exercise during pregnancy should be a pleasant activity with the aim to maintain the mother's fitness level Aerobic Exercise for Women during Pregnancy.
  • The mother should be advised to "listen to her body". Activities to be avoided, particularly during late pregnancy, include high risk sports and exercise forms which may compress the uterus or expose it to bouncing movements.
  • Should the mother suffer from complications, the amount of exercise might have to be restricted.

Sex life

  • Sexual intercourse is not hazardous during normal pregnancy.
  • Intercourse is not recommended if the mother suffers from vaginal bleeding or her medical history suggests a risk of preterm birth.

Smoking Pharmacological Interventions for Promoting Smoking Cessation during Pregnancy, Psychosocial Interventions for Supporting Women to Stop Smoking in Pregnancy

  • Nicotine crosses the placenta readily, and the foetus is exposed to the same concentration as the mother.
  • The neonates of smoking mothers are often fretful and tend to cry a lot.
  • In boys, foetal exposure to nicotine has been shown to reduce future sperm production which in turn may lead to later problems in conception.
  • Cigarettes impair the placental functioning and increase the risk of placental abruption. Smoking cessation is of particular importance in situations where disturbances in placental functioning and a low weight of the foetus are noted.
  • Nicotine replacement therapy can be used during pregnancy. Short acting preparations are recommended Smoking Cessation.

Alcohol Psychological and/or Educational Interventions for Alcohol or Drug Consumption in Pregnancy

  • See also Pregnant Substance Abuser.
  • Alcohol crosses the placenta readily and the foetal concentrations may rise even higher than those of the mother.
  • Heavy alcohol consumption and especially drunkenness during early pregnancy may lead to cardiac and limb malformations.
  • Continuation of heavy alcohol consumption after discovery of pregnancy (after first trimester) may lead to FASD (foetal alcohol spectrum disorder Fetal Alcohol Spectrum Disorders) which is characterised by growth deficiencies, microcephaly, various neurological symptoms, developmental disabilities and abnormal facial features.
  • A referral to a maternity clinic should be made at a low threshold Pregnant Substance Abuser. Follow also local instructions and regulations regarding making a child protection report to the relevant authorities.
  • Phosphatidylethanol measurement (blood PEth) is a specific blood test for alcohol consumption and is also useful during pregnancy.

Other substance abuse Psychological and/or Educational Interventions for Alcohol or Drug Consumption in Pregnancy

  • See also Pregnant Substance Abuser.
  • Substance dependence (alcohol, illegal drugs and use of medicinal products for a non-therapeutic effect) is a significant psychosocial problem and should be addressed, particularly during pregnancy Pregnant Substance Abuser.
  • Substance abuse is often associated with psychiatric problems and problems with personal relationships. At a later stage, issues relating to child protection should also be addressed.
  • A referral to a maternity clinic. Follow also local instructions and regulations regarding making a child protection report to the relevant authorities.
  • Hashish and marijuana
    • The active ingredient is tetrahydrocannabinol, which crosses the placenta readily.
    • The risk of malformations or miscarriage has not been shown to increase.
    • Placental circulation, and therefore foetal nutrition, will be reduced leading to increased risk of a low birthweight infant.
  • Amphetamines
    • May cause cardiac problems, developmental abnormality of the head and brains as well as cleft palate.
    • A risk of undernourishment and unbalanced diet.
    • Placental circulation will be impaired leading to retarded foetal growth.
    • An increased risk of elevated blood pressure, premature membrane rupture, preterm birth and infection.
  • Cocaine
    • May cause an atrophy of the optic nerve and other developmental abnormalities of the eyes.
    • Placental circulation will be impaired leading to retarded foetal growth.
    • An increased risk of preterm birth and placental abruption.
  • Opioids
    • No specific risk of malformation has been established.
    • An increased risk of maternal blood loss and placental abruption.
    • The foetus will be at an increased risk of oxygen starvation.
    • An increased risk of early membrane rupture, preterm birth and infections.
    • The newborn might suffer from severe withdrawal symptoms.

Find out also about locally available teratology information service(s) for additional information on external factors harmful for the foetus.

    References

    • Stocky A, Lynch J. Acute psychiatric disturbance in pregnancy and the puerperium. Baillieres Best Pract Res Clin Obstet Gynaecol 2000 Feb;14(1):73-87. [PubMed]
    • Kaaja RJ, Greer IA. Manifestations of chronic disease during pregnancy. JAMA 2005 Dec 7;294(21):2751-7. [PubMed]
    • Benitz WE. Perinatal treatment to prevent early onset group B streptococcal sepsis. Semin Neonatol 2002 Aug;7(4):301-14. [PubMed]
    • Verani JR, Schrag SJ. Group B streptococcal disease in infants: progress in prevention and continued challenges. Clin Perinatol 2010;37(2):375-92. [PubMed]