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Antenatal Care (ANC) - Gynecology & Obstetrics

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Definition

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Objectives of ANC

1. Promote, protect, and maintain the health of the mother during pregnancy
2. Detect "high-risk" cases and give them special attention
3. Foresee complications and prevent them
4. Remove anxiety and dread associated with delivery
5. Reduce maternal and infant mortality and morbidity
6. Teach the mother elements of child care, nutrition, personal hygiene, and environmental sanitation
7. Sensitize the mother to the need for family planning
8. Attend to the under-fives accompanying the mother

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Antenatal Visits

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Components of Every ANC Check-up

I. History Taking (First Visit)

• Confirm the pregnancy
• Identify complications from previous pregnancy/confinement
• Record date of 1st day of Last Menstrual Period (LMP) and calculate Expected Date of Delivery (EDD) - add 9 months and 7 days to the 1st day of LMP
• Record danger symptoms: fever, persistent vomiting, abnormal vaginal discharge or bleeding, breathlessness, generalized swelling, severe headache, blurred vision, burning micturition, decreased fetal movements
• Past medical history: hypertension, diabetes, heart disease, TB, renal disease, epilepsy, asthma, jaundice, malaria, RTI, STD, HIV/AIDS
• Family history: hypertension, diabetes, TB, thalassaemia, twins, congenital malformations
• Drug allergies and habit-forming drugs

II. Physical Examination

• Weight measurement (at every visit)
• Blood pressure monitoring
• Respiratory rate
• Check for pallor (anaemia) and oedema
• Thyroid examination
• Breast examination - check for inverted or flat nipples

III. Abdominal Examination

• Fetal heart sounds - heard after 6th month; normal rate 120-140/min
• Fetal movements - felt by examiner after 18-22 weeks
• Fetal parts - distinguishable (head, back, limbs) after 28 weeks
• Fetal lie and presentation - relevant after 32 weeks
• Suspect multiple pregnancy if uterus larger than expected gestational age

IV. Assessment of Gestational Age

• Most accurate method: early ultrasound (before 20 weeks)
• LMP-based calculation using Naegele's rule
• Clinical assessment using fundal height

V. Laboratory Investigations

• Pregnancy detection test
• Haemoglobin estimation
• Urine test for albumin and sugar
• Rapid malaria test

• Blood group including Rh factor
• VDRL/RPR (syphilis)
• HIV testing
• Blood sugar testing
• HBsAg (Hepatitis B)
• TB skin test (where available)

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Preventive Interventions

1. Iron and Folic Acid (IFA) Supplementation

• Given throughout pregnancy to prevent/treat anaemia
• WHO recommends 60 mg elemental iron + 400 mcg folic acid daily

2. Tetanus Toxoid (TT) Immunization

• Unimmunized woman: 2 doses - 1st at 16-20 weeks, 2nd at 20-24 weeks (minimum 1 month interval)
• Previously immunized: 1 booster dose sufficient (provides cover for next 5 years)
• No pregnant woman should be denied even one dose if seen late in pregnancy
• Avoid TT at every successive pregnancy due to risk of hyperimmunization

3. Nutritional Counselling

• Adequate caloric intake, protein, vitamins, calcium
• Advice on tobacco cessation if applicable

4. Referral Services

• Inform about Janani Suraksha Yojana and other government incentives

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Screening and Detection of Complications

(i) Anaemia

• Most common complication in pregnancy
• Haemoglobin < 11 g/dL indicates anaemia
• Severe anaemia (Hb < 7 g/dL) requires urgent management

(ii) Hypertensive Disorders

• Blood pressure monitoring at every visit
• Presence of hypertension + proteinuria = pre-eclampsia/toxaemia
• Requires close monitoring and timely referral

(iii) Asymptomatic Bacteriuria (ASB)

• Midstream urine culture is the recommended method for diagnosis
• Can lead to pyelonephritis, preterm birth, low birth weight if untreated

(iv) Gestational Diabetes

• Hyperglycaemia first detected during pregnancy
• Family history of diabetes to be recorded at first visit
• Screen with blood glucose testing
• Risk of hypertension, preeclampsia, large baby (>4.5 kg), stillbirth

(v) Syphilis (VDRL)

• Test blood at first visit; ideally retest later in pregnancy
• Congenital syphilis is preventable - treat with procaine penicillin
• Fetal infection most likely after the 6th month

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Risk Approach - "High-Risk" Cases

1. Elderly primigravida (30 years and above)
2. Short-statured primigravida (140 cm and below)
3. Malpresentations (breech, transverse lie)
4. Antepartum haemorrhage, threatened abortion
5. Pre-eclampsia and eclampsia
6. Anaemia
7. Twins, hydramnios
8. Previous stillbirth, intrauterine death, or manual removal of placenta
9. Previous abortion
10. Elderly grandmultiparas
11. Prolonged pregnancy (>14 days after EDD)
12. History of previous caesarean or instrumental delivery
13. Pregnancy with systemic diseases: cardiovascular disease, kidney disease, diabetes, tuberculosis, liver disease, malaria, HIV, RTI/STI

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Indications for Emergency Referral During Labour

1. Fits or loss of consciousness
2. Severe headache, blurring of vision, or diastolic BP >90 mmHg
3. Prolapse of cord or hand
4. Meconium-stained liquor or abnormal fetal heart rate
5. Excessive "show" or bleeding during labour
6. Collapse during labour
7. Placenta not separated within 30 minutes after delivery
8. Postpartum haemorrhage or collapse
9. Temperature of 38°C or above during labour

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Postnatal Transition

• Mother observed for 48 hours after normal delivery
• Rooming-in (baby's crib beside mother) is encouraged to promote breastfeeding and bonding
• Postpartum complications to watch for: puerperal sepsis, thrombophlebitis

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Fetal Development

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Overview of Prenatal Development

By convention, gestational age is counted from the first day of the Last Normal Menstrual Period (LNMP). Embryonic/fertilization age begins ~14 days later at fertilization. The most critical stages of development occur in the first trimester (first 13 weeks).

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Three Phases of Prenatal Development

1. Germinal Stage (Weeks 1-2)

• Begins at fertilization (union of oocyte and sperm) in the uterine tube
• Zygote undergoes cleavage as it travels toward the uterus
• Forms a morula (solid ball of cells), then a blastocyst (with inner cell mass + trophoblast)
• Implantation into endometrium at ~days 6-7
• Key structure formed: placenta (from trophoblast cells)
• Disturbances in this period either kill the embryo or are corrected by the embryo's regulatory properties - they do not typically cause birth defects

2. Embryonic Period (Weeks 3-8)

Week 3

• Primitive streak forms; gastrulation begins (converts bilaminar disc to trilaminar disc with 3 germ layers: ectoderm, mesoderm, endoderm)
• Neural plate and neural groove appear
• Somites begin forming
• Primitive circulatory system starts developing

Week 4

• Heart begins to beat (day 22-23)
• Neural folds fuse to form the neural tube
• Rostral neuropore closes
• Primordia of eyes and ears appear
• Pharyngeal arches form
• C-shaped cylindric embryo takes shape after folding
• Foregut, midgut, hindgut established
• CRL ~ 1.5-3 mm

Week 5

• Head growth exceeds all other regions (brain developing rapidly)
• Facial prominences develop
• Second pharyngeal arch overgrows 3rd and 4th (forms cervical sinus)
• Mesonephric kidneys develop (interim excretory organs)
• CRL ~ 4-7 mm

Week 6

• Lens pits, optic cups, nasal pits forming
• Upper and lower limb buds appear
• Heart bulge visible
• Oral and nasal cavities become confluent
• CRL ~ 9.5 mm

Week 7

• Eyelids forming
• Grooves between digital rays indicate fingers
• Head large but chin poorly formed
• CRL ~ 13 mm

Week 8

• Upper limbs longer and bent at elbows
• Fingers distinct but still webbed
• External genitalia have begun to differentiate (but not yet distinguishable as male or female)
• Toes visible
• Large forehead
• By end of week 8 (Stage 23, day 56): all major organ systems established
• CRL ~ 27-31 mm

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3. Fetal Period (Week 9 to Birth)

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Highlights of Fetal Period: Week-by-Week

Weeks 9-12

• Liver is the major site of erythropoiesis (red blood cell formation)
• By end of 12 weeks: limbs well developed, face has characteristic human appearance
• Spontaneous movements occur (not yet felt by mother)
• Ossification centers appear in skeleton

Weeks 13-16

• Rapid growth phase
• Scalp hair pattern determined
• Eyes and ears approach definitive positions
• Fetal movements may be recognized by experienced examiner (not yet by mother)
• Meconium formation begins in intestines

Weeks 17-20

• Quickening (first fetal movements perceived by mother) occurs at ~18 weeks in multiparas, ~20 weeks in primiparas
• Vernix caseosa (greasy white protective coating) appears on skin
• Lanugo (fine, downy hair) covers entire body
• Fetal movements increase
• Myelination of spinal cord begins

Weeks 21-25 (Viability Threshold)

• Age of viability is approximately 22-26 weeks gestational age
• Innovations in neonatology have lowered this threshold (previously 28 weeks)
• Surfactant production begins - critical for lung function at birth
• Substantial weight gain
• Skin is red, wrinkled, and translucent (due to lack of subcutaneous fat)

Weeks 26-29

• Eyes re-open (had been fused since ~week 9)
• CNS sufficiently mature to direct rhythmic breathing movements
• Adequate control of body temperature begins
• Survival possible with intensive neonatal care from 26 weeks onward

Weeks 30-34

• Testes begin descending into scrotum
• Subcutaneous fat deposits give the body a more rounded appearance
• Lanugo begins to disappear from face

Weeks 35-38 (Full Term)

• Normal birth weight at term: 2500-4200 g
• Skull bones remain separated (fontanelles and sutures) to allow passage through birth canal
• Lanugo almost completely shed
• Vernix caseosa present in skin folds
• Firm grasp reflex

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Derivation from the Three Germ Layers

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Critical Periods of Development

• Weeks 1-2: Environmental disturbances kill the embryo OR are fully corrected - they do NOT cause birth defects (all-or-nothing law)
• Weeks 3-8 (organogenetic period): Most susceptible to teratogens - major structural birth defects result
• Week 9 to birth (fetal period): Physiologic defects and minor morphologic defects more likely; functional disturbances such as cognitive deficiency

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Factors Influencing Fetal Growth

1. Cigarette smoking - reduces fetal growth; associated with low birth weight
2. Multiple pregnancy - each fetus grows more slowly than a singleton
3. Alcohol and illicit drugs - fetal alcohol syndrome; IUGR
4. Impaired uteroplacental blood flow - pre-eclampsia, placental abruption
5. Genetic factors - chromosomal abnormalities, single gene disorders

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Prematurity Classification

• Normal: 2500-4200 g
• Low birth weight (LBW): < 2500 g
• Very low birth weight (VLBW): < 1500 g
• Extremely low birth weight (ELBW): < 1000 g

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Assessment of Fetal Status

Crown-Rump Length (CRL) by transvaginal ultrasound is the most accurate method for estimating gestational age, with accuracy of ±1-4 days between 6-12 weeks.

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• Miller's Anesthesia, 10th Edition, p. 10543

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Schizophrenia

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Definition

• Positive symptoms (hallucinations, delusions)
• Negative symptoms (affective flattening, abulia, apathy, social withdrawal)
• Disorganized symptoms (disorganized speech and behavior)
• Cognitive impairment
• Major impairment in one or more areas of functioning (occupational, interpersonal, self-care)

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Epidemiology

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Etiology and Pathobiology

Genetic Factors

• Twin studies show genetic factors account for up to 50% of risk
• Multiple gene loci are involved (highly heterogeneous)
• Large number of severe ultrarare mutations related to synaptic plasticity
• Higher concordance in monozygotic twins for negative symptoms than positive symptoms
• Increased familial risk for negative and disorganization symptoms over psychotic symptoms

Neuropathology

• Nongliotic neuropathologic process with subtle disruptions of cortical cytoarchitecture
• Postmortem brain studies reveal these subtle abnormalities (distinguishing it from neurodegenerative conditions)
• Considerable neuroimaging evidence supports cerebral dysfunction
• Frontal lobe abnormalities correlate particularly with negative symptoms

Neurotransmitter Hypotheses

• All clinically effective antipsychotic drugs have high affinity for D2 dopamine receptors
• Psychostimulants that increase extracellular dopamine can induce or worsen psychosis in schizophrenic patients
• Subcortical DA hyperfunction (especially striatum) → positive symptoms (respond well to antipsychotics)
• Prefrontal cortex DA hypofunction (mesocortical pathway) → negative and cognitive symptoms (treatment-refractory)

• Glutamatergic systems also play an important role in psychotic symptom production
• NMDA receptor hypofunction is implicated (this explains why NMDA antagonists like PCP mimic schizophrenia)

Neurodevelopmental Theory

• A non-localizable brain lesion is either present at birth or acquired early in life
• Psychosocial factors and neurodevelopment interact with this lesion
• Psychosocial stressors can precipitate exacerbations and worsen the overall course

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DSM-5 TR Diagnostic Criteria

1. Delusions
2. Hallucinations
3. Disorganized speech (derailment, incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (diminished emotional expression, avolition)

Note: ICD-11 requires only a minimum duration of 1 month (not including prodromal phase)

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Core Symptom Domains

1. Psychotic Symptoms (Positive Symptoms)

• Perceptions without external stimuli - most commonly auditory (hearing voices)
• Voices may provide a running commentary, refer to the patient in third person, or give commands
• Schneiderian first-rank symptoms: hearing one's thoughts spoken aloud (écho de la pensée), voices referring to oneself, a running commentary - these were historically considered pathognomonic but are now known to occur in other disorders too
• Hallucinations can occur in any sensory modality (auditory most common; visual, tactile, olfactory also seen)

• Fixed, false beliefs held despite contradictory evidence
• Persecutory delusions most common
• Referential delusions - belief that neutral events/objects have special personal significance
• Delusions of control/passivity - belief that thoughts, feelings, or actions are controlled by external forces
• Other types: grandiose, religious, somatic, nihilistic, erotomanic

2. Negative Symptoms (Five Core Categories - NIMH MATRICS Consensus)

• Associated with: male gender, poor premorbid function, earlier onset, longer duration of untreated illness
• Correlate with frontal lobe dysfunction and neuropathology
• Greater genetic heritability than positive symptoms
• More reliably associated with outcome than positive symptoms
• Reciprocal relationship with affective symptoms (more prominent affective symptoms = milder negative symptoms)

3. Disorganization Symptoms

• Loose associations (derailment) - ideas slip off the track
• Tangentiality - replies to questions obliquely, never reaching the point
• Circumstantiality - excessive irrelevant detail before reaching the point
• Incoherence (word salad) - speech lacks logical connections
• Poverty of thought - little information conveyed
• Neologisms - invented words
• Echolalia - meaningless repetition of another's words

• Difficulty performing goal-directed activities
• Inappropriate affect
• Impulsive, unpredictable behavior

4. Motor Symptoms and Catatonia

• Repetitive hand movements, complex purposeless movements
• Mannerisms (odd caricature of normal movements)
• Echopraxia (mimicking others' movements)
• Rocking, hand-wringing

• "Marked decrease in reactivity to the environment"
• Requires ≥3 of 12 motor signs: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, echopraxia
• Lifetime prevalence in schizophrenia ~8%
• Catatonic excitement (agitated catatonia) is the most common type seen today

5. Cognitive Symptoms

• Impairment in working memory, attention, processing speed, executive function
• Deficits in recognition of emotion
• Cognitive impairment is a distinct domain from negative symptoms (modest but consistent correlation)
• Cognitive deficits are often present before first psychotic episode

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Prodrome

• Social withdrawal, declining academic/occupational performance
• Attenuated psychotic symptoms (odd beliefs, magical thinking, ideas of reference)
• Disrupted sleep-wake cycle, irritability
• May begin years before overt psychosis
• Early identification and intervention in the prodromal phase is an active area of clinical focus

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Course and Prognosis

• Typically characterized by acute psychotic episodes (exacerbations) superimposed on progressively deteriorating baseline functioning
• Prognosis often poor overall
• A small proportion may recover completely
• Antipsychotic drugs significantly reduce relapse rates

• Male sex
• Prominent negative symptoms
• Younger age at first onset
• Enduring psychosocial stressors and family discord
• Longer duration of untreated psychosis (DUP)

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Differential Diagnosis

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Treatment

Antipsychotic Medications

• Mechanism: D2 receptor antagonism
• Prototype: Chlorpromazine (first antipsychotic), Haloperidol
• Effective for positive symptoms
• NOT effective for negative or cognitive symptoms
• Side effects: extrapyramidal symptoms (EPS) - parkinsonism, akathisia, acute dystonia, tardive dyskinesia; hyperprolactinemia

• Lower D2 receptor occupancy (faster dissociation) + serotonin 5-HT2A antagonism
• Lower rates of EPS and tardive dyskinesia
• Less likely to cause hyperprolactinemia
• Efficacy for positive symptoms is generally NOT better than first-generation
• Important agents:

• Associated with greatest reduction in relapse rates (along with clozapine)
• Addresses the major problem of medication non-adherence

Metabolic Monitoring

• Second-generation antipsychotics contribute to obesity and metabolic syndrome in chronic schizophrenia
• Regular monitoring of weight, glucose, lipids is mandatory

Psychosocial Interventions

• Comprehensive psychosocial rehabilitation programs are important for functional outcomes
• Assertive Community Treatment (ACT)
• Cognitive Behavioral Therapy for psychosis (CBTp)
• Family psychoeducation
• Social skills training
• Supported employment
• Prompt use of psychosocial programs at initial onset may improve long-term course

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Comorbidities

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