Antenatal Case Complications, Pregnancy Complications by Age, and Related Programmes

1. What is Antenatal Care (ANC)?

• First visit: Ideally within 12 weeks of pregnancy (as soon as pregnancy is suspected)
• Minimum visits recommended: At least 4 ANC check-ups (WHO now recommends 8+)

2. Components of Antenatal Check-up

3. Antenatal Complications (Direct)

A. Hypertensive Disorders

• Gestational hypertension: BP ≥140/90 mmHg after 20 weeks without proteinuria
• Pre-eclampsia: Hypertension + proteinuria (≥0.3 g/24 hrs) after 20 weeks
• Eclampsia: Pre-eclampsia + convulsions - a major cause of maternal death
• HELLP syndrome: Haemolysis, Elevated Liver enzymes, Low Platelets

B. Haemorrhage

• Antepartum Haemorrhage (APH): Bleeding after 28 weeks
  • Placenta praevia: Placenta covering or near the cervical os
  • Placental abruption: Premature separation of normally situated placenta
• Postpartum Haemorrhage (PPH): Leading cause of maternal mortality globally (>500 mL blood loss after delivery)

C. Anaemia

• Most common medical complication of pregnancy in developing countries
• Defined as Hb <11 g/dL in pregnancy
• Causes: Iron deficiency (most common), folate deficiency, haemolytic disorders

D. Infections

• UTI: Very common; risk of pyelonephritis and preterm labour
• TORCH infections (Toxoplasma, Rubella, CMV, Herpes): Fetal anomalies and teratogenesis
• Malaria: Risk of severe maternal anaemia, low birth weight
• Group B Streptococcus (GBS): Neonatal sepsis risk

E. Preterm Labour and PROM

• Labour before 37 weeks; associated with neonatal morbidity and mortality
• Premature Rupture of Membranes (PROM): Membrane rupture before onset of labour
• Management includes antenatal corticosteroids (betamethasone/dexamethasone) to enhance fetal lung maturity, and antibiotics for PROM

F. Diabetes in Pregnancy

• Gestational Diabetes Mellitus (GDM): Glucose intolerance first detected in pregnancy
• Risks: Macrosomia, shoulder dystocia, neonatal hypoglycaemia, increased risk of type-2 diabetes later

G. Other Complications

• Intrauterine Growth Restriction (IUGR): Fetus fails to reach its growth potential
• Oligohydramnios / Polyhydramnios: Abnormal amniotic fluid volume
• Malpresentations: Breech, transverse, oblique - risk of obstructed labour
• Ectopic pregnancy: Implantation outside the uterus (fallopian tube most common) - emergency

4. Pregnancy Complications by Age

A. Teenage Pregnancy (Age < 18 years)

B. Elderly Primigravida / Advanced Maternal Age (Age ≥ 35 years)

C. Very Advanced Age (>40 years) - NHM Guidelines

D. Grand Multipara (≥4 previous pregnancies)

• Higher risk of PPH (uterine atony), malpresentation, placenta praevia, anaemia

5. High-Risk Pregnancy Identification

• Age <18 or >35 years
• Height <145 cm (risk of contracted pelvis)
• Weight <40 kg
• Hb <7 g/dL
• Previous caesarean section / obstructed labour
• Prior stillbirth, neonatal death, IUGR baby
• Grand multiparity (≥4 deliveries)
• Multiple pregnancy
• Medical disorders: heart disease, diabetes, hypertension, renal disease, epilepsy
• Hydramnios / IUGR detected on current pregnancy
• Malpresentation after 34 weeks

6. National Health Programmes Related to Antenatal Care (India)

A. Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A)

B. Key Programmes Under NHM

C. Pre-Conception and Antenatal Care - Strategic Interventions

• Birth/emergency preparedness
• Promotion of clean birth practices

• Identification of complications and timely referral
• Pre-referral antenatal corticosteroids in preterm labour
• Antibiotics for premature rupture of membranes

• Emergency Obstetric Care (basic and comprehensive)
• Management of preterm labour
• Management of eclampsia, sepsis, haemorrhage

D. Preventive and Social Measures to Reduce MMR

1. Early registration of pregnancy
2. Minimum 4 (ideally 8) antenatal check-ups
3. Dietary supplementation and correction of anaemia
4. Prevention of infection and haemorrhage in puerperium
5. Prevention of complications - eclampsia, malpresentations, ruptured uterus
6. Treatment of medical conditions - hypertension, diabetes, tuberculosis
7. Anti-malaria and tetanus prophylaxis
8. Clean delivery practices
9. Trained village-level health workers (ASHA/ANM)
10. Institutional delivery for women with bad obstetric history
11. Family planning - limit family size, birth spacing
12. Maternal death audit
13. Safe abortion services

7. Causes of Maternal Mortality

1. Postpartum haemorrhage (leading cause)
2. Infections (puerperal sepsis)
3. Eclampsia (hypertensive disorders)
4. Prolonged / obstructed labour
5. Complications of unsafe abortion

• ~50-70% of maternal deaths occur in the postpartum period
• 45% of postpartum deaths occur within the first 24 hours
• Women are most vulnerable in the puerperium

8. Antenatal Monitoring and Fetal Assessment

• Detailed anatomic survey: 18-22 weeks for structural anomalies
• Fetal echocardiography: Indicated for family history of CHD or fetal anomaly screening
• Genetic counselling and testing: CVS (10-13 weeks), amniocentesis (15-20 weeks), microarray for chromosomal abnormalities
• Non-Stress Test (NST) and Biophysical Profile (BPP): Antenatal fetal surveillance in high-risk pregnancies
• Doppler studies: Umbilical artery Doppler in IUGR for fetal wellbeing
• Antenatal corticosteroids: Given between 24-34 weeks when preterm delivery is anticipated to reduce RDS, IVH, and neonatal mortality

Summary Table: Age vs. Key Antenatal Risks

• Park's Textbook of Preventive and Social Medicine, pp. 531-532, 651-655
• Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice, Chapter 20 (Antenatal Monitoring)
• NHM Guidelines for Antenatal Care and Skilled Attendance at Birth
• UNICEF India - Maternal Health