Preconceptional and Antenatal Care: MBBS Notes

Part A. Preconceptional care

Components

• Severe pulmonary hypertension.
• Dilated cardiomyopathy with EF below 40 to 45%.
• Severe symptomatic valvular stenosis or regurgitation.
• Connective tissue disease with a severely enlarged aorta.
• Certain mechanical valves.

Part B. Antenatal care (ANC)

Objectives (Park's)

1. Promote, protect and maintain maternal health.
2. Detect "high-risk" cases and give them special attention.
3. Foresee and prevent complications.
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. Sensitise the mother to family planning, including advice for those seeking MTP.
8. Attend to the under-fives accompanying the mother.

Antenatal visits

• Registration within 12 weeks is the primary responsibility of the ANM. Village Health Nutrition Days are used for this.
• Name-based tracking of pregnant women is used so that missed visits are followed up.
• WHO 2016 raised the recommendation to a minimum of 8 contacts, because more contacts are linked to fewer stillbirths and perinatal deaths (WHO ANC guideline). Park's still lists 4 visits as the Indian minimum, so write 4 for Indian exams and mention the WHO 8 as an update.

• Plan adequate care.
• Record LMP and calculate EDD.
• Assess baseline health (BP, weight, Hb).
• Detect complications early and refer.
• Confirm whether the pregnancy is wanted, and refer for safe abortion if not.
• Build rapport with the woman.

First visit

• Confirm the pregnancy.
• Previous pregnancy complications.
• Current medical, surgical or obstetric conditions.
• LMP and EDD. Naegele's rule: add 9 months and 7 days to the first day of the LMP.
• Danger symptoms: fever, persistent vomiting, bleeding or discharge, breathlessness, generalised swelling, severe headache with blurred vision, burning micturition, reduced fetal movements.
• Systemic illness: hypertension, diabetes, heart disease, TB, renal disease, epilepsy, asthma, jaundice, malaria, RTI/STI, HIV.
• Family history of hypertension, diabetes, TB, thalassaemia, twins or congenital malformation.
• Drug allergies and habit-forming drugs.

• Fundal height: 12 weeks, just palpable above the symphysis. 20 weeks, at the lower border of the umbilicus. 36 weeks, at the xiphisternum. Express gestation in completed weeks.
• Fetal heart sounds: Audible by stethoscope after about 20 weeks (Park's says after the 6th month). Normal rate is 120 to 140 per minute.
• Fetal movements: Felt by the examiner at 18 to 22 weeks.
• Fetal parts: Felt at about 22 weeks. After 28 weeks the head, back and limbs can be distinguished.
• Lie and presentation: Relevant only after 32 weeks.
• Suspect multiple pregnancy if the uterus is larger than the dates.
• Look for an abdominal scar.

• Sub-centre: pregnancy test, Hb, urine albumin and sugar, rapid malaria test.
• PHC/CHC/FRU: blood group and Rh, VDRL/RPR, HIV, blood sugar, HBsAg, malaria test.
• Standard additions in practice: urine culture for asymptomatic bacteriuria, thyroid function, and GTT at 24 to 28 weeks (earlier if high risk). Rubella and TORCH testing is not routine.
• Ultrasound: Dating and viability scan at 6 to 12 weeks. NT scan at 11 to 14 weeks. Anomaly (level II) scan at 18 to 20 weeks. Growth scans if indicated.

Interventions

Prenatal advice (Park's)

• Diet: Pregnancy needs about 60,000 kcal extra overall, and lactation about 550 kcal a day. Normal weight gain is 9 to 11 kg. Poor Indian women gain an average of 6.5 kg. Poor maternal iron stores lead to infant anaemia. (Standard figures for Indian women are about +350 kcal and +25 g protein a day in pregnancy.)
• Hygiene, rest and exercise: Bathe daily and wear clean clothes. Sleep 8 hours, plus at least 2 hours of rest after the midday meal. Prevent constipation with leafy vegetables, fruit and fluids, and avoid castor oil purgatives. Light household work is fine, but heavy manual labour late in pregnancy is not.
• Smoking: Babies are about 170 g lighter. Perinatal mortality is 10 to 40% higher. Nicotine causes uterine vasoconstriction and placental insufficiency.
• Alcohol: Increases miscarriage risk and causes fetal alcohol syndrome (IUGR, developmental delay).
• Drugs: Avoid non-essential drugs. Park's examples:
  • Thalidomide (limb defects, worst at 4 to 8 weeks).
  • LSD (chromosome damage).
  • Streptomycin (8th nerve damage).
  • Iodides (congenital goitre).
  • Corticosteroids (growth impairment).
  • Sex hormones (virilism).
  • Tetracyclines (bone growth and tooth enamel).
  • Pethidine in labour (neonatal respiratory depression).
• Radiation: Avoid X-rays, especially in the first trimester. Intrauterine X-ray exposure is associated with leukaemia and microcephaly.
• Coitus: Restrict in the last trimester.
• Danger signs: Vaginal bleeding, severe headache or blurred vision, convulsions, severe pallor or breathlessness, fever, leaking liquor, reduced fetal movements, swelling of face and hands.
• Birth preparedness: Institutional delivery, transport, blood donor, funds. Counsel on breastfeeding, newborn care and postpartum contraception.

Risk approach: "high-risk" pregnancy (Park's)

1. Elderly primigravida (30 years or older).
2. Short-statured primigravida (140 cm or less).
3. Malpresentation (breech, transverse lie).
4. Antepartum haemorrhage or threatened abortion.
5. Pre-eclampsia or eclampsia.
6. Anaemia.
7. Twins or hydramnios.
8. Previous stillbirth, IUD or manual removal of placenta.
9. Previous abortion.
10. Elderly grand multipara.
11. Prolonged pregnancy (14 days past EDD).
12. Previous caesarean or instrumental delivery.
13. Medical disease: cardiac, renal, diabetes, TB, liver disease, malaria, epilepsy, asthma, HIV, RTI/STI.
14. Treatment for infertility.
15. Three or more consecutive spontaneous abortions.

Records and home visits (Park's)

• The Mother and Child Protection Card is given to the woman and carried to every visit and to delivery.
• At least one home visit by the female health worker or public health nurse. Home visiting is the "backbone of MCH services."

Indian programmes linked to ANC

• JSY (2005): Cash incentive for institutional delivery.
• JSSK (2011): Free services and referral transport for mothers and sick infants.
• Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA): Free specialist ANC check-up on the 9th of every month (recalled from memory).
• Name-based tracking of mothers and children.

Quick revision

• Preconception: folic acid 0.4 mg (4 to 5 mg or 2 to 4 mg for high risk), rubella vaccine, optimise chronic disease, stop teratogens, genetic counselling, an interpregnancy gap of 24 months or more.
• Indian minimum is 4 ANC visits (12 weeks, 14 to 26, 28 to 34, 36 to term). WHO recommends 8 contacts.
• EDD = LMP + 9 months + 7 days.
• Investigations: Hb, urine albumin and sugar, blood group and Rh, VDRL, HIV, HBsAg, blood sugar, malaria test.
• Interventions: IFA from the second trimester for 180 days, 2 doses of TT/Td, calcium, albendazole.
• Risk approach: identify high-risk cases early and refer.

Diagnosis of Pregnancy: MBBS Notes

1. Presumptive signs and symptoms

2. Probable signs

• Abdominal enlargement: Fundal height by month (Dikshit):

• Uterine changes:
  • At about 3 months the uterus feels doughy or elastic.
  • Hegar's sign appears at 6 to 10 weeks. The isthmus is soft and compressible between the firm cervix and the elastic body, felt on bimanual examination.
  • Piskacek's sign is asymmetrical enlargement at the site of implantation.
  • The globular, soft uterus also gives Von Fernwald's sign.
• Cervical changes:
  • Softening from the 2nd month, from below upwards (Goodell's sign).
  • The os is plugged with mucus.
• Braxton Hicks contractions: Painless, irregular, intermittent contractions from about 12 weeks. They are felt on palpation, or on bimanual examination in early pregnancy, and are more evident later.
• Ballottement: Internal ballottement is elicited at 16 to 28 weeks (the fetus rebounds in liquor). External ballottement can be elicited late in pregnancy. Ascites or an ovarian cyst can give a similar sign.
• Fetal parts felt: Palpable from about 20 to 22 weeks, and the examiner can distinguish them by 28 weeks (Park's).
• Uterine souffle: A soft blowing murmur over the uterus, synchronous with the maternal pulse. It can be confused with fetal heart sounds, which are faster.
• Biological tests (hCG): These are probable, not positive, signs because they show hormone production and not a fetus.

3. Positive (conclusive) signs

1. Fetal heart sounds:
   • Heard by stethoscope at about 18 to 20 weeks. Dikshit and Parikh describe them between the 4th and 5th month.
   • Rate is about 160 at 5 months and 120 to 140 near term.
   • Their absence is uncertain negative evidence, so examine repeatedly.
   • Sounds are not heard before 18 weeks, with a fat abdominal wall or hydramnios, with an awkward fetal position, or when the fetus is dead.
   • Doppler detects them from about 10 to 12 weeks.
2. Fetal movements and parts felt by the examiner: After the 4th month, and visible by the 5th. These are indisputable evidence of a living child at the time.
3. Ultrasonography: The most reliable and safest method.
   • Gestational sac at about 4.5 to 5 weeks on transvaginal scan.
   • Yolk sac at about 5 weeks.
   • Fetal pole and cardiac activity at about 6 weeks.
   • Transabdominal scan is about 1 week later than transvaginal.
4. Radiograph of the fetus: The fetal skeleton shows from about the middle of the 4th month (16 weeks). It is avoided because of radiation hazard, and ultrasound is preferred.
5. Fetal cells or DNA in maternal blood: Listed by Parikh. Cell-free fetal DNA is the basis of non-invasive prenatal testing.

4. Pregnancy tests (biological)

• Molar pregnancy and choriocarcinoma.
• hCG-secreting tumours.
• Recent abortion or delivery.
• hCG injections.
• Heterophile antibodies (serum tests).

• Test done too early.
• Dilute urine.
• "Hook effect" at very high hCG (molar pregnancy, twins).
• Ectopic pregnancy, which has low hCG levels.

5. Differential diagnosis of early pregnancy

• Pseudocyesis (spurious pregnancy): amenorrhoea, breast changes and a feeling of fetal movements, but no uterine enlargement. The abdominal distension settles under anaesthesia, and the pregnancy test is negative.
• Amenorrhoea of other causes: PCOS, thyroid disease, hyperprolactinaemia, premature ovarian failure, stress.
• Fibroid uterus or ovarian cyst.
• Hydatidiform mole: uterus large for dates, very high hCG, "snowstorm" on ultrasound.
• Ectopic pregnancy.
• Ascites and obesity.

6. Estimating gestational age and EDD

• Naegele's rule: EDD = LMP + 9 months + 7 days. This assumes a regular 28-day cycle.
• Ultrasound: Crown-rump length in the first trimester is the most accurate and is the "gold standard" for dating (Park's).
• Express duration in completed weeks.

7. Diagnosis of pregnancy by trimester (quick table)

Viva points

• Earliest symptom: amenorrhoea.
• Earliest reliable lab sign: urine/serum hCG.
• Earliest reliable imaging: TVS gestational sac (about 5 weeks), then cardiac activity (about 6 weeks).
• Positive signs: FHS, fetal movements felt by the examiner, ultrasound, X-ray.
• Uterine souffle is synchronous with the maternal pulse. Funic (cord) souffle is synchronous with the fetal heart rate.

Notes on sources and recency