Pregnancy Care and Treatments

GOAL OF ANTENATAL CARE – HAPPY & HEALTHY MOTHER AND BABY

Pregnancy is divided into 3 trimesters for our convenience

1st trimester	2nd trimester	3rd trimester
Formation of Fetus	Growth of Fetus	Maturity around 37 weeks and preparatory stage for delivery

Fig 1.1 Pregnancy Care and Treatments 

FIRST TRIMESTER (Formation of Fetus) : - 1,2,3 months of pregnancy

History taking:

1)    Age

2)    Married life

3)    LMP : EDD

4)    CONSANGUINEOUS / NON-CONSANGUINEOUS

5)    History of previous pregnancies

6)   Any medicines using for Diabetes, Hypertensions, Hypothyroidism, Epilepsy,

          Asthma or Psychiatric problems.

7)   Family History of Diabetes, Hypertension, Twins, Anomaly babies.

8)   Weight, BP, look for Anemia and swelling of feet.

  Routine investigations:- 

   HB%, Blood group, Urine Micro, RBS, T4, TSHScreening tests – HBsag,  Tridot,HCV, VDRL

       Scan:- 

     

           a) Dating Scan:- To the site of pregnancy, Gestational age, Viability fetus.

         
           b) NT Scan (11-13 weeks):- To rule out down’s Syndrome.

     

       Double Marker Test:- 

     

          Done in patients aged > 35years & in all precious pregnancies to rule out down’s           syndrome

     

       AVOID:-  

            
           Sexual contact, Spicy food, Weight lifting, Journeys.

       MEDICINES:-  

           Folic Acid, B12 (B-complex)

     

Fig 1.2 First Trimester during pregnancy 

  Any other drugs should be used only with Doctor’s Advice (Prescription).

SECOND TRIMESTERS (GROWTH OF FETUS):- 4,5,6 Months of pregnancy

Routine Examination:-  Weight, BP, Height of Uterus, Fetal heart rate (Doppler)

Tests:-

• HB%, RBS/PPBS/GCT, Urine Micro          
• Any infection in Urine à Advise to take more liquids and frequent voiding of Urine, keep nails cut.
• Repeated infection in urine à Urine culture/Sensitivity and add Antibiotics. White Discharge:- Anti Fungal, Anti Micro bials if warranted.

Fig 1.3 Second Trimisters during pregnancy 

Scan:-

TIFFA SCAN(Targeted imaging for fetal anomalies) at 20 to 24 weeks

 Most of the anomalies can be identified during TIFFA Scan.

Limitation of Ultra Sono Graphy

1.     Some anomalies develop late in pregnancy

2.  Some of the anomalies like Gastrointestinal tract anomalies,Multiple Cardiac anomalies are difficult to identify

3.  Only structural anomalies can be identified, functional anomalies like speech,  hearing, vision can be identified only after birth.

Fig 1.4 Scan At pregnancy 

MEDICINES:

1.     Iron tablets from 4^th month -  To prevent Anemia

2.     Calcium tables from 5^th month – To strengthen bones and teeth of baby

3.     DHA (Omega-3 fatty acids) from 7^th month – To improve IQ of baby.

Fig 1.5  Medicine to be followed in pregnancy 

ALL THREE MEDICINES CAN BE CONTINUED AFTER DELIVERY.

EXERCISES:

1.     Walking.

2.     Breathing exercises.

3.     Household work.

THIRD TRIMESTER (Maturity of fetus around 37 weeks preparatory stage for delivery):- 7, 8, 9 Months of pregnancy.

CHECK UP:

• Till 7^th month à Monthly Checkup
• 8^th month        à Once in 2 weeks checkup
• 9^th month        à Weekly once checkup

v Normal weight gain is 2kg/month

v If more than 2kg weight gain à look for fluid retention in body seen as swellingof feet, face, abdomen, hands etc.

Fig 1.6 Trimesters of pregnancy 

    

  i) Mainly pregnancy induced hypertension, Anemia, Hypoprotenaemia                                                    

  ii) Rarely Cardiac, Renal causes.

INCASE OF PREGNANCY INDUCED HYPERTENSION/PREECLAMPSIA

1.     Patient should come for frequent checkup and should be under close monitoring to prevent ECLAMPSIA.

2.  To report immediately if there are any imminent symptoms of Eclampsia like            headache, blurred vision, Epigastric pain(vomiting), decreased urine output,              increased pedal edema.

3.     Advise à Diet, Rest and treatment.

SCANS:-

Growth Scan – 8^th Month

9^th Month Scan – 37 weeks.

Emergency visits to hospital in 9^th Month

Leaking, Bleeding, Fever, Pain Abdomen, Decreased Fetal Movements

TESTS:-

• HB%, RBS/PPBS/GCT, Urine Micro
• At 35 weeks à BT, CT, Platelet count, Serum Creatinine, Serum Bilirubin

DIET DURING PREGNANCY

Diet during pregnancy should be adequate to provide

1.     Good Maternal Health

2.     Optimum Fetal growth

3.     Strength and vitality during labour

4.     Successful lactation

Fig 1.7 Diet and Healthy food During Pregnancy 

IRON (40mg/day):-

·     Increases oxygen carrying capacity in blood, prevents – weakness infections Increases pain bearing capacity, improves lactation in mothers, Decreases premature labour and low birth weight of the baby.

1.     Heme iron 

à Animal Sources

à Red meat, egg, fish

2.     Non Heme Iron 

à Vegetable source

à Green Leafy vegetables, Spinach, beans, peas, carrot,beetroot, tomato, potato, broccoli, lentils.

à FRUITS: Straw berry, Apple, Pear, Peach, Plums.

à IRON BOOSTING FRUITS: Citrus, Melons, Guava

à DRY FRUITS: Dates, Figs, Raisins

à SEEDS: Almond, Cashew, Sunflower seeds, Pumpkin seeds, Jaggery,

            Using iron utensils for cooking.

CALCIUM: (1000mg/day): 

• Helps in building bones and teeth of baby

Sources: 

Milk 300mg, Yogurt – 370mg, Cheese, Sesame seeds – 200mg,Spinach – 250mg, Cabbage, Cauliflower, Broccoli, Orange – 60mg, Date – 15mg, Almonds, Figs, Raisins.

                                 

Video 1.1 Normal pregnancy and Treatments 

Calcium Absorption:

• Increased by Vitamin D and Magnesium.
• Decreased by salt, Coffee, Alcohol,
• Phytates (nuts and grains) and oxalates in spinach

PROTEIN (60grams/day): 

• Building block of tissues

Milk – 8gm, Curd – 10gm, Cheese – 14gm, Lentil 1 cup – 15gm, Beans 1 cup – 18gm, Nuts and seeds, Egg – 6gm, Chicken – 27gm, Fish – 23gm.

Fig 1.8 Protein During Pregnancy

FOLIC ACID(400 Micrograms/day):

Prevents:

1.     Neural tube defect

2.     Down’s Syndrome

3.     Recurrent abortions

4.     Preeclampsia

5.     Low birth weight

Sources:-

• Lentils, Spinach and Orange.

OMEGA – 3 Fatty acids (DHA 300mg)

Fetus:-

1.     Brain and Eye development

2.     Decrease low birth weight

3.     Decrease allergy and eczema

Mother:- 

• Decrease pre-eclamptic toxemia, Depression

Sources:- 

• Flax Seeds, Walnuts, Cold water fatty fish (Salmons, Sardine, Cod fish,   HALIBUT)

FAMILY PLANNING METHODS AND TREATMENT TO BE FOLLOWED

The term contraception includes all  temporary or permanent measures, to prevent pregnancy .

         
Ideal contraceptive methods should fulfill the following criteria – widely acceptable, inexpensive, simple to use, safe, highly effective and requiring minimal motivation, maintenance and supervision.

      

Fig 1.1 Family Planning Methods and Treatments 

TEMPORARY:    
                                                            

BARRIERMETHODS

IUCD(INTRAUTERINE contraceptive device)

OCP(oral contraceptive pill)

PERMANENT

MALE ---Vasectomy 

FEMALE---Tubectomy

Fig 1.2 Temporary and permanent method  

BARRIER METHODS

·     
        Mechanical:

       1.  Male – Condom
       2. Female – Condom, diaphragm, cervical cap
           Chemical
        (Vaginal contraceptives)
       3. Creams – Delfen (nonoxynol-9, 12.5%)
       4. Jelly – Koromex, Volpar paste
       5. Foam tables – Aerosol foams, Chlorimin T or Contab, Sponge (Today)
           Combination
        

            Combined use of mechanical and chemical

Fig 1.3 Using Condom to Stop pregnant

CONDOM

ADVANTAGES	DISADVANTAGES
	May accidentally break or slip off during coitus.
	Inadequate sexual pleasure.
Easy to carry, simple to use and disposable.	To discard after one coital act.
Useful where the coital act is infrequent and irregular Protection against sexually transmitted diseases, e.g. gonarrhoea, Chlamydia, HPV and HIV
Protection against pelvic inflammatory diseases

Failure rate – 14(HWY); 3(HWY) when used correctly and consistently.

Precautions:

•   To use a fresh condom for every act of coitus.
•   To cover the penis with condom prior to genital contact
•   Create a reservoir at the tip.
•   To withdraw while the penis is still erect.
•   To grasp the base of the condom during withdrawal.

Fig 1.4 Methods to stop Female Pregnancy 

FEMALE CONDOM (FEMIDOM)

It gives protection against sexually transmitted disease and pelvic inflammatory disease. It is expensive. Failure rate is about 3-5/HWY.

VAGINAL CONTRACEPTIVES:

The cream or jelly is introduced high in the vagina . Foam tablets (1-2) are to be introduced high in the vagina at least 5 minutes prior to intercourse.

Fig 1.5 Safety measures to stop pregnancy and anticare

VAGINAL CONTRACEPTIVE SPONGE (Today)

It is made of polyurethane impregnated with 1gm of nonoxynol-9 as a spermicide. Nonoxynol-9 acts as a surfactant which either immobilizes or kills sperm. The sponge should not be removed for 6 hours after intercourse. It’s failure rate is about 10/HWY.

Fig 1.6 Vaginal Contraceptive Sponge  

RHYTHM METHOD:

This method is based on identification of the fertile period of a cycle and to abstain from sexual intercourse during that period.

The first unsafe day is obtained by subtracting 20 days from the length of the shortest cycle and last unsafe day by deducting 10 days from the longest cycle.

Failure rate 20-30 (HWY)

Not applicable during lactational amenorrhoea or when the periods are irregular

Fig 1.7 Rhythm Method to delay conceive

COITUS INTERRUPTUS:

It necessitates withdrawal of penis shortly before ejaculation. Accidental chance of sperm deposition into the vagina. Failure rate – 20(HWY)

Fig 1.9 Coitus Interupptus

BREASTFEEDING, LACTIONAL AMENORRHOEA (LAM)

Thus during breastfeeding, additional contraceptive support should be given by condom, IUCD or injectable steroids where available to provide complete contraception.

When the women is full breastfeeding, a contraceptive method should be used in the 3^rd postpartum month  and with partial or no breastfeeding, she should use it in the 3^rd postpartum week.

full breastfeeding   and amennorhoehic   - risk of pregnancy <2% in first 6 months

 general  ---  risk of pregnancy 1- 10%

                                          

Fig 1.10 Brestfeeding ,lactional amenorrhoea(LAM)

INTRAUTERINE CONTRACEPTIVE DEVICES(IUCD)

Cu T200B  ------ replaced every 3 years

Cu T 380A:- ----Replacement  every 10 years

Multiload Cu 250:- replacement  every 3 years. Multiload Cu375   replaced every 5 years

Levonorgestrel intrauterine system (LNG-IUS):- n replaced every 5 years.

Fig 1.11 Intrauterine Conceptive Devices

MODE OF ACTION:

Video 1.1 Fertility and Treatments 

•          Biochemical and histological changes in the endometrium
•          Copper devices – Preventing implantation through enzymatic interference.
•          There may be increased tubal motility
•          There may be impaired sperm ascent
•          Levonorgestrel-IUS(Mirena) – It induces strong and uniform suppression of                   endometrium. 
•          Cervical mucous becomes very scantly.
•          I is preferable to insert 2-3 days after the period is over.
• 
  

 CONTRA INDICATION   FOR IUCD INSERTION

1)MENORRHAGEA 

2)PELVIC INFECTION(PID) 

3)DYSMENORRHOEA

factors related to its discontinuation (10%-15%)

Pain, abnormal uterine bleeding and PID

SPONTANEOUS EXPULSION – The expulsion rate is about 5 percent.

FAILURE RATE– 

The pregnancy rate with the device in situ is about 2 per 100 women years of use. Lowest 

pregnancy rates are observed with Cu T 380A (0.8-HWY) and LNG-IUS (0.2 – HWY).

Fig 1.12 Contra indication for insertion 

 Ectopic pregnancy (1-2%).

•     3^rd generation IUCD(Cu T 380A, Multiload Cu375  and Levonorgestrel-IUS(Mirena)
•     Higher efficacy with lowest pregnancy rate (less than one pre 100 women years).
•     Longer duration of action (5-10 years)
•     Low expulsion rate and fewer indications for medical removal.
•     Risk of ectopic pregnancy is significantly reduced (Cu T-380A and LNG-       IUS:0.02HWY)
•     Non-contraceptive benefits specially with LNG-IUD
•     Can be used as an alternative to hysterectomy for menorrhagia, DUB.
•     Apart from the use of Cu T as a contraceptive, it is used following synaecolysis.

OCP(ORAL CONTRACEPTIVE PILLS)   ----- NAMES

COMMERCIAL NAMES	COMPOSITION		No. of tablets
	Progestin’s(mg)	Oestrogen (ug)
1.Mala N( Govt.of India)	Levonorgestreal 0.15	Ethinyl  oestradiaol 30	21+7 Iron tablets
2.Mala- D	Levonorgestreal 0.15	Do	21+7 Iron tablets
3.Femilon (Infar)	Desogestreal 0.15	Ethinyl  oestradiaol 20	21
4.Yasmin(Schering)	Drospirenone 3 mg (p.509)	Ethinyl  oestradiaol 30	21
Depending on the amount of ethinyl oestradiaol (E) and the types of progestin (p) used , pills are defines as: 1ST GENERATION – With E 50 UG or more ; 2nd  GENERATION --  with e 30- 35 ug and p as levonorgestrel or norgestimate ;  3rd GENERATION – WITH e 20- 30 ug and p as desogestrel or gestodene Low dose pills have E less than 50 ug.

HOW TO PRESCRIBE A PILL:

New users should normally start their pill packet on day one of their cycle.

FOLLOW UP:  

After 3months,6 months and yearly check up necessary. The patient above the age 35 should be checked more frequently.

MISSED PILLS:

When she misses two pills in the first week (days 1-7), she should take 2 pills on each of the 

next 2 days and then continue the rest as schedule. Extra precaution has to be taken for next 7 days either by using a condom or by avoiding sex.

If 2 pills are missed in the third week (days 15-21) or if more than two active pills are missed at any time, another form of contraception should be used as back up for nest 7 days as mentioned above. She should start the next pack without a break.

If she misses any of the 7 inactive pills (in a 28day pack only) she should throw away the missed pills. She should take the remaining pills one a day and start the new pack as usual.

Indications for withdrawal : The indication for withdrawal  of the pill are 

                                               
                                                   Fig 1.13 Oral Contraceptive Pills 

1)serve migraine 

2) Visual or Speech disturbance 

3) Sudden chest pain 

4) Unexplained  fainting attack or acute vertigo 

5) Serve cramps and pain sin legs

6) Excessive weight gain 

7) Severe depression

8) Prior to surgery (it should be with held for at least 6 weeks to minimize postoperative           vascular complications). 

9) Patient wanting pregnancy.

pill be continued :

A Woman who does not smoke and has no other risk factor for cardiovascular disease , may continue the pill for 3 to 5 years is considered  enough and safe .

Failure rate:

 1)Protection against unwanted pregnancy (failure rate – 0.1 per 100 women year)

    Non contraceptive benefits  : Improvement of menstrual  abnormalities – 1) Improvement     of menstrual abnormalities

2) Reduction of dysmenorrhea  (40%)

3) Reduction of menorrhagia (50%) 

4) Reduction of premenstrual  tension syndrome (PMS) 

5) Reduction of Mittelschmerz’s  syndrome.

6) Protein against iron deficiency anemia .

 

Video 1.2 Treatments in Andal Fertility clinic

12) Functional  ovarian cysts 

13) benign breast disease

14) Osteopenia and postmenopausal  osteoporotic  fractures. Prevention of malignancies   Endometrial cancer (50%) 

18) Ovarian cancer (40%)

19) Colorectal cancer (40%)  This protective effects persists for 10 -15 years even after stopping the methods following a use of 6 months to 1 years .

SIIDE EFFECTS : 

NAUSEA, VOMITING ,HEADACHE (OGN) AND LEG CRAMPS (PGN) : These are transient and often subside following continuous use for 2-3 cycles .

WEIGHT GAIN: 

Though progestins have got an anabolic effects due to its chemical relation to testosterone, use of low dose COCs does not cause any increase in weight.

MENSTRUAL ABNORMALITIES -
·      

Breakthrough bleeding  is commonly due to sub threshold blood level of hormones

other causes of break through bleeding in pill takers are

                  1) disturbance of drug absorption – diarrhea , Vomiting
               
                  2)use of enzyme inducing drugs (mentioned earlier) , missing pills, use of low does                              pills
               
                  3) pregnancy complications
               
                  4) Diseases  -- cervical ectopy or carcinoma.
·      

Amenorrhea: 

Post pill amenorrhea of more than 6 months duration occurs in less than 1 percent cases. The association is casual not casual .it is usually more in women with per-existing functional menstrual disorders.

Hypertension: Current low dose COC5 rarely cause significant hypertension. Pre-existing Hypertension  is likely to be aggravated.

Fig 1.14 Oral Natural Abnormalities 

VASCULAR COMPLICATIONS (OGN): 

Venous thromboembolism (vtm)  - the overall risk is to the extent of 4-6 times more than the non –users .pre-existing hypertension, diabetes , obesity and elderly patient (over 35 specially with smoking habits ) are some of the important risk factors ethinyl  oestrodiol in preference to menstranol and the reduction of the dose of the oestrogen compound to 20 ug in the pill markedly reduce the incidence

LIPID (OGN): 

Plasma lipids and lipoproteins are increased .total cholesterol and triglycerides are increased .Preparation with more selective, lipid friendly and third generation progestin’s namely desogestrel, gestodeone or norgestimate, HDL Level is some what elevated .

VITAMINS AND MINERALS: 

Vitamins b6,b12, folic acid ,calcium , manganese, zinc and ascorbic acid levels are decreased  while vit a and vit k levels are increased.

INJECTABLE PROGESTINS: 

NET –EN IN A DOSE OF 200 MG GIVEN AT TWO – MONTHLY INTERVELS.DMPA 150 mg three monthly intervals. 

Mechanism of action :

1) Inhibition of ovulation by suppressing the mid cycle LH Peak 

2) cervical mucous becomes thick and viscid therapy prevents sperm penetration 

3) Endometrium is atrophic preventing blastocyst implantation

Fig 1.14.a. Ingectible Progestins 

Advantages :

 1)it eliminates regular medication as imposed by oral pill

 2) it can be used safely during lactation.

Disadvantages :

There is chance of irregular bleeding and occasional phase of amenorrhea. Loss of bone 

mineral density has been observed with along term use of depot provera.

OTHER EFFECTS : 

Weight gain and Headache

EMERGENCY CONTRACEPTION

·         Hormones

·         IUD

·         ANTIPROGESTRONE

·         OTHERS

                 

 POST COITAL CONTRACEPTIVE

DRUGS	Dose	Pregnancy rate (%)
Levonorgestrel	O.75 MG STAT AND AFTER 12 HOURS	0-1
Ethinyl oestrodiol 30ug + Norgestrel 0.25 mg	2 TAB  STAT AND 2 AFTER 12 HOURS	0-2
Mifepristone	100 MG SINGLE DOSE	0-0.6
Copper IUDs	Insertion within 5 days	0-0.1

Levonorgestrel 0.75 MG ,two doses given at 12 hours intervals , is very successful and without any side effects .

No fetal adverse effects has been observed when there is failure of emergency contraception

Mode of action

·         Ovulation is either prevented or delayed when the drug is taken in the         beginning of the cycle

·         Fertilization is interfered

·         Implantation is prevented as the endometrium is rendered unfavorable.

·         Interferes  with the function of corpus luteum or may causes luteolysis.

Fig 1.4.b PostCoaital Contraceptions

Draw backs: 

Nausea and vomiting are much more intense with oestrogen use

Copper IUD: 

Introduction of copper IUD within a maximum period of 5 days can prevent conception following accidental unprotected exposure .this prevent implantation.

Anti progesterone: 

Anti progesterone binds competitively to progesterone receptors and nullifies the effects of endogenous progesterones.

PERMANENT METHODS    

The operation done on male is vasectomy and that on the female is tubal                    
occlusion, or tubectomy

VASECTOMY

Advantages:

1) The operation can be done as an outdoor procedure

2) Failure rate is minimal – 0.15 percent and there is a fair chance of success of reversal anastomosis operation (50%)

Female : TUBECTOMY

Puerperal:- 24-48 hours after delivery

Interval: 3 months after delivery. It is done after periods

Concurrent: 

done along with termination of pregnancy

Open—pomeroy’s method failure rate .1-.3%

Lap—rings  failure rate-.2--.6% 

        

Fig 1.15 Vasectomy 

Contraceptive prescription should be on individual basis. In an individual , Method may vary according to her phase of reproductive life .Teenage girls, Older women should also be protected.