Pregnancy

For the expectant mothers....

“Before you were conceived I wanted you. Before you were born, I loved you. Before you were here an hour I would die for you. This is the miracle of Mother's Love.”-Maureen Hawkins

So you are the miracle called mother, aspiring for another miracle-your baby. It is only natural that you would want only the best!
Here is a comprehensive list you must be aware of. But it is on no way exhaustive as your needs may be a little different from the routine. I am sure your obstetrician will be able to take care of that.

Time-When?	What should be done?	Why it needs to be done...	How is it done?
Before you get pregnant	Pre-pregnancy counseling	To assess your health status before pregnancy. To ensure you embark on pregnancy in optimal health.	1) Folic acid supplements for 3 months prior. 2) Rubella immunization 3) Weight reduction (if obese). 4) Optimize medical conditions (asthma, epilepsy, hypertension, diabetes, Thyroid disorders etc.) which may have been existing before 5) Stop smoking and alcohol
First visit: Immediately after a missed period.	Diagnosis of pregnancy	Confirmation that the missed period is because of pregnancy and not just an over-due period.	1) Urine pregnancy test 2) Trans-vaginal ultrasound 3) Internal examination
First trimester (up to 13 weeks)	Period of formation of fetal organs. Avoid medications other than those prescribed. Frequency of clinical examination: Once in 4-6 weeks
6-8 weeks	History and examination	1) Risk assessment-Categorization as high risk or low risk pregnancy. 2) Calculating the expected date of delivery.(EDD) 3) Preliminary examination of blood pressure, height and weight. General systemic examination. 4)Assessment of early pregnancy 5) Testing for HIV, hepatitis, syphilis, blood group and type, hemoglobin and blood sugars. Rubella and chicken pox susceptibility may also be tested	1) Detailed family history of diabetes, twins, hypertension, thyroid, autoimmune and other disorders. 2) Personal history of any pre-existing medical or surgical conditions, or allergies along with the treatment details 3) General and Internal examination 4) Blood and urine tests 5) Medication: Folic acid supplementation.
8-14 weeks	Screening for abnormalities like Down Syndrome and others.	This is optional. Your doctor will discuss your age related risk for Down syndrome and will offer the screening test.	Trans-vaginal scan for Nuchal translucency (NT) and other subtle markers for Down Syndrome. 2. Blood tests (free beta hCG and PAPP-A hormones)
Second trimester (13 to 28 weeks)	Period when the formed organs begin to function. During clinical examination, you are serially assessed for blood pressure, anemia, feet/facial swelling, and weight gain. Baby is assessed for growth, position, movement and heartbeats. Frequency of examination: once in 4 weeks. Medications- Iron and Calcium supplements. Tetanus toxoid injection (TT)-Two shots at an interval of at least 4 weeks in-between.
18-22 weeks	1) Detailed look at the growing baby  to see if all organs appear normal 2) Screening for high risk cases	1) As all the major organs are formed now, it is possible to pick up most anomalies. 2) Termination of pregnancy may be offered for potentially uncorrectable/ lethal deformities. 3) In high-risk cases (hypertension in pregnancy, previous bad outcomes etc.) the blood flow pattern to the uterus and from placenta to the baby is assessed. It is of predictive value.	1. Detailed anomaly scan. 2. Uterine and umbilical artery Doppler studies. May be done at the same sitting as an anomaly scan.
26-30 weeks	To look for diabetes in pregnancy	Some women may manifest diabetes in pregnancy for the first time now	Oral glucose challenge test-Blood sugar estimation on empty stomach and 2 hours after drinking 75 gms of glucose mixed in water.
Third trimester (29 to 40 weeks)	Period when the functioning organs continue to mature During clinical examination, you are serially assessed for blood pressure, anemia, feet/facial swelling, and weight gain. Baby is assessed for growth, position, movement, descent into the pelvis (at advanced stages), heartbeats and also the amount of fluid around it. Frequency of examination: once in 2-3 weeks, or as per your doctor’s advice.
36 weeks	Relook at the well-being of the baby. Monitoring the baby’s environment in high-risk cases.	Gastro intestinal anomalies may manifest for the first time. Some high risk babies need supervision frequently	1) Abdominal Obstetric scan 2) Bio-physical scoring-same sitting as the scan 3) Non-stress test(NST)
38 weeks	Assessment of the birth passage, especially for the first time mothers.	To evaluate if the descent of head has begun (By 36 weeks in first pregnancies) and if labor is likely to start earlier	Internal examination.
Term (40 weeks)	Reassess  for delay	Is there any harm waiting for another week? What tests must be done to ensure that the baby is safe inside?	1) Clinical examination 2) Ultrasound and biophysical score 3)NST

Emergency Contraception

What is Emergency Contraception (EC)?

Most sexually active women have had a scare of an unprotected sexual Intercourse (UPSI) at some time or the other during their lives. Emergency contraception is that ‘second chance’ to prevent an unwanted pregnancy. It offers a solution to such women by ensuring that they do not become pregnant from the UPSI episode.

When does the need for EC arise?

Changing norms and habits in the modern society and women empowerment have contributed greatly to the need for emergency contraception.

1. Method failure: Failure or non-usage of regular contraception. Some women might have forgotten to take their regular dose of oral contraceptive pills, condom slippage/tear, or incorrect use of any other precaution.
2. A chance/surprise/accidental encounter resulting in UPSI
3. For women who have irregular cycles and those who have occasional sex.
4. Women in the perimenopausal period (nearing menopause) who might be having irregular cycles and hence unpredictable ovulation.

5. Victim of sexual assault What are the dangers of UPSI?

1. Pregnancy, of course
2. Sexually transmitted diseases (STDs) especially with a new partner and without barrier contraceptives. However, ECs offer protection only against pregnancy and not against STDs.

What is the scientific basis of Emergency contraception?

After its release from the ovary, the unfertilized egg can live in the woman’s body (in the Fallopian tube) for 24-36 hours. The human sperm which enters the female body after UPSI, has the capacity to stay alive for 2-3 days. This means that having an UPSI 2-3 days before or after ovulation (release of egg) can potentially cause fertilization. Even after fertilization, it takes another 2-3 days for the fertilized product (zygote) to attach itself to the uterus and begin to grow. (implantation) What are the available emergency contraceptives? Currently, oral pills (LNG or Ulipristal containing medicines) and Intra Uterine Contraceptive Devices (IUCD) are the methods being offered for EC. What are the LNG oral pills? And how should they be used? Often referred to as the ‘morning-after pills’ All of them contain the ingredient Levo Norgestrel (LNG).LNG causes alteration in the secretions of the cervix (Entry point to the uterus), impairs sperm transport and hence prevents fertilization. The total dose needed for emergency contraception is 1.5 milligrams. The medication must be taken immediately after the act and within 72 hours to be effective at all. If the formulation contains two tablets of 0.75 milligrams, then the woman may take one tablet immediately followed by another 12 hours later. However taking the entire dose (two tablets of 0.75 milligrams=1.5 mgms) at one go is slightly more effective than splitting the dose. What is an Ulipristal containing EC pill? At the time of writing (December 2012) Ulipristal containing medications are not available in India. Ulipristal not only makes the environment hostile for sperm entry but also inhibits ovulation. These EC pills contain 30 milligrams of Ulipristal and one tablet offers protection if taken within 120 hours (5 days!) of the UPSI, and irrespective of the number of exposure.

What is IUCD? How are they useful as emergency contraceptives?

The IUCD is more popularly known as Copper-T today. (The olden day Lippes’ Loupe and the current LNG-containing IUCD is not being referred to in this section) Actually the Copper-T is classified as a LARC (Long acting Reversible contraceptive) It may be used for a fairly long time contraception (3 or 5 or even 8-10 years). The copper it contains is capable of killing the sperms (spermicidal) and the fertilized zygote (blastocidal) function. Its physical presence inside the uterus may also prevent the implantation of the zygote. Copper-T inserted within 5 days after UPSI acts as an effective emergency contraceptive.
Are there any other methods than LNG/Ulipristal or Copper-T? Yes. In case of a REAL emergency when LNG/Ulipristal pills are not available or Copper-t is unwanted, you could take the usual contraceptive pill that contain LNG (Total dose How successful are the emergency contraceptive methods? LNG containing pills prevent 95% of pregnancies if taken within24 hours of UPSI (84% if within35-48 hours and 58% if within 48-72 hours) Randomized control trials have shown that Ulipristal is as effective, Copper-T has the lowest failure rates, less than 1% and also the advantage that it can be continued as a LARC.

What are the side-effects, contraindications and precautions?

Though the ECs are relatively safe and are promoted as over the counter drugs (OTCs) it is always safe and sane to consult medical care givers before you use them, at least for the first time.Nausea and vomiting can occur. If vomiting occurs within 2-3 hours then you may need to repeat the dose for efficacy. As Yuzpe’s regime has high doses of estrogen, it is more likely thereMenstrual irregularity-Most women may have a normal period around the expected date. Some may experience prior spotting (LNG pills) and some may have an early period (Yuzpe’s) Ectopic pregnancy rates because of method failure may be slightly more than observed in the general population.
If pregnancy occurs, then there are no documented fetal effects.There are conflicting reports of Ulipristal usage for more than once during a menstrual cycleThere are claims that no drug overdose or dependency (in the sense of drug dependency!) has been reported with LNG pills. The World Health Organization (WHO) says that the “repeated use [of EC] poses no known health risks,”The contraindications for EC are; pregnancy, geriatric age group (over 65 years). It must not be used as a routine contraceptive! Women are advised to adopt more comprehensive methods after the first EC itself! Follow up after using the emergency contraception.

1. Remember that one dose of emergency contraception does not provide protection for the complete cycle.
2. For victims of sexual assaults or UPSI with an unknown partner, it is important to undergo tests for sexually transmitted diseases (STDs) like HIV, Syphilis and hepatitis etc.
3. Report to the doctor if you do not get your expected period eve by the end of a week.
4. Report to the doctor in case of pain abdomen, spotting and giddiness-It could be symptoms of ectopic pregnancy.
5. Do not forget to consult your doctor for detailed information about future contraception as emergency contraceptives are meant for emergencies only and not for routine use….!

GENERAL ADVICE IN PREGNANCY-Working during pregnancy- It is safe to continue working during pregnancy.Standing for long hours and work involving heavy physical activity must be avoided Diet in Pregnancy

1) reduce the risk of listeriosis by:

1. Drinking only pasteurised or UHT milk
2. Do not eating ripened soft cheese such as Camembert, Brie and blue-veined cheese. (No risk with hard cheeses, such as Cheddar, or cottage cheese and processed cheese)
3. Do not eat pâté (of any sort, including vegetable Not eating uncooked or undercooked ready-prepared meals

2) Reduce the risk of Salmonella:

1. avoiding raw or partially cooked eggs or food that may contain them (such as mayonnaise)
2. Avoiding raw or partially cooked meat, especially poultry. Exercise in pregnancyBeginning or continuing a moderate course of exercise during pregnancy is not associated with adverse outcomes. There are potential dangers in certain activities during pregnancy, for example, contact sports, high-impact sports and vigorous racquet sports that may involve the risk of abdominal trauma, falls or excessive joint stress, and scuba diving, which may result in fetal birth defects and fetal decompression disease. Sexual intercourse in pregnancySexual intercourse in pregnancy is not known to be associated with any adverse outcomes.

Alcohol consumption in pregnancy

1. women planning a pregnancy are advised to avoid drinking alcohol in the first 3 months of pregnancy if possible because it may be associated with an increased risk of miscarriage
2. Getting drunk or binge drinking during pregnancy (more than 5 standard drinks or 7.5 UK units on a single occasion) may be harmful to the unborn baby.
3. if women choose to drink alcohol during it must not be more than 1 to 2 UK units once or twice a week (1 unit= half a pint of ordinary strength lager or beer, or one shot [25 ml] of spirits. One small [125 ml] glass of wine= 1 to 1.5 UK units). Although there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level there is no evidence of harm to the unborn baby.Smoking in pregnancyDiscouraged completely. Even Second hand smoking.Air travel during pregnancyLong-haul air travel is associated with an increased risk of venous thrombosis, although whether or not there is additional risk during pregnancy is unclearCar travel during pregnancyThe correct use of seatbelts (that is,three-point seatbelts 'above and below the bump, not over it').Travelling abroad during pregnancyIf you are planning to travel abroad, discuss considerations such as flying, vaccinations and travel insurance with your doctor. Nutritional supplements

1. 1. dietary supplementation with folic acid, before conception and
2. a. throughout the first 12 weeks, reduces the risk of having a baby with a neural
3. b. Tube defect (for example, anencephaly or spina bifida). The recommended
4. c. dose is 400 micrograms per day
5. 2. vitamin A supplementation (intake above 700 micrograms) might be teratogenic and should therefore be avoided.Pregnant women should be informed that liver and liver products may also contain high levels of vitamin A, and therefore consumption of these products should also be avoided3. It is important to ensure adequate vitamin D stores during pregnancy and whilst breastfeeding.

Medication:

1. 1) Few medicines have been established as safe to use in pregnancy. Prescription medicines should be used as little as possible during pregnancy and should be limited to circumstances in which the benefit outweighs the risk.
2. 2) Few complementary therapies have been established as being safe and effective during pregnancy and they should be used as little as possible during pregnancy.

Pet care and Gardening:

1. 1) Avoid handling cat litter.
2. 2) Use gloves when gardeningHandling Babies/ ChildrenThe body fluid of babies and children below 5 years (saliva, nasal discharge, urine) are sources of cytomegalovirus. So be careful while handling them.