Prenatal Care

Overview

Prenatal care can aid in the health of both you and your baby. Babies born to moms who do not receive prenatal care are three times more likely to have a low birth weight and five times more likely to die than babies born to mothers who do receive prenatal care.

When doctors meet moms on a regular basis, they can detect health concerns early on. This helps doctors to treat them as soon as possible. Many issues can be cured and others avoided if they are treated early. Doctors can also advise pregnant women on what they can do to give their unborn children a healthy start in life.

Throughout your pregnancy, you will get prenatal care from a doctor, nurse, or midwife. It contributes to the health of both you and your future child.

Prenatal Care definition

Prenatal care is a form of preventative medicine. It is provided in the form of medical checkups, which include recommendations on how to live a healthy lifestyle and the provision of medical information such as maternal physiological changes in pregnancy, biological changes, and prenatal nutrition, including prenatal vitamins, which prevents potential health problems throughout the pregnancy and promotes the health of both the mother and the child.

Routine prenatal care, including prenatal screening and diagnosis, has helped to reduce the frequency of maternal mortality, miscarriages, birth abnormalities, low birth weight, newborn infections, and other avoidable health issues.

Traditional prenatal care in high-income countries generally consists of:

• monthly visits during the first two trimesters (from the 1st week to the 28th week)
• fortnightly visits from the 28th week to the 36th week of pregnancy
• weekly visits after 36th week to the delivery, from the 38th week to the 42nd week
• assessment of parental needs and family dynamics

The conventional method of prenatal care dates back to the early 1900s, and there is no evidence to show that it is the best approach to provide antenatal care. Antenatal care can be expensive and time-consuming. The paragraphs that follow highlight studies on different types of prenatal care that may alleviate the demand on maternity services in all nations.

Visits numbers

The WHO advises that all pregnant women get at least eight prenatal checkups to detect and manage issues, as well as obtain vaccines. Although prenatal care is vital for both mother and baby's health, many women do not receive eight sessions. There is minimal evidence to support the number of prenatal appointments that pregnant women get, as well as the care and information provided at each visit.

Women with low-risk pregnancies may need fewer prenatal checkups, according to some experts. When this was evaluated, mothers who had fewer visits had kids who were far more likely to be admitted to neonatal critical care and stay there for a longer period of time (though this could be down to chance results). As a result, the decreased visits approach is unlikely to be perfect, especially in low-income countries (LICs), where pregnant women already attend fewer checkups.

Not only is attending prenatal care early strongly advised but there is also a more flexible approach enabling additional visits from the moment a pregnant woman books for prenatal care, perhaps affording more attention to those women who arrive late. Furthermore, women who had fewer prenatal appointments were less satisfied with the treatment they got than women who had the regular number of visits. Telemedicine is a novel option for certain routine prenatal care sessions.

There are several approaches to change health systems to assist women obtain prenatal care, including new health policies, health worker education, and health service reorganization. Community initiatives to assist people in changing their behavior may also have a role. Media campaigns reaching a large number of people, empowering communities to take care of their own health, informative-education-communication activities, and financial incentives are examples of interventions.

An evaluation of these treatments discovered that one of them helps increase the proportion of women obtaining prenatal care. However, combining measures may minimize baby fatalities throughout pregnancy and early life, lower the number of low birth weight babies delivered, and increase the number of women getting prenatal care. According to the World Health Organization (WHO), over 830 women died per day in 2015 as a result of complications during pregnancy and delivery. Only five were from high-income nations. The remainder resided in low-income nations.

I'm thinking about becoming pregnant. How can I take care of myself?

Before attempting to conceive, you should start taking care of yourself. This is known as preconception health. It requires comprehending how certain health conditions and risk factors may affect you or your unborn child if you get pregnant. Some foods, activities, and medications, for example, have the potential to damage your child even before he or she is born. Some health problems may also have an effect on pregnancy.

Consult your doctor before getting pregnant to learn what you may do to prepare your body. Before participating in sexual activity, women should make plans for pregnancy. Ideally, women should give themselves at least three months to prepare before becoming pregnant.

The five most important things you can do before becoming pregnant are:

1. Take 400 to 800 micrograms (400 to 800 mcg or 0.4 to 0.8 mg) of folic acid every day for at least 3 months before becoming pregnant to reduce your chance of brain and spinal birth abnormalities. Folic acid may be obtained from a variety of foods. However, it is difficult to receive all of the folic acid you require from meals alone. The best and simplest approach to ensure you're receiving enough folic acid is to take a vitamin containing it.
2. Stop using tobacco and consuming alcohol. Consult your doctor for assistance.
3. Check to see whether you have a medical issue that is under control. Asthma, diabetes, depression, high blood pressure, obesity, thyroid illness, and epilepsy are some of the disorders. Check to see if your vaccines are up to date.
4. Discuss with your doctor any over-the-counter or prescription medications you are taking. Dietary or herbal supplements are examples of this. Some medications are not safe to use while pregnant. At the same time, discontinuing necessary medications might be detrimental.
5. Avoid coming into contact with potentially dangerous poisonous chemicals or materials at work and at home. Avoid chemicals and cat or rodent excrement.

Prenatal examinations

Using a specific booking checklist, pregnant women are classified as either normal risk or high risk at their initial antenatal care session. Many countries give women a summary of their case notes, which contains important background information about their pregnancy, such as their medical history, growth charts, and any scan results. If the mother is transported to another hospital for treatment or to give birth, the midwives and doctors can use a summary of her case notes until her hospital notes arrive.

The women reported that having their notes gave them a sense of control and that they would like to have them again in future pregnancies. Despite the fact that none of the ladies forgot to bring their personal notes to any of their appointments, 25% of them reported that their hospital notes were misplaced at the hospital.

Prenatal diagnosis, often known as prenatal screening, is the act of checking a newborn or embryo before birth for diseases or problems. By completing a series of periodic check-ups, obstetricians and midwives can monitor the mother's health and prenatal growth during pregnancy.

Physical examinations generally consist of:

• Collection of (mother's) medical history
• Checking (mother's) blood pressure
• (Mother's) height and weight
• Pelvic exam
• Doppler fetal heart rate monitoring
• (Mother's) blood and urine tests
• Discussion with caregiver

In several countries, including the United Kingdom, the symphysial fundal height (SFH) is measured as part of prenatal examinations beginning at 25 weeks gestation. The SFH measurement assists in the identification of neonates who are either little or too large. The review recommends that the SFH be measured in the future because it is affordable and extensively utilized.

Typically, obstetric ultrasounds are performed around week 20 of the second trimester. Ultrasounds are relatively safe and have been used to monitor pregnancy for more than 35 years. Ultrasounds are utilized for a wide range of applications, including:

• Diagnose pregnancy (uncommon)
• Check for multiple fetuses
• Evaluate the mother's potential dangers (e.g., miscarriage, blighted ovum, ectopic pregnancy, or a molar pregnancy condition)
• Examine for fetal malformations (e.g., club foot, spina bifida, cleft palate, clenched fists)
• Determine whether or whether there is an intrauterine growth retardation condition.
• Take note of how fetal body parts grow (e.g., heart, brain, liver, stomach, skull, other bones)
• Examine the amniotic fluid and umbilical cord for any abnormalities.
• Determine the deadline (based on measurements and relative developmental progress)

In general, an ultrasound is scheduled anytime an anomaly is suspected or on a timetable similar to the one shown below:

• 7 weeks confirm pregnancy, ensure that it's neither molar or ectopic, determine due date
• 13–14 weeks (some areas) — evaluate the possibility of Down syndrome
• 18–20 weeks — see the expanded list above
• 34 weeks (some areas) — evaluate size, verify placental position

There is no indication that either the mother or the baby will benefit. Early scans allow multiple pregnancies to be diagnosed at an early stage of pregnancy and provide more precise due dates, resulting in fewer women being induced who do not need to be.

The ultrasound can provide varying degrees of feedback. When parents can view the screen and are given a clear description of what they can see, they offer positive comments. When the findings are reviewed at the conclusion and the parents are given a picture of the ultrasound, this is considered low feedback.

Although there is little data to draw firm conclusions, the various methods of providing feedback influence how much parents worry and the mother's health behavior. In a tiny study, moms who received positive feedback were more likely to quit smoking and drinking alcohol. However, the study's quality was low, and further research is needed to determine which sort of feedback is preferable.

Women who are pregnant with a challenging pregnancy may get a Doppler ultrasound to check the blood flow to their unborn baby. This is done to discover signals that the infant is not receiving normal blood flow and is hence 'at danger.' Doppler ultrasounds may have decreased the incidence of avoidable newborn deaths, but the data was insufficient to urge that they be made standard for all pregnant women.

Prenatal screening tests

Screening tests screen for various fetal metabolic, chromosomal, and anatomic defects.

First-trimester screening tests may include the following:

• -hCG (beta human chorionic gonadotropin): To identify and diagnose pregnancy; in quantitative analysis, -hCG levels lower than predicted for supposed gestation might warn the doctor to an ectopic pregnancy or imminent termination.
• PAPP-A (pregnancy-associated plasma protein-A): To detect instances of trisomy 18 and 21 (in combination with -hCG and ultrasonography for nuchal translucency).

Second-trimester screening tests may include the following:

• Maternal serum alpha-fetoprotein (MSAFP)
• Serum β-hCG
• Unconjugated estriol (uE3)
• Inhibin A
• Maternal hexosaminidase test
• Fetal cells in maternal circulation

The "triple screen" consists of MSAFP, serum -hCG, and uE3; the inclusion of inhibin A results in the "quadruple screen." The panel findings, coupled with gestational age, can indicate a variety of fetal abnormalities, depending on the pattern of results.

Prenatal diagnostic tests

When circumstances that raise the risk of chromosomal abnormalities are present or suspected, diagnostic testing are recommended (eg, advanced maternal age, suggestive findings on fetal ultrasonography [US]). Genetic counseling provided by experienced specialists in a timely and compassionate manner is an important supplement to prenatal diagnosis.

First-trimester diagnostic tests may include the following:

• Fetal US
• Chorionic villus sampling
• Early amniocentesis
• Preimplantation biopsy: conducted for preimplantation diagnosis in a fetus of parents with a high risk of a known genetic condition, as well as in women who have miscarried several times owing to chromosomal translocation
• Coelocentesis: Considered investigational because of reportedly high rates of pregnancy loss

Second-trimester diagnostic tests may include the following:

• Midtrimester amniocentesis
• Percutaneous umbilical blood sampling or cordocentesis
• Late chorionic villus sampling
• Fetal muscle and liver biopsy

Assessment of fetal well-being in the third trimester, when preterm birth is imminent, and during labor may involve the following diagnostic tests for prompt and appropriate intervention:

• Amniocentesis
• Nonstress test (NST)
• Biophysical profile test: Combines the NST with an assessment of amniotic fluid volume (AFV), fetal breathing movements, fetal activity, and fetal muscle tone
• Contraction stress test
• Doppler study: Assesses fetal umbilical arterial blood flow velocity or resistance to flow

Radiologic studies

Diagnostic imaging modalities include the following:

• US: Single most valuable modality for identifying fetal and/or placental structural anomalies
• Magnetic resonance imaging (MRI): Important adjunct to ultrasonography
• Computed tomography (CT): Limited applications in prenatal diagnosis
• Fetal magnetocardiography: Prenatal detection of a prolonged QT interval or Wolff-Parkinson-White syndrome

Fetal management

The following are options for medical and surgical fetal therapy to manage various fetal malformations:

• Termination of the pregnancy
• Elective cesarean delivery
• Preterm delivery
• Prenatal medical treatment
• Prenatal invasive fetal surgery

Surgical interventions in invasive fetal therapy include the following three approaches:

• US-guided vesicoamniotic and, less commonly, thoracoamniotic shunt placement
• Fetal procedures for umbilical cord ligation in acardiac twins, selective laser photocoagulation of communication arteries in twin-to-twin transfusions, and posterior urethral valve ablation
• Open fetal surgery

Fetal ultrasonography

The most reliable method of dating naturally conceived fetuses is fetal US in the first trimester; cell division and growth occur at a predictable rate during the early stages of development. The standard mid-second trimester fetal anatomic assessment may be used to accurately determine anatomic abnormalities such as NTDs and abdominal wall defects, congenital diaphragmatic hernia (CDH), limb abnormalities, and heart problems. 

With the introduction of first-trimester nuchal lucency screening in the United States in combination with PAPP-A measures to diagnosis trisomy 21, some experts have recommended for the anatomic survey to be performed concurrently with the nuchal lucency evaluation. Enhanced US resolution and technique have improved fetal visibility, and multiple studies have demonstrated that first-trimester anatomic surveys are as reliable as more typical evaluations at 18-22 weeks in finding anatomic anomalies. Given the importance of many of the flaws that can be found, the benefits of early identification are obvious.

Chorionic villous sampling

Chorionic villous sampling (CVS) is the preferred procedure for prenatal diagnosis prior to 12 weeks' gestation for the identification of chromosomal anomalies, DNA molecular diagnosis of classic genetic diseases, and the detection of deficiencies in lysosomal enzymes or mucopolysaccharidoses.

An allele-specific amplification analysis approach of CVS DNA can be used to diagnose enzymatic abnormalities such as 21-hydroxylase deficiency, which causes congenital adrenal hyperplasia (CAH).

Preliminary US is conducted to detect fetal viability, gestation, anatomy, and placental placement. Under US instructions, a sample of placental tissue is collected using a 16-gauge polyethylene catheter for analysis. The test is normally conducted between 8 and 12 weeks of gestation.

The method is dependent on the position of the placenta. After 13 weeks of gestation, a transabdominal technique is preferable for anterior and fundal placentas, as well as active vaginal and cervical infections. The sample collected is smaller than that acquired using the transcervical approach.

The transcervical technique is used when there are interposed intestinal loops or uterine retroversion, as well as a posterior or low-lying placenta. When the placenta is situated posteriorly, the uterus is retroverted and retroflexed, and the cervical canal points toward the abdomen, the transvaginal method is performed.

Chromosomal analysis of the sample is performed in two ways, as follows:

• The direct approach assesses metaphysis from the outer layer of cytotrophoblasts in the chorionic villi; findings are available in two days.
• A long-term culture of trophoblasts' inner mesenchymal layer yields findings in 10-14 days; these results more closely coincide with the genuine karyotype.

Long-term cultures of trophoblasts, amniotic cells, or fetal lymphocytes must be used to confirm an aberrant direct outcome. A normal direct result is occasionally followed by aberrant culture findings, which are verified by fetal tissue results. Chromosomal mosaicism occurs in 1.2-2.5 percent of samples and can result in diagnostic mistake.

In 70-80% of instances, the mosaicism is exclusively extraembryonic, and it is more prevalent in direct preparations. If mosaicism is detected in both direct preparation and long-term cultures, a level 2 US screening for abnormalities and amniocentesis or cordocentesis is recommended to confirm mosaicism in the fetal blood.

Complications associated with first-trimester CVS include the following:

• Although it was once thought that the pregnancy loss risk was higher with first-trimester CVS than with midtrimester amniocentesis, several retrospective studies have found the aggregate loss rates to be similar; limb reduction defects and oromandibular malformations are more likely in some studies, especially if the procedure is performed prior to 10 weeks.
• Fetomaternal transfusion can occur regardless of the method employed; consequently, Rh isoimmunization is a relative contraindication, and Rh immunoprophylaxis is given to Rh-negative women following the surgery.

Early amniocentesis

This method is best conducted between 15 and 22 weeks of gestation (see below), however it may be done as early as 14 weeks PMA. When CVS is unreliable, as in higher-order multiple pregnancies, twins with fused placentae, and certain biochemical abnormalities, it is preferable. On the basis of fetal cell karyotyping, chromosomal abnormalities may be detected with 99 percent confidence.

AFP and acetylcholinesterase (AChE) tests have a sensitivity rate of 90-95 percent for NTDs and omphalocele. In both situations, AFP levels are raised, but AChE levels are higher in NTDs but absent in abdominal wall abnormalities.

The operation entails aspirating amniotic fluid (one milliliter per week of gestation) from an amniotic fluid pocket with a 22-gauge needle under US guidance.

Complications associated with amniocentesis include the following:

• Uterine bleeding (1.9%)
• Uterine cramping
• Leakage of amniotic fluid (2.9%)
• Pregnancy loss (1.4-4.2%)
• Increased risk of clubfoot when performed prior to 12 weeks' gestation
• Procedural failure due to tenting of the membranes ahead of the needle
• Culture failure rates of 1% overall and 5% if the procedure is performed prior to 12 weeks' gestation

Preimplantation biopsy

This contentious treatment is used for preimplantation diagnosis in a fetus of parents who are at high risk of a known genetic abnormality, as well as in women who have had many miscarriages owing to chromosomal translocation.

At the eight-cell stage of the embryo, a single cell is extracted and tested for X-linked recessive disorders (blastomere biopsy). Following in-vitro fertilization, only XX embryos are transplanted. More trophectodermal cells from the blastocyst can be extracted for examination. Because it shares the same genetic make-up as the ovum, the second polar body can be tested for disorders caused by recognized gene flaws, such as cystic fibrosis, hemophilia, and 1 antitrypsin deficiency.

Management

Fetal disorders that require treatment include the following:

• Neural tube defects
• Congenital adrenal hyperplasia
• Thyrotoxicosis
• Hypothyroidism
• Methylmalonic acidemia
• Multiple carboxylase deficiency
• Lung prematurity
• Maternal HIV infection
• Immune hydrops
• Fetal thrombocytopenia
• Fetal hemoglobinopathies, immune deficiency diseases, inborn errors of metabolism
• Congenital heart disease
• Certain fetal arrhythmias (eg, sustained supraventricular extrasystoles, atrial flutter), supraventricular tachycardias, and congenital complete heart block

Conclusion 

Prenatal care is one of the most common reasons for a woman to visit a doctor in the United States, accounting for over 22 million visits each year. The scope of prenatal treatment is not well defined. It consists of a battery of diagnostic and screening tests, health-related behavior counseling, social support, and physiologic monitoring. The research basis for many components of prenatal care differs significantly.

The actual substance of prenatal care may vary greatly since it contains a wide range of components, some of which have not been demonstrated to be effective. The Agency for Healthcare Research and Quality-sponsored U.S. Preventive Treatments Task Force (USPSTF) thoroughly reviews the evidence regarding the effectiveness of preventive services.

It then provides recommendations and assigns a grade to the quality of the evidence supporting those suggestions. Several components of prenatal care have recently been recommended, including urine culture, anemia screening, urinalysis, and an oral glucose tolerance test.