ANTENATAL CARE – FIRST TRIMESTER

• Antenatal care refers to the healthcare that women receive throughout pregnancy 

Aims and Objectives

• To detect high-risk pregnancies
• To monitor the course of pregnancy and Foetal development
• To ensure continued medical surveillance and prophylaxis
• To motivate the couple about the need for family planning
• To advise the mother about breastfeeding, post-natal care, and immunization

Schedule for Antenatal Visits 

• up to 28th week – Monthly 
• From 28th week – 36th week – Every two weeks
• From 36th week until birth – Every week

• Physiological and Hormonal changes associated with pregnancy

Symptoms

• Amenorrhoea – Some women tend to have minimal bleeding in early pregnancy, usually in & around the time of the next period. This is largely physiological and called implantation bleeding or placental sign
• Nausea & Vomiting – Nausea and vomiting in early pregnancy (morning sickness) is largely due to the hCG in circulation & rarely last beyond 16 weeks
• Increased frequency of micturition
• The fullness of breast & pricking sensation

Signs

• Breast changes – Breast enlarges, nipple & areola becomes darker, sebaceous glands around the areola enlarge & are called Montgomery’s tubercles
• Jacquemier’s or Chadwick’s sign – Bluish hue in the vestibule & anterior vaginal wall
• Osiander’s sign – Increased pulsations felt through lateral fornices
• Goodell’s sign – Softening of cervix
• Hegar’s sign – softening of the lower part of the uterus and asymmetrical enlargement of the upper part enables the approximation of the vaginal fingers & abdominal hand over the isthmus during a bimanual examination
• Size of the uterus – bulky at 6 weeks; the size of an orange at 8 weeks, roughly the size of a foetal head at 12 weeks; felt at the level of symphysis pubis at 12 weeks
• Piskacek’s sign – lateral implantation results in initial asymmetric growth of the uterus with an area of implantation being softer than the rest
• Palmer’s sign – Regular & Rhythmic contraction of the uterus can be felt as early as 6 – 8 weeks
• White discharge per vaginum – Non-pruritic white discharge is common & normal 

In all Visits

• Maternal weight / BMI
• Blood pressure
• Urine routine (Albumin, Sugar)
• Blood group & Rh type (Both partners)
• Hb, PCV ( Once every trimester)
• HbsAg, HIV, VDRL
• Thyroid screening – TSH
• Test for haemoglobinopathies such as thalassemia (in high-risk group only)
• HbA1c (Overt diabetic patients)
• Prenatal screening – Pregnancy-associated plasma protein A (PAPP-A) and β – hCG (in high-risk groups)

Ultrasound

• A well-done TVS should be done in the first trimester (6 -8 weeks); for confirming the exact site of pregnancy (whether intra – or extra-uterine), the number of gestational sacs, the viability of the intrauterine pregnancy, to rule out molar pregnancy & for exact dating of pregnancy
• Ultrasound screening for Down’s syndrome (NT Scan) – done between 10 to 14 weeks by measuring Nuchal translucency (NT), absence of nasal bone, etc

Antenatal Advice

Diet 

• Diet should be nutritious, balanced, light, easily digestible, rich in proteins, minerals, and vitamins

 Rest & Sleep 

• Excessive and strenuous work should be avoided in the first trimester and last 4 weeks
• 8 hrs of sleep at night
• At least 2 hrs sleep after mid-day meals

Bowel

• Regular bowel movements may be facilitated by regulation of diet, taking plenty of fluids, vegetable, and milk

Bath

• Should take a daily bath but be careful against slipping in the bathroom due to imbalance

Clothing, shoes, and belts

• Should wear loose but comfortable garments
• High heels should be avoided in advanced pregnancy
• Avoid constricting belts

Dental care

• Good dental and oral hygiene should be maintained

Care of breasts 

• A well-fitting brassiere gives relief from the discomfort due to breast engorgement

Coitus

• Should be avoided in 1st trimester and last 6 weeks

Travel

• Travel by vehicles having jerks - is better to be avoided
• Long journeys should be limited to 2nd trimester
• Air travelling is contraindicated in Placenta Previa, pre-eclampsia and severe anaemia

 Smoking and alcohol

• It is better to stop smoking and alcoholism during pregnancy
• Heavy smokers have abortions or low birth weight babies
• Alcohol during pregnancy leads to foetal growth retardation

Immunization

• 2 dose of TT – first dose in early pregnancy, second dose 4 weeks after the first dose
• If a mother received 2 TT doses in the last pregnancy and gets pregnant again within 3 years then only one booster dose of TT is recommended
• Hepatitis B vaccine, Influenza vaccine, Hepatitis A vaccine – Safety during pregnancy is not determined. Should be advised only in patients having a very high risk
• Strongly Contraindicated - Most of the live attenuated vaccines like Measles, Mumps, Rubella, Varicella, Meningococcal, Human Papilloma Virus (HPV) vaccine, Pneumococcal polysaccharide vaccine, Oral poliovirus (OPV), Inactivated polio vaccine (IPV), Typhoid vaccine, Cholera vaccine, Plague vaccine, Japanese encephalitis Vaccine

Supplementation

• Folic acid 5 mg (better to start preconceptionally)

Ayurvedic Management

• In general, food having hridya, drava, madhura rasa, snigdha guna & processed with deepaneeya drugs should be used
• Navaneeta, Gritha & Ksheera should be advised
• Jeevaneeya oushadas can be used
• Rasayana drugs having Balya, Jeevana, Brimhana, Vayastahapana, Prajasthapana, sramahara, Hridya, Pushtidayaka, Sonitaprasadana, Agnideepana, and Medhya properties such as Satavari, Bala, Draksha, Amalaki, Guduchi, Jeevanthi, Ashwagandha, Brahmi, Gokshura, Yashti, etc can be used according to the condition
• For Garbhasthapana – Prajasthapana & Pumsavana drugs can be used
• For drinking – Boiled & cooled water should be used
• Ksheerapaka of Bala, Lakshmana, Bruhati respectively for first, second & third month of pregnancy