Antenatal Advise

Antenatal Advise
It is classified into the following:
1. Investigations
2. Diet
3. Supplements
4. General Advise

Antenatal investigations

Antenatal investigations play an important role in the management of a pregnant female. Many underlying disorders can be diagnosed by performing antenatal investigations. The basic investigations that a pregnant female has to undergo can be broadly classified as:

1. Blood examination.
2. Urine routine.
3. Ultrasound scan.

The Antenatal investigations include:

I. Blood examination

1. Haemoglobin: To rule out anaemia.
2. Blood group: For Rh incompatibility.
3. Human immunodeficiency virus (HIV): For neonatal risk.
4. Hepatitis B surface antigen (HBsAg): For Hepatitis B, to know the state of the mother, whether carrier or active, and to plan mode of delivery.
5. Venereal Disease Research Laboratory (VDRL) Test: for syphilis status of the mother and to plan mode of delivery.
6. Random blood sugar: Screening for diabetes.
7. Thyroid Stimulating Hormone (TSH): To rule out thyroid disorders.

II. Urine Routine
Look for proteinuria and urinary tract infection.

III. Ultrasound obstetrics
Ideally, three ultrasound scans are required during the entire pregnancy period.

(a) First ultrasound
First ultrasonography is advised at the first visit, in the first trimester, with an aim to:

1. Confirm pregnancy.
2. Confirm whether the pregnancy is intrauterine or extra-uterine.
3. Tells whether the fetus is viable or not.

(b) Second ultrasound
Second ultrasound scan is advised at around 18-20 weeks to:

1. Screen the fetus.
2. Assess the growth of the fetus.
3. Detect multiple pregnancies.
4. Detect fetal-anomalies.
5. Know placental localisation.

(c) Third ultrasound
Third ultrasound scan is advised at around 32 weeks, with an aim to:

1. Screen the fetus.
2. Find the estimated fetal weight.
3. Note the growth profile of the baby.

Investigations for high-risk pregnancy

A. Biochemical tests

(a) Maternal serum alpha-fetoprotein (MSAFP)

1. It increases in Neural tube defects, multiple pregnancies, Intrauterine Fetal Death (IUFD), renal anomalies.
2. It decreases in Down syndrome and gestational trophoblastic diseases.

(b) Triple test / triple marker test

1. It is a combined biochemical test which includes maternal serum alpha-fetoprotein (MSAFP), Human Chorionic Gonadotropin (HCG) and unconjugated estriol (uE3). The maternal age is also considered before the interpretation of the result.
2. Alpha-foetoprotein (AFP) and unconjugated estriol (uE3) are low, and Human Chorionic Gonadotropin (HCG) is high in Down syndrome.
3. It gives a relative ratio. The test is positive if the ratio is 1: 250.
4. Confirmation is done by amniocentesis.

(c) Acetylcholinesterase (AChE)
Increases in neural tube defects.

(d) INHIBIN A
Increases in Down syndrome.

(e) PAPPA – Pregnancy-associated placental protein A.
Decreases in Down syndrome.

B. Cytogenic tests
These are investigations where the fetal cells are obtained and studied.

CVS – chorionic villus sampling or CVB – chorionic villus biopsy. It is done at 10-12 weeks under ultrasound guidance to obtain trophoblast cells.

Amniocentesis
It is done at 14-16 weeks under ultrasound guidance, to obtain amniotic fluid and fetal cells.

Cordocentesis
It is done at 18-20 weeks; fetal blood cells are obtained from the umbilical cord under ultrasound guidance.

C. Ultrasonography
Anomaly scan
It is a specialised ultrasound, where all the organs of the fetus are scanned, a detailed study of the fetus is carried out.
Colour doppler
It is a specialised ultrasound done to see the blood flow through the placenta and also the umbilical vessels is noted. It is advised in females suffering from pre-eclampsia and eclampsia.

Antenatal diet advice

1. A pregnant female needs an extra 300 Kcal per day, especially during the later half of pregnancy.
2. Diet should be light, nutritious, easily digestible and rich in proteins, minerals (iron), vitamins and calcium. Healthy and hygienic food should be consumed during pregnancy.
3. It is advisable to have a half litre of milk every day and include green vegetables and fruits in the diet.
4. Salt consumed should be just enough to make food palatable. Avoid excess salt in the diet.
5. Patient should be advised to include foods which are a good source of iron, calcium and proteins.

Examples of food rich in iron:

1. Meat.
2. Dark green leafy vegetables.
3. Beans.
4. Dried fruit such as apricot and raisins.
5. Dates.
6. Jaggery.

Examples of food rich in calcium:

1. Milk.
2. Yoghurt.
3. Cheese.
4. Beans.
5. Soya.
6. Dark leafy vegetables.

Examples of food rich in protein:

1. Milk and milk products.
2. Meat.
3. Fish.
4. Cheese.
5. Sprouts.
6. Egg.
7. Soya.
8. Nuts and seeds.

Supplements required during pregnancy

The following supplements are very essential during pregnancy; as they help in maintaining the health of the female and also help in the development of many maternal and fetal complications during pregnancy. The female is advised to continue iron and calcium supplements till delivery.
First trimester
Folic acid 5 mg and Vitamin B12 100mg/day.
Second trimester

1. Iron: 70-80 mg of elementary iron, i.e. one capsule/day should be prescribed from 12 weeks.
2. Calcium: 1000mg/day should be started from 20 weeks of pregnancy.
3. Amino acids tablets can also be given to a  patient who is not gaining adequate weight, suspected intrauterine growth retardation, suffering from pre-eclampsia or eclampsia. It is usually started in the third trimester of pregnancy.

Immunisation
Injection Tetanus toxoid 0.5 ml intramuscular, 2 doses, is given at an interval of 4-6 weeks. Immunisation is given after 20 weeks.  The efficacy of the vaccine is for 6 months and hence, tetanus immunisation is never given in the first trimester.

General advice

1. A pregnant female needs 8 to 10 hours of sleep daily, especially during the last 6 weeks of gestation.
2. A female can continue all her usual activities throughout pregnancy, but she should be careful and avoid activities which increase intra-abdominal pressure.
3. During pregnancy, it is advisable to increase fluids and fibre in the diet to prevent constipation.
4. Retracted or inverted nipples need correction during pregnancy, this will help in establishing fruitful lactation later after delivery.
5. Avoid coitus in the first trimester and last 6 weeks as it can precipitate abortion or premature rupture of membranes.
6. Avoid smoking and alcohol should not be consumed during pregnancy, as these can directly cross the placental barrier and affect the fetus.
7. Travelling in a two-wheeler or auto should be prohibited. Long journeys should be avoided as far as possible. A train journey is safe compared to road journey. Flights have to be avoided in the first 6 weeks and last 6 weeks.
8. It is advisable to avoid wearing very tight clothing and high heels footwear during pregnancy.
9. Antenatal exercises and yoga can be advised during pregnancy, they help in toning up the muscles and also in rapid involution after delivery.
10. Avoid any form of mental or physical overexertion during pregnancy.
11. Regular walks, yoga and meditation should be advised, these will help physically as well as alleviate the general mood of a pregnant female.
12. Avoid hot water bath during pregnancy as it can cause vasoconstriction which may lead to decreased blood flow to the uterus.

Antenatal exercises

The pregnant female should always take the advice of the obstetrician before starting any exercise.

1. Simple walking should be encouraged.
2. Simple stretching of muscles of the upper extremities, lower extremities, abdomen and back should be advised.
3. Yoga, breathing exercises and meditation will help during pregnancy and also helps in leading a healthy life.
4. Swimming is beneficial during pregnancy, it can be performed with caution.
5. Pelvic floor exercises or Kegel’s exercise should be promoted. The female is asked to voluntarily tighten the pelvic floor muscles and count 1 to 10 and then release the muscles, this can also be explained to her by asking her to hold the urine or stools and not passing them. (This contracts the pelvic floor muscles.) This exercise can be done anytime, anywhere, while sitting, standing or lying down. It will help to build the tone of the pelvic floor. It also helps to prevent future prolapse of uterus and stress-induced urinary incontinence.
   * Sit with the back straight and fold the legs. Place the hands over knees, relax, take deep breath slowly and then expire out slowly. 
   * Sit on the ground with one leg folded and other straight, bend towards the straight leg, touch the toe with one hand and the other hand in stretched and kept straight above the head. Repeat the same steps on the opposite side.
   * Lie flat on the back, bend the knees and raise the head slowly above the ground, count 1 to 10 and then touch the head back to the ground.
   * Stand straight with the shoulders upright, now raise the hands to the level of shoulders, then slowly bend your knees, keeping the hands extended, count 1 to 5 and then slowly go back to the original position by extending the knees. This will help in relaxing the back muscles as well as quadriceps.
   * To stand on all the four limbs, gradually raise the neck count 1 to  5, the weight is distributed on all 4 limbs. This helps in toning the abdominal muscles, back muscles and the quadriceps.

Benefits of exercise during pregnancy

1. It helps in building and/or maintaining the muscle tone.
2. It prevents prolapse of the uterus in later years.
3. It helps in bearing down process during labour.
4. The post-partum recovery is better in females who exercise regularly.
5. It helps in the involution of the uterus.
6. It also benefits in constipation during pregnancy.
7. It helps to get a sound sleep.
8. It also makes a female feel more cheerful and alleviates the mood.

Role of homoeopathy in antenatal care

Pregnancy is a period where a female experience a lot of physical changes as well as emotional and psychological changes. There is a sense of fulfilment and expectation at the same time.
– Pregnancy comes with its own bundle of symptoms, which may be annoying at times. Each female will have different reactions to a similar complaint. This change or the reaction is very important from a homoeopathic point of view as it will help to select the suitable homoeopathic remedy.
– Pregnancy is like a physiological test which a female undergoes. Some clinical conditions may be diagnosed at the time of pregnancy, for example, some congenital heart disorder, where the heart may not be able to take the overload and may express itself in the form of signs and symptoms for the first time, during pregnancy.
– A female responds better to a good homoeopathic prescription during pregnancy than at any other time. It is often possible to cure her chronic complaints during pregnancy that one may have failed to do so before she got pregnant.
– A female, mentally and physically, is most receptive to a homoeopathic remedy during pregnancy than any other period of her life.
– The susceptibility is very high during pregnancy.
– A mother’s emotional state during pregnancy is also of the utmost value as it directly influences the fetus. Hence, the importance of emotional support and counselling during pregnancy is a part and parcel of good antenatal care.
– Patients suffer from various minor and major complaints during pregnancy.
– Homoeopathy helps female suffering from various ailments during pregnancy and also helps in uneventful delivery of a healthy baby. By prescribing the acute homoeopathic remedy, one can borrow some time from the patient and work at a deeper level, later.
– Homoeopathic therapeutics have a very important role in treating pregnant females.
– One should always aim at prescribing a constitutional remedy during pregnancy. But many times, there are many obstacles in prescribing the constitutional remedy, e.g.:

1. Non-cooperative patient.
2. Language barrier.
3. Ignorant patient.
4. Patients with lack of time.
5. Snobbish patient.
6. Incomplete history.
7. Incomplete symptoms.
8. Telephonic / Skype consultation.
9. Patient is on other medical lines of treatment.
10. Low susceptibility.

Reference: A Concise Textbook of Obstetrics & Neonatology with Homoeopathic Therapeutics by Dr Trupti M Deorukhkar