First Trimester, Second and Purpeurium → Antenatal😊😍

Antenatal Care & Vaccinations

Gravida & Parity

• Gravida:
• Total number of times a female has conceived
• Includes: Past + present pregnancies

• Parity:
• Number of pregnancies that have crossed period of viability (i.e. 28 weeks)
• Present pregnancy: Not included

• Multipara: ≥2 previous births

• Grand multipara: ≥5 previous births

• Note: Twins/Triplets: Counted as 1 in gravida and parity

Representation

• G a Pb:
• a: Gravida
• b: Parity

• G a Pb+c:
• a: Gravida
• b: Parity
• c: Number of abortions
• Pregnancy loss at ≤20 weeks which includes:
1. Abortion,
2. MTP
3. Ectopic pregnancies
4. Molar pregnancies

• GTPAL: Gx PT+P+A+L
• x: Gravida
• Twins/Triplets = 1 (for G and P)
• T: Number of term deliveries
• P: Number of preterm deliveries
• A: Number of abortions
• L: Number of living children at present (Twins = 2, triplets = 3)
• Mnemonic: TaPAL

Vaccination In Pregnancy

Vaccines Absolutely C/I In Pregnancy

• Mumps

• Measles

• Rubella

• Small pox

• Chicken pox

• BCG

• HPV

• Mnemonic: MMR, Small chicken, BC HP

Hepatitis B mothers

• New born baby vaccination
• Hepatitis B vaccine and immunoglobulins
• WITHIN 24 HRS

Caloric Requirement

RDA Update (2020)

variable	Sedentary worker	moderate worker	Heavy worker
Female	1660 Kcal	+ 500	+ 600
Male	2100 Kcal	+ 600	+ 700
ㅤ	21 yr male 16 year old female	ㅤ	ㅤ

• 1 Kcal = 4.184 KJ

Macronutrients

• Pregnancy : Average +350 Kcal/day

• Trimester Kcal/day

Trimester	Calorie (Kcal/day)	Protein (g/day)
Non-pregnant	• 1660	• 45
ㅤ	Additional	ㅤ
1st Trimester	• 70–80 OR • No additional calorie requirement	• Nil
2nd Trimester	• 280	• + 10g
3rd Trimester	• 450	• +20g

• Lactation:
• 0 to 6 months: + 600 Kcal/day
• 6 to 12 months: + 520 Kcal/day

• Carbs in females:
• Non-pregnant: 130 g/day .
• Pregnant: 175 g/day .
• Lactating: 200 g/day .

• Fat req:
• 28 g/day

Micronutrients

• Sodium: 2000 mg/day (5g of salt)
• Double of calcium

• Potassium: 3500 mg/day.
• Triple of calcium

• Iodine (I2) req. : 250 mcg/day.

• Vitamin A = Calcium

ㅤ	male	Non-pregnant female	Pregnant	Lactating
Iron (mg/day)	19	29	27	23
Vitamin A (mcg/day)	1000	850	900	950
Folic acid (mcg/day)	-	220 (200)	570 (600)	330 (300)
Calcium (mg/day)	1000	1000	1000	1200

Nutritional Requirement ↑

• During pregnancy:
• Iron, Folic Acid, Protein, Zinc

• During lactation:
• Calcium, Vitamin A, Iodine, Vitamin C, Carbohydrate
• Ac yil irunn choru thinn paalu kudikkanam

• Iodine requirement in pregnancy
• 280 µg/day

• Iodine requirement for children
• 90-120 µg/day

Recommended Weight Gain in Pregnancy

• In normal BMI females: 11-12.5 kg

• In females with low BMI (Thin females): 12.5 - 18 kg

• In females with BMI >30 (Obese): 7 kg (5 - 9 kg)

Investigations Done At 1st Antenatal Visit

• ABO, Rh typing

• Hb (Checked at least 4 times in pregnancy), Hematocrit

• VDRL

• HbsAg

• Urine R/M

• HIV testing: Opt-out approach (Patient can refuse)

• DIPSI (Diabetes in Pregnancy Study Group India → OGTT)
• Repeat at 24-28 weeks

• Group B Streptococcus: 35-37 weeks (Rectovaginal swab taken)

Additional tests (Voluntary)

• TSH

• Aneuploidy

• If Rh-ve: Husband’s Rh typing, Indirect Coombs’ test

Antenatal Visits

• Ideal:
• 11-15
• Till 28 weeks: 1 visit/4 weeks
• 28-36 weeks: 1 visit/2 weeks
• ≥36 weeks: 1 visit/week

• Minimum Visits
• WHO: 8
• Government of India: 4

Arjun (32/M) visits your clinic for a routine health examination along with his wife (28/F). Arjun weighs 65 kgs and leads a mostly inactive lifestyle. His wife, who is in her second trimester, weighs 55 kgs and is currently pregnant. She also has a sedentary lifestyle. In accordance with the ICMR 2020e, what is the recommended calorie intake for Arjun and his wife individually?

First Trimester Screening (11 to 13 weeks + 6 days)

Aneuploidy screening:

• Universally done in all pregnant females, irrespective of maternal age.

Dual Test:

• Note: In Down's: hCG is increased (↑), rest all parameters are decreased (↓).

• If Dual test positive → Next step
• USG: Nuchal translucency → Called as combined test (Better sensitivity)

USG In Pregnancy

Modality Timing

• Dating/Viability scan: 6-8 weeks

• Nuchal Translucency scan (NT scan): 11 to 13 weeks + 6 days

• Anomaly scan/target scan (TIFFA/Level 2 scan):
• Mandatory in all pregnant females
• 18 to 20 weeks (Can be extended up to 22 weeks)

• Growth scan: 32 & 34 weeks

• Placental localization: 32 weeks (Repeat at 36 weeks)

• Fetal Echo (Only if CHD is suspected in the fetus): 20 & 24 weeks

NT Scan

• Also known as Nasal bone NT scan.

• 1st Trimester screening for Down's Syndrome.

• Performed at 11 - 13 weeks + 6 days

NT should be measured:

1. Mid sagittal plane.

2. Between >11 & < 14 weeks or
   when CRL <84 mm.

3. Head should be in neutral position.

4. From inner border to inner border.

5. Amnion should be visible separately.

---

Combined Test:

• Dual test + USG Nuchal translucency (better sensitivity)

Findings increasing risk of Down's syndrome:

• Nuchal Translucency Thickness.
• Increase in >3mm
• Note: x 2
• 2nd trimester → Nuchal fold thickness ≥ 6mm

• Nasal Bone.
• Absence

• Finding is not specific

• Karyotyping is performed to confirm.

If NT ≥3 mm:

• Next step: Karyotyping (Diagnostic)
• In T1 material obtained by: Chorionic villi sampling

• Euploid → Fetal ECHO

• Mnemonic: Do (dual test) not (NT) cry (karyotyping)

Causes of ↑ nuchal translucency (NT ≥3 mm):

• Mnemonic: Nude (NT) Anu (aneupoidy) sister (cystic hygr) has heart (heart ds) disease (diaphragmatic hernia)
1. Aneuploidy (M/c):
2. Congenital heart defects of fetus
3. ↑NT in twins: Early marker for Twin to Twin Transfusion Syndrome (TTTS)

Differential Diagnosis (D/D) of NT:

• Cystic hygroma
• Cystic hygroma is a better marker of aneuploidy than nuchal translucency.
• More fluid collection.
• More widespread.
• Septa may be seen

Estimation Of Gestational Age

• Earlier the timing of USG: ↑Accuracy of estimating gestational age

Trimester Best Parameter

• T1: Best time → CRL > MSD

• T2/CRL ≥84mm: BPD > HC

• T3: Femur length

Crown rump length (CRL)

• Can be used till: 13 weeks + 6 days (Till CRL <84 mm)

• Most accurate gestational age: Determined by CRL b/w 7-9 weeks

• CRL + 42: Gestational age in days

• Smallest measurable CRL: 5 mm

Abdominal Circumference

• Best USG parameter for fetal growth

• Plane of measurement: Measured when all three structures visible together

• Hockey stick sign




1. Fetal stomach
2. Portal sinus
3. Umbilical vein

• Note: Fetal weight estimation.
• a. Best clinical formula: Johnson formula
• Above station 0
• [Fundal height - 12] x 155g
• Below station 0
• [Fundal height - 12] x 155g
• b. Best method: Hadlock formula/Shepard formula
• Mnemonic: John (Johnsons) had (Hadlock) shepherd (Shepard)

Structures seen on USG in Pregnancy

• Order of appearance: G. sac → Yolk sac → Fetal pole (CRL) → Cardiac activity

• Note: β HCG: Best parameter to differentiate b/w ectopic & intrauterine pregnancy

• Gestational sac:
• Only indicates pregnancy
• Intrauterine pregnancy: True gestational sac
• Ectopic pregnancy: Pseudo gestational sac

• G. sac + Yolk sac:



• Inside the uterus → Intrauterine pregnancy
• Inside the fallopian tube → Ectopic pregnancy

Important Cut-offs

• MSD to measure CRL: 25 mm

• CRL to get cardiac activity: 7 mm

• HCG to see gestational con TVS (Critical titre): 2000 IU

• Minimum value of HCG at which G. sac is seen: 1000 IU

Scenarios And Protocols

• G. sac (Confirmatory):
1. MSD ≥25 mm & CRL cannot be measured:
• Missed abortion (Anembryonic pregnancy loss)
• MTP
2. MSD <25 mm & CRL not seen:
• Wait & watch
• Repeat USG after 1 week
3. CRL ≥7 mm & cardiac activity -:
• Missed abortion
• MTP
4. CRL <7 mm & cardiac activity -:
• Wait & watch
• Repeat USG after 1 week

Anomalies Detected On Level 1 Scan

Neural Tube Defects

• Most common congenital abnormality of neurologic system in children.

• Types
• Cranial + Caudal defect:
• Craniorachischisis
• Caudal defects:
• Meningocele,
• Meningomyelocele
• Cranial defects:
• Anencephaly
• Encephalocele (Herniation of brain tissue through a small defect covered by scalp, hair and meninges)

Diagnosis:

• Antenatal USG: Can pick up large NT defects.

• Maternal serum or Amniotic fluid markers.

• α-fetoprotein levels or Acetylcholinesterase levels.

• Neuroimaging to know extent

Anencephaly

• Failure of closure of the rostral or anterior neuropore
• By 4 weeks of life
• (the opening of the anterior neural tube).

• Brain tissue exposed to external environment

• Earliest anomaly detected on USG.

• Presents with Frog Eye Sign.

• Open calvarium is present.

• MTP needed.

Features:

• 1st anomaly to be detected on USG

• Earliest detected by 10 weeks

• Best detected by 14 weeks

Diagnosis:

• Screening test: Level 1 scan

• Diagnostic test: Level 2 scan

• Best biochemical marker:
• Acetylcholinesterase levels

USG Signs:

• Shower cap sign (Exposed brain tissue)

• Frog eye sign (Bulging eyes)

• Mickey mouse sign (Triangular face)

• Exposed brain tissue

• Deep eye sockets

Management:

• MTP

Spina Bifida

• USG Signs:
• Banana sign:
• Downward displacement of cerebellum
• Lemon sign:
• Bossing of frontal bones

• Meningocele: Herniation of meninges

• Meningomyelocele: Herniation of meninges & spinal cord

Duodenal Atresia

• Features:
• Defect in swallowing
• A/w Down’s syndrome

• USG: Double bubble sign

• Note:
• Gross Congenital Anomalies: Best detected on level 2 scan
• Best time to check maternal serum AFP: 16-18 weeks

Posterior Urethral Valve

• A/w: Oligohydramnios

• USG: Keyhole sign

Second Trimester Screening

• 15 - 20 weeks
• Abort before 20 weeks

A. Biochemical method:

• In Down's syndrome
• β Hcg and Inhibin ↑

Double test + NT = First trimester

• 11 - 13 weeks

• Include
1. Alpha feto protein: (↓)
2. HCG: (↑)

Triple test/ Bart / Kettering test:

• 15 - 22 weeks

• HAE
1. HCG: (↑)
2. Alpha feto protein: (↓)
3. Unconjugated E3: (↓)

Quadruple test:

• I Am
• Add: Inhibin - A: (↑)
• aka BART / KETTERING TEST

Integrated test:

• PAPP-A in T1 +

• USG for NT + Quadruple test in T2

Combined Test:

• Dual test + USG Nuchal translucency (better sensitivity)

Findings increasing risk of Down's syndrome:

• Nuchal Translucency Thickness.
• Increase in >3mm
• Note: x 2
• 2nd trimester → Nuchal fold thickness ≥ 6mm

• Nasal Bone.
• Absence

• Finding is not specific

• Karyotyping is performed to confirm.

B. USG: Soft tissue markers

• Any of the above present: Screening positive
• Nuchal fold thickness ≥ 6mm
• Absent nasal bone
• Short femur/humerus
• Sandal gap
• Duodenal atresia (Double bubble sign)
• Echogenic intracardiac focus
• Echogenic bowel
• Choroid plexus cyst

• Note: 
• Most common heart disease in Down's syndrome:
• Endocardial cushion defect

Second Trimester Screening Steps

• If screening is positive (T1 or T2)

If first screening is positive

1. Secondary screening test
• Non-invasive prenatal testing (NIPT)
• (Secondary screening test)
• If negative: Rule out Down's syndrome
• If positive (+): Must do karyotyping

2. Diagnostic test
• Karyotyping (Invasive test)

NIPT:

• Secondary screening test

• Best screening test

• Done beyond 10 weeks

• Does not give full karyotyping

• Cell free fetal DNA
• From Placental Cell Apoptosis
• Sample: Maternal blood
• Time: ≥10 weeks
• Sensitivity: 99%

• Drawback:
• Very expensive
• Only for high risk patients

Methods of Obtaining Genetic material

Puerperium

Lochia

• Shedding of decidua after delivery.

• Average duration: 1 month +/- 6 days

• Sequence of lochia:
• Lochia Rubra (Up to ≥4 days) → Lochia serosa (Up to ≥10 days) → Lochia alba (Up to ≥21 days)

• Placental site after delivery
• The complete regeneration takes 6 weeks

Uterine Involution