Early Pregnancy Care
Before a woman becomes pregnant it is important to check certain things with her that may aid the ease of her pregnancy, some of these are as follows:
- Discuss previous pregnancies and outcome
- Health check including cervical smear (if appropriate and not recently performed as part of cervical screening program)
- Rubella status (and immunisation prior to conception if needed)
- Optimise chronic health conditions e.g. diabetes, epilepsy
- Check medication she is currently on, are any particularly teratogenic? Could these be switched to something else?
- Smoking, alcohol and recreational drug advice
- Folic acid supplementation (0.4 mg/day) to reduce NTD (neural tube defect) incidence
Progesterone and beta HCG levels are used to determine whether someone is pregnant
- Progesterone: blood test, reflects how the maternal body ‘feels’ the pregnancy is doing. The higher it is the more viable the pregnancy and vice versa
- Beta HCG: detected in the urine (over the counter pregnancy test) or in the blood, reflects how the fetus ‘feels’ the pregnancy is doing. The higher it is the more viable the pregnancy and vice versa.
How the hormone levels change over time are more important then the level itself, as the trend will give a much better indication of how the pregnancy is progressing. Therefore repeat testing can be beneficial. If levels of either hormone are rising then the pregnancy is progressing, but if levels of either hormone are dropping then the pregnancy is failing.
This should ideally be performed within the first 10 weeks of gestation. It is used to convey information, gain information from the mother and assess risk. Take this opportunity to clarify cultural and language factors, is there any culture specific wishes you should know about and would an interpreter be helpful?
Key elements from the history need to be assessed including:
- Age - < 17 and > 35 have increased risk of complications
- LMP - to help date the pregnancy
- Past pregnancies - some conditions are known to have a recurrence rate, e.g. pre-eclampsia, gestational diabetes, small foetus, stillbirth and hemorrhage. Who was she looked after in previous pregnancies (midwife led/consultant led - see below)?
- Many conditions are important here including high BP, diabetes, autoimmune and inherited diseases, but also any serious illness (e.g. cardiac/renal). Ask about depression, (past episodes of depression greatly increase the chance of post natal depression)
- Abdominal surgery? Uterine surgery? Cervical smear history?
- DH - any contraindicated in pregnancy? (may need specialist advice, e.g. you often can't just stop an antiepileptic!)
- FH - there are some familial obstetric conditions, including gestational diabetes, pre-eclampsia and problems with clotting
- SH - alcohol, smoking and recreational drugs, always make a point of clarifying relationships here, is there current/a risk of domestic violence?
Alongside the history, height and weight need to be assessed (calculate BMI, >30 associated with increased complications) alongside a baseline BP being taken. VTE (venous thromboembolism) risk assessment should be performed.
Folic acid should ideally be taken from pre conception right through to the end of the first trimester in every pregnancy. Vitamin D should also be supplemented in some cases (e.g. BMI >30, South Asian or Afro Caribbean origin).
Antenatal classes should be discussed and planning pregnancy care should also be covered. Is the woman going to be managed as part of community care or consultant led care? Community care is run by midwives and is the "standard" but in some pregnancies and high risk pregnancies are looked after by both midwives and consultants.
Booking bloods and Other Investigations
FBC, Group and save, serum antibodies, HIV and Hep B, Rubella and Syphilis, blood glucose, haemoglobinopathy (looking for sickle cell disease, thalassemia etc.).
Should also do MSU and urinalysis and offer a chlamydia test.
USS (ultrasound scan) should be arranged for between 10 and 12 weeks as a dating scan. This scan can also be used (if wished) to measure nuchal translucency which when combined with blood levels of beta hCG and PAPPA (pregnancy associated plasma protein A) forms one of the screening options for chromosomal abnormalities. This is known as the combined test, (nuchal translucency + beta hCG + PAPPA). At 28wks repeat FBC, blood glucose and serum antibodies.