Dietary Guidelines For Pregnant Ladies

Pregnancy is a normal physiological condition during which a baby is growing inside the mother's womb. There are different hormonal changes causing taste changes, food cravings and associated nausea, vomiting or gastrointestinal issues. During pregnancy the nutritional requirements are increased to meet the demands of the body for proper growth and development of the baby. 

Positive nutritional support during pregnancy leads to a good outcome for both mother and baby. 

Eating a balanced diet is very important and never think of starving yourself to avoid weight gain during pregnancy. 

A basic guideline is given is given below: 

- Consume a diet containing vegetables, fruits, and whole grains. 

- Take Vitamin supplements as prescribed by your doctor.

- Vitamin A containing supplement should be avoided especially during the first 3 months. 

- Drink 1-2 cups of fresh milk daily. If you like drinking flavored milk you can enjoy adding your preferred flavors.

- Avoid caffeine containing drinks. 

- Soak 7-9 almonds overnight and eat them with 3 dates in morning. 

- Take a cup of yogurt with bread or parahata (Asian bread ) 

- Eggs are safe and good source of protein. Take in any form you like boiled, omellete etc. 

- Oatmeal is healthy and helps with preventing constipation. 

- Morning sickness is common during the first 3 months, to prevent vomiting don't stay with an empty stomach, take some crackers or wheat biscuits' when you wake up in the morning. 

- Avoid taking too much liquid during mealtimes.

- Avoid foods with strong odors. 

- Drink coconut water or lemon drink whenever easily available.

- Eat proper meals containing meat, vegetables or lentils . Take small frequent meals if you face any digestive issues. 

- Totally avoid soft drinks. 

- No alcohol and No smoking. 

- Drink 8-10 glasses of water daily. 

- Avoid spicy and oily foods.

- Diet needs to be modified if you suffer from any other medical condition or gestational diabetes.

Have a safe and heathy pregnancy. 

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Routine Prenatal Care

The objective of prenatal care is to optimize the outcome for both mother and baby. This is achieved through a series of visits with the mother during which history, physical examination, laboratory and other measurements, and patient education all are essential parts.

On the first visit, the last menstrual period is ascertained to date the current pregnancy. In addition, the patient is questioned about previous pregnancies, ethnic background, current problems, current medications, and medical, social, psychosocial, nutritional, and family history. Also on the first (or an early) visit, the mother is given a screening physical examination and a full pelvic examination including estimation of uterine size and clinical pelvimetry. Her weight and height are recorded, and blood pressure measured. Urine is examined for protein and glucose and may also be screened for bacteriuria. Standard blood studies include complete blood count, Venereal Disease Research Laboratory test (VDRL) for syphilis, rubella antibodies, hepatitis B surface antigen, blood type and Rh, and red cell antibodies.

Down’s Syndrome Screening- A Brief Introduction

Down’s syndrome screening
The screening procedures offered currently in most of the countries are listed here. Each consists of a risk assessment based on maternal age and a scan performed in the first trimester or a blood test in the first or second trimester or a combination of scans and blood test.

Triple test
Done in early second trimester (14–20 completed weeks). This test is based on the measurement of

1. α-fetoprotein,
2. unconjugated oestriol (uE3) and 
3. hCG (either total hCG or free β-hCG)

together considering the maternal age.

Nuchal translucency scan
A first trimester (11–13 weeks) test is based on the measurement of the fold of skin on the back of the fetal neck.

Quadruple test
Early second trimester (14–21 weeks) test is based on the measurement of

1. α-fetoprotein, 
2. uE3, 
3. free β-hCG (or total hCG) and 
4. inhibin-A 

together considering the maternal age.

Combined test
Late first trimester (10–13 weeks) test is based on combining NT measurement with free β-hCG, pregnancy associated plasma protein-A (PAPP-A) and maternal age.

Integrated test
This is the integration of different screening markers measured at different stages of pregnancy into a single test result. Unless otherwise qualified, ’Integrated test’ refers to the integration of NT measurement and PAPP-A in the first trimester with serum α-fetoprotein, β-hCG and uE3 in the second.

Recurrent Miscarriage - Causes And Workup

Recurrent miscarriage (RM), which is defined as three or more consecutive miscarriages, is relatively uncommon – affecting about 1 to 2% of couples who conceive.

Three strands of evidence supports that Recurrent Miscarriage is a distinct clinical entity rather than one which occurs purely by chance alone.

1. First, the observed incidence of RM is significantly higher than that expected by chance alone (0.4%); 
2. second, a woman’s risk of miscarriage is directly related to the outcome of her previous pregnancies ; and 
3. third, in contrast to sporadic miscarriage, women with RM tend to lose pregnancies with a normal chromosome complement, suggesting the presence of a persistent underlying cause for pregnancy loss among these women.

Despite major advances in medicine the understanding of the cause of RM is sometimes not clear and even after comprehensive investigation, no cause for pregnancy failure is identified in approximately 50% of couples. This has led to the situation where women with RM have been, and continue to be, subjected to investigations and treatments based on trial and error approach. 

Contemporary investigative screen for recurrent miscarriage:

• Male and female parental blood karyotypes
• Lupus anticoagulant
• IgG and IgM anticardiolipin antibodies
• FactorV genotype
• FactorII genotype
• Activated protein C resistance
• Pelvic ultrasound to determine ovarian morphology and uterine anatomy
• Early follicular phase FSH
• Insulin resistance status

Rh(D) Immunoglobulin / Anti D Immunoglobulin - Uses And Dose.

Rho(D) immune globulin is a medication used to prevent Rh isoimmunization in mothers who have a Rh negative blood group. 

When a a woman with RhD negative blood is exposed to RhD positive blood in pregnancy she can develops an immune response to it and develop anti D antibodies. In later pregnancies, anti-D antibodies can cross the placenta, causing rhesus haemolytic disease in the Rh positive fetus, and is worsened with subsequent pregnancies. 

Rhesus disease can largely be prevented by giving an injection of a medication called anti-D immunoglobulin to the Rh negative mother.

The anti-D immunoglobulin neutralizes any RhD positive antigens that may have entered the mother’s blood during pregnancy. If the antigens have been neutralized, the mother’s blood won't produce antibodies.

It is often given both during and following pregnancy. 

Indications

• Following potentially sensitizing events in pregnancy, it is recommended that anti-D Ig should be administered as soon as possible and always within 72 hours of the event.
• If, exceptionally, this deadline has not been met, some protection may be offered if anti-D Ig is given up to 10 days after the sensitizing event.
• It may also be used when Rh negative people are given Rh positive blood.
• Anti D Immunoglobulinis also used to treat idiopathic thrombocytopenic purpura (ITP) in people who are Rh positive.

Spontaneous Miscarriage - The New Classification And Management

Introduction
Spontaneous miscarriage is one of the commonest complication of early pregnancy. It occurs in approximately 15–20% of all pregnancies.
It is important to take a good clinical history in every case of pregnancy loss and classify the type whenever possible.
Increasing knowledge about early pregnancy development, with the more widespread availability of measurement of serum Beta HCG (human chorionic gonadotrophin) , the advent of high resolution ultrasound and a clearer description of gestational age at pregnancy loss make for a more sophisticated assessment of miscarriage history.

Diagnosis
Role of ultrasound
The first demonstration of an intrauterine pregnancy by means of transvaginal ultrasound was reported in 1967. Major improvements in ultrasound resolution since then have revolutionized the assessment and management of early pregnancy problems.

Ultrasound plays a major role in maternal reassurance, where fetal cardiac activity is seen and is pivotal in the assessment of early pregnancy complications, such as vaginal bleeding. 

However, there are limits to ultrasound resolution of normal early pregnancy development.

• Expert advice concludes that the diagnosis of an empty gestation sac can only be made when the mean gestation sac diameter is greater than 20 mm, and that the crown–rump length must be 6 mm or greater before one can say for certain that fetal heart activity is absent. 
• If measurements are below these thresholds a repeat transvaginal ultrasound examination after at least a week should be offered . 

Ultrasound features such as a sac that is much smaller than expected from a certain last menstrual period; a sac that is low in the uterus or the presence of fetal bradycardia are strongly suggestive but

not diagnostic of impending miscarriage. In addition, the possibility of incorrect dates should always

be remembered by the alert clinician. Wherever possible, the term ‘missed abortion’ should be replaced by ‘delayed miscarriage’.

The impact of a diagnosis of a miscarriage should not be underestimated. It is recommended that ‘Early intrauterine death should be regarded as of equal significance to fetal death occurring at a later stage.’ It is therefore important that within an area where early pregnancy scans are performed, there is a quiet room for counselling, and staff working within this setting should have training in the emotional aspects of early pregnancy loss.

Modern classification of pregnancy loss type

The revision of early pregnancy nomenclature is both desirable and essential in raising the standard of reporting.

Pre-Pregnancy Counselling

Introduction
It is important that the parents to be should plan for a pregnancy under conditions most likely to ensure a best outcome for both the mother and the baby.

The following points should be considered during a counselling to a couple who are planning to get pregnant.

1. Reduce weight if obese .
2.Ensure the woman is immune to rubella prior to pregnancy.
3.Optimal control of chronic disease (like  diabetes) before conception. This is also important for hypothyroidism as the fetus cannot make thyroxine until 12 weeks and under-replacement may affect neurodevelopment.
4.Strict diet is  essential peri-conceptually for women with phenylketonuria (PKU).
5. Stop teratogens (drugs and alcohol that may lead to fetal abnormalities) or seek expert advice prior to conception .
6.Start Medication to protect the fetus from abnormality (e.g folate supplements for neural tube defects).

Chorionic Villus Sampling

It is one of the obstetric procedures and is summarized as follows:

Procedure:
-This is a diagnostic outpatient office procedure performed under ultrasound guidance without anesthesia.
-The catheter is placed directly into the placental tissue without entering the amniotic cavity.
-Chorionic villi, which are placental precursors, are aspirated from a pregnant uterus between 10 and 12 weeks’ gestation.
-The tissue is sent to the laboratory for karyotyping.
-The chromosomes of the villi are almost always identical to those of the embryo.

Nature of Tissue Obtained:
The procedure can be performed either transcervically or transabdominally. Since the fetus and chorionic villi are both derived from a common origin (the zygote), their karyotype is identical more than 99% of the time.

Placenta Previa - A Low Lying Placenta

With placenta previa, the placenta is implanted in the lower uterine segment, where it encroaches on the internal cervical os. This disorder, one of the most common causes of bleeding during the second half of pregnancy, occurs in approximately 1 in 200 pregnancies, more commonly in multigravidas than in primigravidas. Generally, termination of pregnancy is necessary when placenta previa is diagnosed in the presence of heavy maternal bleeding. Maternal prognosis is good if hemorrhage can be controlled; fetal prognosis depends on gestational age and amount of blood lost.

Causes
With placenta previa, the placenta may cover all (total, complete, or central), part (partial or incomplete), or a fraction (margin or low-lying) of the internal cervical os. The degree of placenta previa depends largely on the extent of cervical dilation at the time of examination because the dilating cervix gradually uncovers the placenta. Although the specific cause of placenta previa is unknown, factors that may affect the site of the placenta’s attachment to the uterine wall include:

• defective vascularization of the decidua
• multiple pregnancy (the placenta requires a larger surface for attachment)
• previous uterine surgery
• multiparity
• advanced maternal age.

With placenta previa, the lower segment of the uterus fails to provide as much nourishment as the fundus. The placenta tends to spread out, seeking the blood supply it needs, and becomes larger and thinner than normal. For unknown reasons, eccentric insertion of the umbilical cord often develops. Hemorrhage occurs as the internal cervical os effaces and dilates, tearing the uterine vessels.

Signs and symptoms
Placenta previa usually produces painless third-trimester bleeding (typically the first complaint). Because of the placenta’s location, various malpresentations occur that interfere with proper descent of the fetal head. (However, the fetus remains active, with good heart tones.) Complications of placenta previa include shock or maternal and fetal death.

Diabetic In Pregnancy- A Brief Discussion

Pregnancy places special demands on carbohydrate metabolism and causes the insulin requirement to increase, even in a healthy woman. Consequently, pregnancy may lead to a prediabetic state, to the conversion of an asymptomatic subclinical diabetic state to a clinical one (gestational diabetes occurs in about 1% to 2% of all pregnancies), or to complications in a previously stable diabetic state.
Prevalence of diabetes mellitus increases with age. Maternal and fetal prognoses can be equivalent to those in nondiabetic women if maternal blood glucose is well controlled and ketosis and other complications are prevented. Infant morbidity and mortality depend on recognizing and successfully controlling hypoglycemia, which may develop within hours after delivery.

Causes
In diabetes mellitus, glucose is inadequately used either because insulin isn’t synthesized (as in type 1, insulin-dependent diabetes) or because tissues are resistant to the hormonal action of endogenous insulin (as in type 2, non–insulin-dependent diabetes).

Protective mechanisms
During pregnancy, the fetus relies on maternal glucose as a primary fuel source. Pregnancy triggers protective mechanisms that have anti-insulin effects: increased hormone production (placental lactogen, estrogen, and progesterone), which antagonizes the effects of insulin; degradation of insulin by the placenta; and prolonged elevation of stress hormones (cortisol, epinephrine, and glucagon), which raise blood glucose levels.
In a normal pregnancy, an increase in anti-insulin factors is counterbalanced by an increase in insulin production to maintain normal blood glucose levels. However, women who are prediabetic or diabetic can’t produce sufficient insulin to overcome the insulin antagonist mechanisms of pregnancy, or their tissues are insulin-resistant.
As insulin requirements rise toward term, the patient who is prediabetic may develop gestational diabetes, necessitating dietary management and, possibly, exogenous insulin to achieve glycemic control. The insulin-dependent patient may need increased insulin dosage.

What Is Chemical Pregnancy ?

Introduction:
A chemical pregnancy is actually a very early miscarriage which takes place at a time when ultrasound scan could not show a gestational sac. The only evidence that indicates that the woman got pregnant is that she gets a positive pregnancy test which was done at a very early time.

The excitement of getting a positive pregnancy test usually ends up with getting a period shortly after or b y a negative test when the test is repeated.

Pathophysiology:
A chemical pregnancy occurs when an egg is fertilized but it does not implant on the uterine wall. As a result of fertilization the pregnancy hormone beta HCG starts to be produced in the body. Measuring this hormone in the blood or urine is the first documentation of being pregnant and since a number of pregnancy tests available in the market today can detect this hormone at a very early stage the woman thinks she is pregnant but since the implantation fails this very early miscarriage occurs at a time just around the expected time of periods and without the gestational sac being formed.

Causes:
There are a number of possible cause and is very common and usually goes unidentified since not all woman take a pregnancy test that early.

• Inadequate uterine lining.
• Low hormone levels
• Luteal phase defect
• Infections
• Chromosomal abnormalities in the fertilized ovum
• Unknown reasons

Intrauterine Fetal Demise (IUFD)

Intrauterine fetal demise (IUFD) refers to fetal death prior to delivery and may occur at any time prior to delivery.

The timing of the IUFD is important for the physician to appreciate both for consoling and advising the parents and for anticipating the likelihood of successful neonatal resuscitation after delivery. The appearance of the fetus at delivery can be used to estimate whether the fetal demise occurred
antepartum or peripartum.
The process of tissue degeneration (maceration) is due to the effects of autolytic enzymes on the fetus in a sterile environment.

• Lysis occurs at the epidermal- dermal junction with subtle changes in the gross appearance of the fetus.
• Skin desquamation and positive Nikolsky sign can be seen as early as 6 hours.
• Further changes involve desquamation and bullae formation of the face, back, or abdomen by 12 hours, at least 5% of the body surface at 18 hours, and generalize skin desquamation at 24 hours. 
• Sloughing of skin from a large area indicates a prolonged interval between death and delivery. 
• Mummification occurs after approximately 2 weeks.

Management: