Maternal Care and Health Quizzes

Breast Care

• Wash breasts with clean tap water.
• Avoid massaging breasts, as it may stimulate oxytocin release and cause contractions.
• Counsel mothers to be mentally prepared for breastfeeding.

Schedule of ANC

• Check-up every four weeks until 28 weeks gestation.
• Check-up every two weeks until 36 weeks gestation.
• Weekly check-ups until delivery.
• More frequent visits for abnormalities or danger signs.

Laboratory Investigations & Ultrasound

• Routine and specific tests are performed.
• Ultrasound for gestational age estimation, amniotic fluid volume check, placental position check.
• Ultrasound for detection of multiple pregnancies and congenital malformations.
• Ultrasound for fetal position assessment.

Dental Care

• Brush teeth carefully after each meal.
• Encourage regular dental check-ups and cleanings for routine examination.
• Consider local anesthesia if a tooth extraction is required during pregnancy.

Diet

• Daily caloric requirement during pregnancy is approximately 2500 calories.
• Increase vegetable, fruit, protein, and vitamin intake, and decrease fat intake.
• Purpose:
  • Growth of the fetus.
  • Maintenance of mother health.
  • Physical labor strength.
  • Successful lactation.

Exercises

• Implement simple exercises.
• Walking is ideal but prolonged walking should be avoided.
• Avoid lifting heavy objects (mattresses, furniture) to prevent abortion.
• Avoid prolonged standing to minimise varicose veins.
• Avoid crossing legs to maintain good blood circulation.

Cervical Changes

• Softening and enlargement of the cervix (Hegar sign) observed around 6 weeks.
• Chadwick sign (bluish discoloration of the cervix due to venous congestion), observed around 8-10 weeks.
• Note breast changes.

Pregnancy Tests

• Serum pregnancy test: Detects hCG levels between 5 and 10 mIU/mL.
• Quantitative serum pregnancy test: Measures hCG levels as low as 1-2 mIU/mL.
• Urine pregnancy test: Most common office method, detects hCG levels of 20-50 mIU/mL.

Danger Signs in Pregnancy

• Vaginal bleeding (including spotting).
• Persistent abdominal pain.
• Severe and persistent vomiting.
• Sudden gush of fluid from the vagina.
• Absence or decreased fetal movement.
• Severe headache.
• Edema (swelling) of hands, face, legs, and feet.
• Fever above 100°F (37.7°C).
• Dizziness, blurred vision, double vision, painful urination.

False Negative Pregnancy Test Results

• Missed abortion.
• Ectopic pregnancy.
• Too early pregnancy.
• Urine stored too long at room temperature.
• Interfering medications.

Human Chorionic Gonadotropin (hCG)

• Structure: glycoprotein hormone with two glycosylated subunits (alpha and beta).
• Source: syncytiotrophoblast.
• Function: maintains corpus luteum and progesterone production.
• Time: secreted into the maternal circulation after implantation (6-12 days after ovulation).
• Concentration: doubles every 29-53 hours during the first 30 days of a viable intrauterine pregnancy. Slow rise may indicate an abnormal pregnancy.

False Positive Pregnancy Test Results

• Proteinuria.
• Hematuria.
• Time of ovulation (cross-reaction with LH).
• hCG injection for infertility treatment (within 30 days).
• Thyrotoxicosis (high TSH).
• Premature menopause (high LH & FSH).
• Early days after delivery or abortion.
• Trophoblastic diseases.
• hCG-secreting tumors.

Metabolic Changes (Weight Gain)

• Average weight gain during pregnancy: 10-12 kg.
• This gain occurs mainly in the second and third trimesters at a rate of 350-400 grams per week.
• Composition of weight gain: 6 kg maternal tissues (breasts, fat, blood, uterine tissue), 5 kg fetus, placenta, and amniotic fluid.
• Water makes up ~7kg, ~3kg is fat, and ~1kg is protein.

The Uterus

• Size increases.
• Weight increases from 50 grams to 1000 grams at term.
  • Due to hypertrophy and multiplication of muscle fibers (stimulated by oestrogen and progesterone) and increased elastic connective tissue mass.
• Capacity increases.
• Shape becomes globular by the 8th week, pyriform by the 16th week, and remains until term.
• Position ascends from the pelvis and usually rotates slightly rightward (due to colon placement).
• Consistency progressively softens due to increased vascularity and amniotic fluid presence.
• Contractility: irregular contractions (Braxton Hicks) beginning in the first trimester, which are usually painless.
• Uteroplacental blood flow increases progressively to approximately 500 ml/minute at term.
• Formation of the lower uterine segment after 12 weeks (isthmus) to expand gradually.

The Breasts

• Tenderness and tingling in early weeks.
• Increase in size and becoming nodular in the second month due to mammary alveoli hypertrophy.
• Delicate veins become visible beneath the skin.
• Primary areola deepens in pigmentation.
• Nipples become larger, pigmented, and more erectile.
• Montgomery's follicles (hypertrophic sebaceous glands, appear as non-pigmented elevations) appear in the primary areola.
• Colostrum (thick yellowish fluid) can be expressed from the nipples after the third month.
• Pigmented area around primary areola (secondary areola) is apparent in the fifth month.

Respiratory System

• Dyspnea (shortness of breath) may be caused by:
  • Increased respiratory center sensitivity to CO2 (possibly due to high progesterone levels).
  • Diaphragm elevation by the enlarging uterus.

Hematologic Changes (Blood Volume)

• Total blood volume increases steadily from early pregnancy, reaching a maximum of 35-45% above the non-pregnant level by 32 weeks.
• Plasma volume increases by 40%.
• Red blood cell mass increases by 20%, resulting in hemodilution (physiological anemia).

Endocrine System

• Pituitary gland: Anterior pituitary enlarges due to increased prolactin-secreting cells (lactotrophs), Prolactin levels increase to 150 ng/mL at term to support lactation.
• Thyroid gland: Increases in size and T3, T4 levels, as well as T4-binding protein (T4-BP) increases.
• Parathyroid glands: Increase in size and activity to regulate increased calcium metabolism.
• Adrenal glands: Cortex hypertrophy, resulting in increased mineralocorticoids (aldosterone) and glucocorticoids (cortisol).

Urinary System

• Kidneys: Renal blood flow and glomerular filtration rate increase by ~50%.
• Ureters: Dilate due to progesterone relaxation and pressure against pelvic brim by the uterus, especially on the right side.
• Bladder: Frequency of urination increases in early pregnancy due to pressure on the bladder from the enlarging uterus and congestion of the bladder mucosa. Urinary stress incontinence may develop.

Arteries

• Arterial blood pressure usually decreases in the second trimester due to peripheral vasodilatation (progesterone, prostaglandins).
• Posture affects blood pressure (highest sitting, lowest lateral recumbent, intermediate supine).
• Supine hypotensive syndrome—compression of inferior vena cava by the gravid uterus, decreasing venous return, cardiac output, and blood pressure—leads to fainting potential.

Etiology (of Anemia)

• Three main causes of anemia:
  • Decreased red blood cell production (hypoproliferative). Includes Fe deficiency and folic acid deficiency.
  • Vitamin B12 deficiency.
  • Red blood cell destruction or loss.
• 90% of anemia in pregnancy is due to iron deficiency.

Anemia in Pregnancy

• Definition (WHO): 1st trimester/3rd trimester Hb < 11 gm/dL, 2nd trimester Hb < 10.5 gm/dL; Severe anemia Hb < 7gm/dL
• Effects on mother and fetus:
  • Mother: High output cardiac failure (especially in pre-eclampsia), postpartum hemorrhage (PPH), predisposition to infection, delayed recovery after c-section.
  • Fetus: Intrauterine growth restriction (IUGR), preterm birth, delayed cognitive function

Megaloblastic Anemia

• Complicates approximately 1% of pregnancies.
• Characterized by high MCV and altered white blood cell morphology (hypersegmented neutrophils).
• Often caused by folate or vitamin B12 deficiencies (possibly from exposure to drugs like sulfa drugs or hydroxyurea, or anticoagulants).
• Folic acid deficiency can lead to neural tube defects in the fetus.

Common Types of Anemia in Pregnancy

• Nutritional deficiencies (iron, folate, vitamin B12).
• Hemoglobinopathies (thalassemias, SCD).
• Rare types: Aplastic anemia, autoimmune hemolytic anemia, leukemia, Hodgkin's disease.

Investigations (for Anemia)

• Serum iron: decreased in iron deficiency
• Total iron-binding capacity: increased in iron deficiency
• Ferritin: <15 pg/L in iron deficiency anemia (often the first abnormal test).

Management (of Anemia)

• Objectives: Achieve normal Hb levels by the end of pregnancy; Replenish iron stores.
• Methods:
  • Iron supplementation (oral or parenteral).
  • Blood transfusion (in severe cases).
• Choice of method: Depends on anemia severity, gestational age, and additional risk factors.

Beta Thalassemia (Minor and Major)

• Minor: Heterozygous inheritance, mild anemia, normal pregnancy management with iron and folate supplements, avoid parenteral iron, and possible blood transfusion closer to delivery.
• Major: Homozygous inheritance, severe anemia, usually diagnosed in childhood, requires blood transfusions.

Sickle Cell Anemia (SCD)

• Sickling crises frequently occur during or after pregnancy.
• Increased risk of abortion, intrauterine fetal death (IUFD), intrauterine growth restriction (IUGR), premature birth, increased perinatal mortality, and complications (e.g., pain, infections.)
• Treatment: symptomatic, including hydration, analgesia, folic acid, and prophylactic antibiotics. Avoid blood transfusions unless severe. Management during labor should implement strategies for fetal well being, such as comfortable position, adequate analgesia, and oxygen inhalation.

Iron Deficiency Anemia

• Iron requirement during pregnancy: ~1000mg
• Treatment: non-anemic gravidas 30-60mg elemental iron per day, whereas anaemic gravidas require 120–240 mg elemental iron daily. In tolerance to iron tablets, use enteric coated tablets or liquid supplements. Supplementation with folic acid and vitamin C is also recommended.

Septic Abortion

• Signs and symptoms: abdominal pain, fever, bad smelling vaginal discharge, sick/jaundiced appearance, tender uterus, offensive vaginal discharge, cervical dilation.
• Clinical grading: Infection localized within the uterus (Grade 1), beyond the uterus (Grade 2), generalized peritonitis or endotoxic shock (Grade 3.)
• Complications: immediate hemoorrhage, peritonitis, pelvic abscess, endometritis, septicemia, septic/hemorrhagic shock; late post-infection complications include Pelvic Inflammatory Disease (PID), pelvic adhesions, infertility.

Abortion

• Termination of pregnancy before the fetus is capable of extra-uterine survival (e.g. ~20 weeks/500gm).

Blighted Ovum

• Empty gestational sac without fetal development.

Any Vaginal Bleeding Before 20 Weeks

• Early-pregnancy bleeding, needs to be investigated.

Types of Abortion

• Spontaneous: isolated (i.e. threatened, inevitable, complete, incomplete, missed, septic abortion); recurrent abortion (habitual abortions, miscarriages, recurrent miscarriages)
• Induced: Legal or illegal abortion

Etiology (of Abortion)

• Genetic factors.
• Endocrine factors.
• Anatomic causes (including congenital abnormalities), infectious causes, or immunological problems.

Complete vs. Incomplete Abortion

• Complete: expulsion of all products of conception, cessation of bleeding and pain, empty uterus on ultrasound. Management involves anti-D immunoglobulin.
• Incomplete: incomplete expulsion of products of conception, ongoing bleeding and pain, incomplete uterus on ultrasound. Management involves further treatment for expulsion of the retained parts.

Recurrent Miscarriage

• Defined as 3 or more consecutive pregnancy losses.
• Other names: habitual abortions, habitual miscarriages, recurrent abortions, recurrent miscarriages.

Ectopic Pregnancy

• Fertilized ovum implants and develops outside the normal uterine cavity.

Complete Hydatidiform Mole

• "Snowstorm" appearance on ultrasound.
• Multiple placental vesicles.

Causes of Bleeding in Early Pregnancy:

• Ectopic pregnancy.
• Abortion.
• Hydatidiform mole.
• Related to pregnancy state (e.g., cervical lesions/erosions, polyps, or malignancy, ruptured varicose veins, or implantation bleeding).

Antepartum Hemorrhage

• Definition: vaginal bleeding after 24 weeks of gestation and before delivery.
• Classification: Spotting (mild <50mL), Major (50-1000mL), Massive (>1000mL).
• Complicates ~3-4% of pregnancies.
• Obstetric emergency.

Etiology of Antepartum Hemorrhage

• Placental abruption: Premature separation of the placenta from the uterine wall. Characterized by PAIN.
• Placenta previa: Placenta partially or completely covering the internal os. Characterized by PAINLESS blood.
• Vasa previa: Umbilical vessels are implanted in/through the membranes, resulting in bleeding at the time of rupture of the membranes or earlier. Characterized by bleeding after ROM, fetal distress, and bradycardia.)
• Other causes: cervical bleeding (cervicitis, neoplasm, polyps, trauma or infection).

Examination (of Antepartum Hemorrhage)

• Vital signs (pulse, blood pressure).
• Uterine examination (tenderness, firmness).
• Fetal heart rate/CTG.
• Speculum examination (to document cervix/vaginal bleeding). Ultrasound (to assess placenta previa and other causes.)

Initial Investigations (of Antepartum Hemorrhage)

• CBC (complete blood count)
• DIC workup
• Coagulation studies (platelets, PT, PTT, fibrinogen, D-dimer)
• Blood type and crossmatch.
• Ultrasound (to exclude placenta previa or other conditions).

Placental Abruption Classifications

• Mild: detectable separation of only a small % of the placenta, normal fetal heart rate
• Moderate: moderate separation, tachycardia/variability, mild late decelerations seen in fetal heart rate
• Severe: significant separation, severe late decelerations/bradycardia, high chance of fetal death

Placenta Previa

• Characterized by painless late-trimester bleeding.
• Pathophysiology: avulsion/stretching of the villi of the abnormally implanted placenta.
• Classifications grade 1 (lateral), grade 2 (marginal), grade 3 (partial), grade 4 (complete).
• Possible causes: Prior cesarean deliveries, prior placenta previa, multiple gestation.

Predisposing Factors for Placenta Previa

• Multiple gestation.
• Previous Cesarean section.
• Advanced maternal age (>40 years old).
• Multiparity.
• Previous placenta previa.
• Assisted conception.
• Endometritis.
• Uterine structural abnormalities (e.g., septate uterus).
• Smoking
• Fetal congenital anomaly or malpresentation.

Grading of Placenta Previa

• (1) Lateral/ (2) Marginal: Placental implantation in the lower segment of the uterus, not reaching the internal os.
• (3) Partial: Placenta partially covers the internal os.
• (4) Complete: Placenta completely covers the internal os.
• Grade 1 and 2: considered "minor PP".
• Grade 3 and 4: considered "major" PP.

Management of Placenta Previa/Abruption

• General approach: Depends on the severity of bleeding, gestational age, and condition of mother and fetus.
  • Emergency: C-section, vaginal delivery.
  • Conservative: in-hospital management.
• Important considerations:*
• - Fetal well-being*
• - Maternal stability*

Test your knowledge on essential maternal care practices, including breast care, antenatal check-ups, laboratory investigations, dental care, and dietary needs during pregnancy. This quiz covers a variety of important topics to help ensure the health of both mother and baby.