Gynaecological Conditions

Normal Pregnancy

This is a transient physiological state during a woman’s reproductive years, but it requires important considerations regarding diet, life-style and drug therapies to achieve a good foetal outcome with minimal maternal morbidity and mortality.

Treatment

Instruct the woman regarding

1. Diet: Caloric requirements depends on the physical work done by the women. The increased requirement of 300 Cals. For the pregnancy state is to be made available by exogenous supply of diet. An ideal pregnancy diet should be light, nutritious, easily digestible and rich in proteins, vitamins and minerals. The diet should consist of at least half-a-litre if not one litre of milk, plenty of green leafy vegetables (one katori serving in each meal) and fruits as available, in addition to normal Indian diet consisting of a balanced cereals and pulses combination. Foods rich in iron like green vegetables, jaggary, and protein rich foods like nuts should be stressed upon. Fat consumption can be predominantly of animal source so as to take care of vitamins A & D.
2. Exercise: Any exercise, the woman is accustomed to can be continued, but not to the point of fatigue. No new exercise should be initiated during pregnancy. Sedentary women should be allowed only walking. Women with multiple foetuses and complications like heart disease, pregnancy induced hypertension, intrauterine growth
   retardation should not exercise.
3. Clothing: Should be non-constricting.
4. Travel: Road travel is allowed with safety belt. Traveling in a pressurized aircraft is of no risk, should walk about every 2 hours.
5. Employment: Jobs requiring prolonged standing (> 8 hours/day) are associated with a minimum risk of pre-term delivery.
6. Clinical workup during each antenatal visit – BP, weight-gain, oedema feet, symphyseal-fundal height, presentation, fetal heart rate(s), amniotic fluid volume, inquiry about daily foetal movement charting, and pelvic assessment at 38 weeks. Rh -ve women (with Rh +ve husband) need to be monitored on similar lines with additional testing with Indirect Coomb’s test (ICT) at first visit, 28 weeks and 34-36 weeks. Antenatal Anti D immunoglobulin 100 mcg IM is recommended in ICT negative patients at 28 weeks of pregnancy and postpartum 350 mcg IM if baby is Rh +ve. ICT +ve patients are to be managed only at centres with facilities for amniocentesis and/or cordocentesis, amniotic fluid optical density estimation and intrauterine foetal transfusions.
7. Lab workup during pregnancy as follows:
   

   Gestational Age	Lab Assessment
   Initial (as early as possible)	- Haemoglobin - Urine (routine & Microscopy) - Blood groups and Rh typing - Screen for syphilis - Hepatitis B infection screening - HIV screening (Ethical issues) - Cervical cytology
   16-18 weeks	- Ultrasound for foetal anomalies
   26-28 weeks	- Haemoglobin - Diabetes screening
   32-36 weeks	- Ultrasound - Haemoglobin

8. Tab. Folic acid supplements 5 mg once daily, at least 3 months before conception, and continue till 12 weeks of gestation.
9. Dose of Iron (60-100 mg elemental iron) and Folic acid (Tab. Iron
   folic acid) once daily and calcium gluconate 500 mg tablet twice daily from 12 weeks till 3 months postpartum.
10. Immunization: 2 doses of tetanus toxoid 4-6 weeks apart, (mumps, measles and rubella vaccines are contraindicated). Rest of the vaccines can be administered, if indicated as in nonpregnant state.

Patient education

• Explain the danger signals when she should report to the health center
• vaginal bleeding, swelling on face or hands, severe or continuous headache, blurring of vision, abdominal pain, persistent vomiting, oliguria, fever, dysuria, escape of fluid from vagina or change in frequency or intensity of foetal movements.
• Explain about black staining of stools due to oral iron, therefore not to worry about it
• Iron and calcium supplements should be taken at different times of the day at least 2 hours apart.
• Discuss birth spacing after delivery.
• Sexual intercourse should be avoided when abortion/pre-term labor threatens, and during last 4 weeks in any pregnancy.
• Bowel: constipation, fissures and haemorrhoids are common during pregnancy and should be treated with fluids, exercise and bulk laxatives and stool softeners.
• Smoking, alcohol and drug abuse: smoking, alcoholism and drugs are contraindicated. Caffeine is best avoided.
• Daily foetal movement charting (DFMC): After 28 weeks, the woman should keep foetal movement count.
• Follow-up visits: every 4 weeks till 28 weeks, every 2 weeks till 36 weeks and weekly thereafter.

References

F Gary Cunningham, Paul. MacDonald, Kenneth J Leveno et al, 1997.