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What to expect with your medical care during pregnancy

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The Importance of Prenatal Care

Almost 4 million American women give birth every year, says the Centers for Disease Control and Prevention (CDC). Nearly one third of them will have some kind of pregnancy-related complication. Those who don't get adequate prenatal care run the risk that such complications will go undetected or won't be dealt with soon enough. That, in turn, can lead to potentially serious consequences for both the mother and her baby.

These statistics aren't meant to be alarming, but to convey the importance of starting prenatal care as early as possible - ideally, before a woman even becomes pregnant.

Of course, this isn't always possible or practical. But the sooner in a pregnancy good care begins, the better for the health of both moms and their babies.

Prenatal Care Before Becoming Pregnant

Ideally, prenatal care should start before you get pregnant. If you're planning a pregnancy, see your health care provider for a complete checkup. Routine testing can make sure you're in good health and that you don't have any illnesses or other conditions that could affect your pregnancy. If you've been experiencing any unusual symptoms, this is a good time to report them.

If you're already being treated for a chronic condition, such as diabetes, asthma, hypertension (high blood pressure), a heart problem, allergies, lupus (an inflammatory disorder that can affect several body systems), depression, or some other condition, you should talk to your doctor about how it could affect your pregnancy.

In some cases, you may need to change or eliminate medications - especially during the first trimester (12 weeks) - to reduce risk to the fetus. Or, you may need to be even more vigilant about managing your condition. For example, women with diabetes must be especially careful about keeping their blood glucose levels under control, both before they begin trying to conceive and during their pregnancy. Abnormal levels increase the risk of birth defects and other complications.

This is also a good time to talk with your health care provider about other habits that can pose a risk to your baby, such as drinking alcohol or smoking. Ask about starting a prenatal vitamin that contains folic acid, calcium, and iron.

It's especially important for women who are planning to become pregnant to take vitamins with folic acid beforehand, because neural tube defects (problems with the normal development of the spine and nervous system) happen in the first 28 days of pregnancy, often before a woman even knows she's pregnant.

If you have or your partner has a family history of a significant genetic disorder and you suspect either of you may be a carrier, then genetic testing may be advisable. Talk this over with your health care provider, who can refer you to a genetic counselor if necessary.

If you find out that you're pregnant before you do any of this, don't worry. It's not too late to get the care that will help to ensure your health and that of your baby.

Finding Medical Care

Pregnant women usually are cared for by:

  • Obstetricians/gynecologists (OB/GYNs) - doctors who specialize in pregnancy and childbirth, as well as women's health care
  • Certified nurse-midwife - an advanced practice nurse specializing in women's health care needs, including prenatal care, labor and delivery, and postpartum care for pregnancies without complications
  • Family practitioners - doctors who provide a range of services for patients of all ages - in some cases, this includes obstetrical care - instead of specializing in one area

Any of these care providers is a good choice if you're healthy and there's no reason to anticipate complications with your pregnancy and delivery.

Your OB provider may refer you to a doctor with expertise in high-risk pregnancies if you:

  • have a chronic condition like diabetes or heart problems
  • have an increased risk of preterm labor
  • are older than 35
  • are pregnant with more than one fetus
  • have some other complicating factor that might put you in a high-risk category

Your First Visit

You should call to schedule your first examination during the first 6 to 8 weeks of your pregnancy, or when your menstrual period is 2 to 4 weeks late. Many health care providers will not schedule the first visit before 8 weeks, unless there is a problem.

During your first visit, you'll be asked a lot of questions about your health and habits that may have an impact on your pregnancy. It's important to try to remember the date of your last menstrual period so your doctor can estimate the duration of your pregnancy and predict your delivery date.

You can expect to have a full physical, including a pelvic and rectal examination. A blood sample will be taken and used for a series of tests:

  • a complete blood cell count (CBC)
  • blood typing and screening for Rh antibodies (antibodies against a substance found in the red blood cells of most people)
  • for infections such as syphilis, hepatitis, gonorrhea, chlamydia, and human immunodeficiency virus (HIV)
  • for evidence of previous exposure to chickenpox (varicella), measles (rubeola), mumps, or German measles (rubella)
  • for cystic fibrosis (health care providers recently started to offer this even if there's no family history of the disorder)

Some blood tests are offered only to women of certain ethnic backgrounds, who may be at higher risk of carrying genes for specific diseases. For example, women of African or Mediterranean descent are usually tested for thalassemia or sickle cell trait or disease because they're at higher risk of these chronic blood diseases or carrying the sickle cell trait, which can be passed on to their children.

Talk with your health care provider to see if any of these genetic tests may be recommended for you.

During the first visit, you also can expect to provide a urine sample for testing and to have a Pap test (or smear) for cervical cancer. To do a Pap smear, the doctor uses what looks like a very long mascara wand or cotton swab to gently scrape the inside of the cervix (the opening to the uterus that's located at the very top of the vagina). This generally doesn't hurt; some women say they feel a little twinge, but it only lasts a second.

Routine Visits and Testing

If you're healthy and there are no complicating risk factors, you can expect to see your health care provider:

  • every 4 weeks until the 28th week of pregnancy
  • then every 2 weeks until 36 weeks
  • then once a week until delivery

At each examination, your weight and blood pressure are usually recorded. The size and shape of your uterus may also be measured, starting at the 22nd week, to determine whether the fetus is growing and developing normally. Your baby's heart rate will also be measured.

During most of your visits, you'll be asked to provide a small urine sample to be tested for sugar and protein. Protein may indicate preeclampsia, a condition that develops in late pregnancy and is characterized by a sudden rise in blood pressure and excessive weight gain, with fluid retention and protein in the urine.

Screening for diabetes usually takes place at 12 weeks for women who are at higher risk of having gestational diabetes (diabetes that occurs during pregnancy). That includes women who:

  • have previously had a baby that weighs more than 9 pounds
  • have a family history of diabetes
  • are obese

All other pregnant women are tested for diabetes at 24 to 28 weeks. This test involves drinking a sugary liquid and having a blood glucose test (which involves having blood drawn) after an hour. If the sugar level in the blood is high, further testing might be done to diagnose gestational diabetes.

Prenatal Tests

Many expectant parents also choose to have one or more of the following prenatal tests, which can help predict the likelihood, or even detect the presence, of certain developmental or chromosomal abnormalities in the fetus:

First trimester screening: Between 10 and 14 weeks, your doctor might recommend a blood test to measure two substances - pregnancy-associated plasma protein (PAPP-A) and hCG (human chorionic gonadotropin), both produced by the placenta in early pregnancy. You also might be sent for an ultrasound test for fetal nuchal translucency, which measures the amount of fluid at the back of your developing baby's neck.

Second trimester screening: Between 16 and 18 weeks, the level of alpha-fetoprotein, a protein produced by the fetus, can be measured in a pregnant woman's blood. If the level is high, she may be carrying more than one fetus or a fetus with spina bifida or other neural tube defects. A high level can also indicate that the date of conception was miscalculated. If the level is low, the fetus may have chromosomal abnormalities, such as Down syndrome.

Along with AFP, two hormones produced by the placenta are often measured - hCG and estriol. The level of these three substances can help doctors identify a fetus at risk for certain birth defects or chromosomal abnormalities. When all three are measured, the test is called the triple screen or triple marker. Often a fourth placental hormone is measured, called Inhibin-A. In this case, the test might be called the quadruple screen, quad screen, quadruple marker, quad marker, or multiple marker screening.

Sometimes both first and second trimester screening tests are done. This is called an integrated screening test.

It's important to keep in mind that abnormal results of screening tests don't automatically indicate a problem; rather, they indicate the need for further testing, which yields normal results in many cases.

Additional testing that might be recommended can include the following:

Amniocentesis (also called an amnio): In this test, a needle is used to remove a sample of the amniotic fluid from the womb; it's usually performed between 15 and 20 weeks. Testing the fluid can identify certain fetal abnormalities such as Down syndrome or spina bifida. Typically, amniocentesis is recommended only if there is reason to believe that the risk for such conditions is higher than usual, perhaps due to maternal age (35 or older), abnormal screening results, or family history. Although the test poses a small risk for causing preterm labor and inducing miscarriage, the large majority are performed without any problem.

Chorionic villus sampling (CVS): This procedure is used during the first trimester for the same purposes as an amniocentesis. (Women usually have one or the other, but not both, if such testing is deemed necessary.) It involves taking a sample of the tissue that attaches the amniotic sac (the sac around the fetus) to the wall of the uterus. Like amniocentesis, CVS is typically done only when there are certain risk factors; its primary advantage is that results are available sooner. CVS also carries a slightly increased risk of miscarriage and other complications.

Ultrasound (also called a sonogram, sonograph, echogram, or ultrasonogram): You'll likely have at least one ultrasound examination to make sure the pregnancy is progressing normally and to verify the expected date of delivery. Usually, an ultrasound is performed at 18 to 20 weeks to look at the baby's anatomy, but can be done sooner or later and sometimes more than once. An ultrasound poses no risk to you or your baby.

Some health care providers may have the equipment and trained personnel necessary to provide in-office ultrasounds, whereas others may have you go to a local hospital or radiology center.

Wherever the ultrasound is done, a technician will coat your abdomen with a gel and then run a wand-like instrument over it. High-frequency sound waves "echo" off your body and create a picture of the fetus inside on a computer screen.

Ultrasound scanning is used to:

  • determine whether the fetus is growing at a normal rate
  • record fetal heartbeat or breathing movements
  • see whether you might be carrying more than one fetus
  • identify a variety of abnormalities that might affect the remainder of the pregnancy or delivery

There are ultrasounds available at shopping malls as a way to have a "portrait" of your baby. However, the individuals using the equipment are not necessarily trained as ultrasound technicians. Before committing to having one of these done, it would be wise to discuss it with your health care provider.