Diagnosis
Once your pregnancy is confirmed, you should make an appointment with your healthcare professional, usually an obstetrician, nurse-midwife, or family practitioner.
This first visit will likely take much longer than other appointments over the next few months. It should include:
- A complete health history
- A complete physical examination, including blood pressure, height and weight measurements
- Blood tests to check for your blood group, blood type, Rh factor, anemia, immunity to rubella (German measles), hepatitis B virus and some sexually transmitted diseases (STDs)
Rh factor is a protein that 85 percent of people have on red blood cells. These people are called "Rh-positive." If you belong to the 15 percent of the population that doesn't have the protein, you're known as "Rh negative." Since Rh positive individuals are in the majority, it is likely that your baby's father may be Rh positive, so your baby may also be Rh positive.
If you have Rh-negative blood and your baby's father is Rh-positive, you and your baby may develop health problems. To reduce this risk, your health care provider will give you injections of Rho (D) immune globulin (RhoGAM) at 28 weeks of pregnancy. The drug prevents your body from recognizing Rh positive cells so your body will not attack and destroy your baby's blood cells. After the baby is born, his/her Rh status will be determined andif the baby is Rh positive, your will be offered RhoGAM again. Receiving RhoGAM while pregnant will not harm you or your baby if, after delivery, the baby is found to be Rh negative like you.
Your health care professional may ask whether you've been tested for HIV, the virus that causes AIDS. If you haven't been tested for HIV, he or she will likely suggest you be tested, regardless of whether you are in a high-risk category.
Depending on your ethnic background, your health care professional may also test your hemoglobin (a protein carried in your red blood cells), to look for genetic conditions such as sickle cell disease or thalassemia that could be passed onto your baby.
During this first visit, your health care professional will also do an internal pelvic exam, likely the only one you'll have until your final weeks of pregnancy. He or she will examine your internal reproductive organs to check for changes in your cervix and the size of your uterus.
A urine test is a sometimes a routine part of every prenatal visit, so you should drink a lot of water drink before your visit. These tests provide information about glucose (sugar) and protein levels. A high glucose level may indicate gestational diabetes, a form of diabetes that only occurs during pregnancy, while a high protein level could signal potential kidney problems or infection.
This first visit also may include a Pap smear to detect changes in your cervix that could be an early sign of cancer.
Other tests may be recommended depending on your age and other risk factors. These include routine screenings for genetic disorders such as cystic fibrosis and more specialized genetic tests, if your medical history suggests them.
Prenatal visits after this one will be relatively brief, and most likely include the following:
- Urine sample to check for sugar and protein
- Blood pressure measurement to gauge whether your levels are normal
- Weigh-in to make sure you are gaining enough weight and let you know if you're gaining too much
- Checking the baby's heartbeat
- Checking the size and position of your uterus and the baby by feeling on your stomach
- Providing information and education about what you can expect over the next month, and any signs of problems you should look for.
This might all sound a little scary, but don't worry -- Most women in the U.S. have healthy pregnancies that lead to healthy babies.
Still, throughout your pregnancy your health care professional will recommend a handful of standard tests to check the health of your baby. These include:
Ultrasound. Also known as a sonogram, this test uses short pulses of high-frequency, low-intensity sound waves to create images of the baby inside your uterus. Unlike x-rays, there is no radiation exposure to you or the baby. This test can be performed in a health care professional's office or in an outpatient diagnostic center.
Ultrasound has been used safely in obstetrics for decades. When performed early in the pregnancy, it can provide an accurate gestational age and due date for your baby and is sometimes more reliable than calculating your due date mathematically from your last period. Many expectant moms like to get an ultrasound hoping to learn the child's sex, but health care professionals are much more focused on looking for possible birth defects. If they suspect any problems with your baby, you may need other tests.
You may have more than one ultrasound throughout pregnancy. In the decades of its use, there is no evidence of harm to either the mother or baby. Most women experiencing a healthy pregnancy receive only one, however, usually around 16 weeks.
To perform the test, a technician rubs a thin layer of lubricating jelly on your belly and passes a hand-held instrument called a transducer over that part of your body.
Additionally, you may need a transvaginal ultrasound early first trimester to confirm your pregnancy and/or to determine how healthy the pregnancy is if you're experiencing any bleeding, signs of preterm labor or other risks that require a careful examination of your cervix. This type of ultrasound is similar to the kind of internal exam you get during a Pap smear, only instead of a speculum inserted into your vagina, the ultrasound wand is inserted.
Regardless of which type of ultrasound you have, during the test itself the technician occasionally stops to take ultrasound images, which record the size of certain body parts and other developmental features of the baby. Also, an ultrasound can usually determine if you're carrying more than one baby.
Multiple births (twins, triplets, or more) have become much more common in the U.S. over the past 20 years, according to the National Center for Health Statistics. The dramatic rise, especially in triplet-or higher births, is associated with two related trends: advances in and greater access to assisted reproductive therapies like in-vitro fertilization, and more women having children at an older age (women in their thirties are more likely to have a multiple birth than younger women even without the use of fertility therapies).
But the rate of triplet and higher births seems to be leveling off, according to statistics from the National Center for Health Statistics. Reasons include a declining population of older women of childbearing years (30 years and older) and refinements in assisted reproductive techniques that lower the risk of multiple births.
Maternal serum screening. This test detects substances in your blood that come from the baby that could be a sign of a birth defect. All pregnant women are offered this test between weeks 15 and 18 of pregnancy. The results may indicate the need for further tests such as amniocentesis.
One of the more common substances tested is alpha-fetoprotein (AFP). High levels may be a sign of a neural tube defect (such as spina bifida), in which the brain or spinal cord doesn't develop normally. Low levels could be a sign of Down's syndrome, a chromosomal defect that results in various developmental disabilities and physical problems.
Don't panic if the results aren't ideal. The tests are just a marker for these conditions; other test can provide more certain information.
Other genetic screening tests identify individuals who "carry" genes for certain genetic conditions and who may pass those genes onto their children.
These include Tay-Sachs and sickle cell disease, both of which are more common in certain ethnic groups. If you belong to one of these groups, your health care team may recommend you talk with a genetic counselor and/or have additional genetic screenings.
Amniocentesis: This screening is performed between the 15th and 20th week of pregnancy. It enables your health care professional to examine fetal cells in the amniotic fluid for any chromosomal abnormalities. If you are 35 or older when you're due to have your baby, your health care professional will likely discuss the risks of chromosomal abnormalities based on your age, and recommend this test.
That's because women over 35 have a higher risk of having a baby with Down's syndrome. An amniocentesis is also recommended if you've already had a child with certain birth defects, or if you have a family or personal history that puts you at risk for certain inherited diseases. You might choose to have this test if you had abnormal blood tests that suggest there might be a problem.
Amniocentesis can diagnose numerous conditions, but only if the lab evaluating the amniotic fluid knows which tests to conduct. Also, these tests are very expensive, so talk with your health care professional about which ones are necessary based on your history and risk factors. It can take anywhere from a few days to a few weeks to get the results.
During an amniocentesis, the doctor inserts a needle through your abdomen into the amniotic sac and removes a small amount of amniotic fluid. The doctor uses ultrasound to guide the needle and avoid inserting it into the placenta.
An amniocentesis has a complication rate of less than 1 percent, but there is a small risk of miscarriage associated with this procedure. The test can be performed on an outpatient basis in a health care professional's office or in a hospital.
Although amniocentesis is performed in the second trimester, between 15 and 20 weeks as noted, a study done by researchers at New York's Columbia University College of Physicians and Surgeons and published in the New England Journal of Medicine shows that for Down's syndrome testing, a less invasive test performed in the first trimester (11 weeks) may be the better at detecting the disorder.
Researchers tracked more than 38,000 women who received the less invasive test, which combines a blood test with an ultrasound at 11 weeks, and found it to be more effective than screening in the second trimester. This means pregnant women now have a first trimester option for for screening for Down's syndrome.
Chorionic villus sampling (CVS). During this test, a sample of chorionic villi, a portion of the placenta, is removed and analyzed. It occurs between 10 and 13 weeks of pregnancy and is usually offered to look for certain kinds of birth defects.
There are two types of CVS tests:
- Transcervical. This is the most common method. The doctor uses ultrasound to guide a thin catheter through your cervix to the placenta, suctioning the chronic villi cells into the catheter.
- Transabdominal. The doctor uses ultrasound to guide a long, thin needle through your abdomen to the placenta, using a needle to draw a tissue sample. This is similar to the amniocentesis.
CVS carries a higher risk of miscarriage than amniocentesis, but some women prefer this test because it can be performed earlier than amniocentesis.
First trimester screening (FTS): This test, also called combined screening, involves an ultrasound scan between 11 and 14 weeks of pregnancy as well as blood testing. The ultrasound measures the "nuchal translucency", or thickness of skin on the back of the baby's neck. This measurement, in conjunction with levels of certain proteins found during the blood test, can help predict the risk of chromosomal abnormalities in the baby.
Combination screening allows women under 35 to get more information about the health of their babies without having to undergo the more invasive tests described earlier.
Fetal heart rate monitoring. This test enables health care professionals to monitor your baby's heart rate and check his or her wellbeing before delivery. This test is generally performed during the last 10 to 12 weeks of your pregnancy.
However, it may be performed earlier if a problem arises during the pregnancy, such as high blood pressure in you, or if you don't feel the baby moving.
There are two types of fetal monitoring -- non-stress and stress. During both, a device is strapped to your abdomen and the results recorded on a tracing.
Non-stress test (NST). During this test, you sit quietly while the monitor records any movement of the baby and records the baby's heart rate. If the heart rate goes up when the fetus moves, the test is normal. If the heart rate doesn't increase, the baby may be "sleeping." Sometimes, the technician may want you to "wake up" your baby, by rubbing your abdomen or making a loud noise above your abdomen with a special device.
Contraction stress test (CST). This test is often recommended r if you have an abnormal non-stress test. Uterine contractions are produced either by stimulating the woman's nipples or via an intravenous administration of pitocin. Oxytocin/pitocin is a hormone that causes the uterus to contract. When your uterus contracts, the baby is momentarily deprived of its usual blood supply and oxygen. Most babies have no problem with this, but some aren't healthy enough to handle the stress, and they develop an abnormal heart rate pattern.
It is typically done to assess fetal well-being before you are in labor. By providing a contraction i.e. a stress to your baby as labor often does, your health provider can better assess your baby's health by his/her ability to tolerate stress.
If the baby's heart rate slows down rather than speeds up after a contraction, the baby may be in jeopardy, and you may need to have a cesarean section to get the baby out quickly. The stress test is considered more accurate than the non-stress test when it comes to a baby's condition, but it's not 100 percent accurate. Your health care professional might want to repeat it to ensure accuracy. Most women describe this test as mildly uncomfortable, but not painful.
Biophysical profile. If the baby doesn't react during a non-stress test , your doctor may order a biophysical profile . This test uses a combination of a non-stress test and a detailed ultrasound to evaluate the baby's movement, body tone and breathing efforts, as well as amniotic fluid volume.
Amniotic fluid index. This test is often performed weekly towards the end of pregnancy in women with high blood pressure, diabetes or other medical problems. It estimates the amount of amniotic fluid in the fetal sac to make sure there isn't too much (a condition called polyhydramnios) or too little (a condition called oligohydramnios). Both conditions may cause problems for mom and baby and can be a sign of other problems. If your doctor suspects an abnormal fluid level, he or she may perform an amniotic fluid index (AFI). During an AFI, an ultrasound machine is used to scan the uterus and measure the amniotic fluid around the baby.
Blood sugar screening. The American College of Obstetricians and Gynecologists' (ACOG) strongly suggest all pregnant women be screened for gestational diabetes, a form of diabetes that occurs on during pregnancy.
Generally, the screenings occur between the 24th and 28th weeks of pregnancy, which coincides with the end of your second trimester or the beginning of your third trimester. Screening is so important because intervention can make a big difference in the health outcome of both a mother with gestational diabetes and her baby. A study in the June 2005 issue of the New England Journal of Medicine showed that women with gestational diabetes who received intervention in the form of dietary advice, blood glucose monitoring, and insulin therapy had fewer prenatal complications and a better quality of life after delivery than the women who received routine care.
Glucose loading test (GLT). Also called a glucose challenge test, this test is easy and painless. You drink a super-sweet glucose liquid and one hour later your blood sugar level are measured to see how your body handles the sugar. You shouldn't eat or drink anything (except water) during the one-hour waiting period. If you're scheduled for this test, ask your health care professional if you have to fast beforehand, or make any other special preparations.
If your blood sugar level is less than 140 mg/dL, it's very unlikely you have gestational diabetes. If, however, your blood sugar level is above 140, the test is considered "positive." But since not all women with a positive screening have diabetes, further testing is required with a three-hour glucose tolerance test (GTT), described below. Note: Some health care professionals use a lower threshold of the GLT/GCT, such as 130 to 135 mg/dL, to decide if a three-hour GTT is necessary.
Three-hour glucose tolerance test (GTT). This test usually occurs first thing in the morning in your health care professional's office or a laboratory. You must follow certain steps before the test. For three days before the test, you should eat a daily diet with at least 150 grams of carbohydrates. For 10 to 14 hours before the test, you shouldn't eat or drink anything except water.
The day of the test, a technician draws your blood to measure your fasting blood sugar level. Then you drink some more of the super-sweet glucose drink. Some women feel nauseated when they drink this, but nausea should subside quickly. Then blood is drawn every hour for three hours after the glucose drink. If two or more of your blood sugar levels are higher than a certain threshold, you have gestational diabetes.
Gestational diabetes is a form diabetes that occurs because of pregnancy-induced changes in the way your body processes sugar (glucose) from food, leading to high blood sugar levels. An estimated 2 to 5 percent of all pregnant women in the U.S. are diagnosed with the condition. It doesn't cause birth defects because women with the condition don't experience abnormal blood sugar levels during the first trimester, when most diabetes-related birth defects occur. However, if your blood sugar remains high, the baby may grow too large to pass easily through your birth canal.
You are at greater risk for developing gestational diabetes if you are obese; have a family history of diabetes or have previously given birth to a very large infant; have had a stillbirth or a child with certain birth defects. A previous birth with too much amniotic fluid is also a risk factor. And a 2002 study published in the Journal of the American Medical Association showed a strong relationship between a mother's own birth weight and her risk of getting gestational diabetes during her first pregnancy--women with low or high birthweights had an increased risk.
You also have a greater risk of developing the condition if you're over 25, Hispanic, African American, Native American, South or East Asian, Pacific Islander or indigenous Australian.
Gestational diabetes almost always disappears after you deliver your baby, although your risk for developing diabetes later is now increased. A very small percentage of women continue to have diabetes after delivery, so your blood sugar will be assessed two to six weeks after the birth to make sure your diabetes is gone.
The main concern with gestational diabetes is that the baby may develop a fetal macrosomia, a condition in which it grows more than 9 pounds, 4 ounces before birth, regardless of its gestational age. This occurs because the baby is getting large amounts of glucose from the mother, which triggers the baby's pancreas to produce more insulin. The extra glucose, then, is converted to fat.
In some cases, the baby becomes too large to be delivered through the mother's vagina, requiring a cesarean delivery.
Gestational diabetes also increases the risk of hypoglycemia, or low blood sugar, in the baby right after delivery. This medical problem typically occurs if the mother's blood sugar levels have been consistently high, leading to high blood levels of insulin in the baby. After it's born, the baby continues to have a high insulin level, but no longer has the high levels of glucose from the mother. So the newborn's blood sugar levels drop sharply and suddenly. Your baby's blood sugar levels will be checked in the newborn nursery, and if they're too low, the baby may receive oral or intravenous glucose.
Babies whose mothers have gestational diabetes are also at higher risk for respiratory distress syndrome (RDS) after birth, a condition that makes it hard for the baby to breathe.
Additionally, children whose mothers had gestational diabetes are at higher risk for getting diabetes as they get older, and are more likely to be obese (very overweight) as children or adults, which can lead to other health problems.
Like other forms of diabetes, this condition can be managed once it is diagnosed. The goal is to keep your blood sugar levels within normal ranges (less than 95 mg/dL when fasting, less than 140 mg/dL one hour after eating).
You can usually do this by following a specific diet high in complex carbohydrates (e.g. whole-grain cereals) and low in simple sugars, such as cakes and candies. Ask to meet with a nutritionist to develop the right diet for you.
You may also need to monitor your blood glucose yourself. Self-blood glucose monitoring allows you to track your glucose levels at home without requiring extra trips to your health care professional. You may need to test your blood several times a day, usually first thing in the morning before eating and one to two hours after each meal.
You do this with a special device that pricks your finger for a drop of blood. You put the blood on a special test strip, insert it into a small machine, and voila! The results appear on the monitor.
If you can't control your blood sugar levels through diet alone, you may need insulin, a hormone you take via a shot that helps return your blood glucose levels to normal.
There's no cut-off point that automatically triggers the need for insulin. Many health care professionals recommend insulin treatment when blood sugar levels exceed 95 mg/dL first thing in the morning (the fasting sugar) or if post-meal level exceeds 140 mg/dl on two separate tests.
Pre-eclampsia. This condition, also known as toxemia, usually occurs during the second half of pregnancy, although it may occur earlier and can continue after the baby is born.
It occurs in at least 5 to 8 percent of pregnancies. Signs include high blood pressure, swelling that doesn't get better, and higher-than-normal amounts of protein in your urine. Symptoms include headaches, changes in your vision, abdominal pain, and shortness of breath.
However, high blood pressure alone doesn't automatically mean you have pre-eclampsia. Likewise, swelling on its own also doesn't always indicate a problem. Many women experience some swelling during pregnancy. If your rings or shoes start feeling too tight, don't panic. But if swelling in your hands and feet doesn't subside after resting, or if you have obvious swelling in your hands and face, contact your health care professional.
Pre-eclampsia is more likely to develop during your first pregnancy and if other women in your family developed it during their pregnancies. It's also more common in women pregnant with more than one baby, those in their teens and over 40, and those with high blood pressure or kidney disease.
Pre-eclampsia is dangerous for your baby because it can interfere with your placenta's blood supply. The placenta is the source of nutrition and oxygen for your baby. Any problems with the blood supply then, affect the amount of nutrients and oxygen the baby receives, and could lead to a low birth weight or other problems. Additionally, a small number of women go on to develop eclampsia, which includes dangerous seizures.
Unlike gestational diabetes, there really isn't one test that can diagnose pre-eclampsia. That's why it's so important that your blood pressure and urine be checked during each prenatal visit. Blood pressure readings significantly higher from one visit to the next could be an early sign of pre-eclampsia, as can high levels of protein in your urine.
Other warning signs that could indicate pre-eclampsia include:
- Weight gain of more than five pounds in one week
- Severe headache that doesn't improve with acetaminophen (Tylenol)
- Abdominal pain in the upper right area just below your rib cage
- Double vision or blurred vision, or persistent spots before eyes
- Excessive swelling of the feet and hands that doesn't get better with rest
- Sudden blindness
- Lower back pain
- Nausea or vomiting
We don't know what causes pre-eclampsia, but there are several theories, including:
- Not enough blood getting to the uterus
- Hormonal imbalances affect the size of blood vessels
- Damage or injury to blood vessel linings
- Too little calcium
- Undiagnosed high blood pressure of other condition such as diabetes, lupus, sickle cell disease, hyperthyroidism or kidney disease
- Immune system deficiency
- Too little or too much protein in the diet)
- Poor diet (not enough fruits and vegetables)
- High levels of body fat
- Too little magnesium and vitamin B6
One theory about the disease suggests that harmful molecules called free radicals damage blood vessels. Vitamin C, a powerful antioxidant, can neutralize some of the ill effects of these molecules, which may be why a study published in the July 2002 issue of the journal Epidemiology found some evidence that a daily dose of vitamin C during pregnancy could reduce a women's risk of developing pre-eclampsia.
The findings suggested that women who ate less than the recommended five daily servings of fruits and vegetables, and got less than 85 milligrams of vitamin C per day (below the recommended amount), were twice as likely to develop pre-eclampsia as those who got enough of the vitamin in their diets.
Most women with pre-eclampsia give birth to healthy babies because the condition is usually identified early enough in pregnancy for your health care professional to intervene.
The single most important thing you should do is rest and reduce the stress in your life. Also ask your health care professional about any dietary changes that may help you stay healthy. Your health care professional may also want to see you more often to monitor your blood pressure and weight gain. Additionally, you may need a non-stress test, biophysical testing and fetal movement counts to keep an eye on how your baby is doing in light of your high blood pressure.
If you are on or near your due date and have been diagnosed with pre-eclampsia, discuss the risks and benefits of delivering early via induced labor or Cesarean with your health care professional as a way to end the preeclampsia. A cesarean is onl |
