it includes event in normal pregnancy and antenatal care and minor problem during pregnancy with its management.

1. DR.BIJAY KUMAR SAH
MBBS(BANGLADESH)
NMC REG. 17158

2. NORMAL PREGNANCY
Duration of pregnancy:-
1) 9 calendar months+7 days from the first day of last
mensuration(LMP).
2) 280 days or 40 weeks from LMP.
TRIMESTERS OF PREGNANCY:-
1st trimester= first 12 wks of pregnancy
2nd trimester= 13-28 wks of pregnancy
3rd trimester= 29-40 wks of pregnancy
EXPECTED DATE OF DELIVERY(EDD): 9 calendar month plus 7 days
from the 1st day of last mensuration.
CRITERIA OF NORMAL PREGNANCY:- are delivery a single baby in
good condition between 38-42th wks by dates,with fetal
weight of more than 2.5 kg & with no maternal complication.

3. 1ST TRIMESTER OF PREGNANCY
Symptoms:-
1) Amenorrhoea
2) Morning sickness:- nausea on rising bed, loss of appetite
and occasionaly vomiting, that usually does not affect the
health status of the mother. It occurs in about 50% cases
and appears soon after missed period and rarely last
beyond 3rd month.
3) Frequency of micturation
4) Breast discomfort like fullness
5) Others like fatigue, constipation and backache

4. SIGNS:-
1) Breast change:- valuable only in primigravida
I. Enlargement,pain & tenderness.
II. Pigmentation of primary areola & nipple.
III. Montgomary’s tubercles are prominent.
IV. Thick yellow secretion(colostrum) as early as 12wks.
2) Abdominal exam:- uterus remain in the pelvic cavity and soft
uterine fundus can be felt as a suprapubic bulge.
3) Per vaginal examination:-
a) jacquemier’s/chadwick’s sign: congestion of the pelvic
vasculature causes bluish or purplish discoloration of the
vagina.
b) vaginal discharge: copious non-irritating mucoid
discharge.
c) osiander’s sign: increase pulsation felt through the lateral
fornices.
d) vaginal wall: becomes soft.
e) goodell’s sign: softening of cervix occurs at 6 wks.

5. f) bimanual examination reveals soft and elastic
uterus.
g) hegar’s sign: on bimanual examination, abdominal &
vaginal fingers seem to appose below the body of uterus.
h) palmer’s sign: regular & rhythmic uterine
contraction can be elicited on bimanual examination.
INVESTIGATION:-
1) Detection of HCG level in maternal serum and urine.
2) USG of abdomen and pelvic.
COMPLICATION OF PREGNANCY IN 1ST TRIMESTER:-
1) Abortion
2) Hyperemesis
3) Molar pregnancy
4) Ectopic pregnancy
5) UTI and acute retension of urine

6. USG FINDINGS IN 1ST TRIMESTER:-
1) Gestation ring- 5th wk
2) Fetal pole- 6th wk
3) Yolk sac- 6th wk
4) Cardiac pulsation- 7th wk
5) Embryonic movement- 8th wk
6) Fetal heart sound can be heared by doppler ultrasound as
early as 10 wks.

7. 2nd trimester of pregnancy
SYMPTOMS:-
1) Amenorrhoea for 4 to 7 months.
2) Progressive enlargement of lower abdomen from 5th
month.
3) Quickening- means first perception of active foetal
movements by the mother occurs at 18-20 wks in
primigravida and 14-16 wks in multigravida.
4) Disapperance of morning sickness syndrome.
SIGNS:-
1) Chloasma: pigmentation over the forehead, bridge of the
nose & cheek may appear after 16 wks gestation.
2) More enlargement of breast with prominent veins under
the skin.

8. 3) Abdominal examination:-
a) apperance of linea nigra(linear pigmentation in the midline
from umbilicus to pubis) and striae.
b) uterus is felt as a soft, elastic mass in the midline.
16th wk- 5 cm from the pubic symphysis
20th wk- 2.5 cm below the umbilicus
24th wk- at the level of umbilicus
28th wk- at lower 1/3rd the distance from umbilicus and
xiphoid process.
c) braxton-hicks contraction: intermittent, painless
contractions can be elicited by placing a palm on uterus at
irregular interval of 10-20 min from 16th wk followed by
relaxation. Women can not feel this contraction.
d) Fetal heart sound heared around 18-20 wks by odinary
sthetoscope and by fetoscope in a slender women at 17-18th wk
and rate is 140 beats/min.

9. e) fetal souffle due to rush of blood through umbilical
arteries.
f) uterine souffle due to increase of blood through
uterine arteries.
4) Per vaginal examination:-
vagina and cervix appears bluish,soft and moist.
INVESTIGATION:-
USG:- detects foetal heart movement, position of placenta,
crown-rump length and bi-parietal diameter, measures
gestational age

10. 3RD TRIMESTER PREGNANCY
SYMPTOMS:-
1) Amenorrhoea
2) Progressive enlargement of the abdomen
3) More pronounced foetal movement.
SIGNS:-
1) Prominent linea nigra, striae gravidarum and abdomen is
hugely distended.
2) Foetal heart sound, movement and parts can be felt.
3) Engagement of head may be present.
4) Cervix becomes ripe.
INVESTIGATION:-
1) USG detects BPD, FL, AFI.
2) Amniotic fluid analysis.

11. CAUSES OF ABSENT OR NON-AUDIBLE FETAL HEART SOUND:-
1) IUFD
2) Polyhydromnious
3) Maternal obesity
4) Occipito-posterior position.
COMPLICATION OF 3RD TRIMESTER OF PREGNANCY:-
1) pre-eclampsia or eclampsia
2) Ante-partum haemorrage
3) Pre mature rupture of membrane
4) Inta uterine foetal death
5) Deep vain thrombosis
6) Haemorrage leads to shock

12. ANTENATAL CARE(ANC)
Periodic & regular systemic supervision(examination & advice) of a
women during pregnancy is called antenatal check up or care.
AIMS:-
1) To screen out the high risk cases.
2) To ensure continued medical surveillance & prophylaxis.
3) To prevent or detect & treat any unwanted complications as
early as possible.
4) To educate the mother about the physiology of pregnancy &
labour.
5) To discuss with the couple about the time,place and mode of
delivery.
6) To motivate the couple about the need of family planning.
7) To counsel the couple seeking medical termination of
pregnancy.
8) To motivate the mother about the need of breast feeding.
9) To asscess health status of mother to baseline
information(pulse,BP) at term.

13. OBJECTIVES:-
To ensure a normal pregnancy with delivery of a healthy baby
from a healthy mother.
NET EFFECT OF ANC CARE:-
1) Marked reduction in maternal mortality & morbidity.
2) Reduction in perinatal mortality & morbidity.
3) Prevention of IUGR.
4) Helps to screen out the high risk cases.
WHO RECOMMENDED SCHEDULE OF ANC:- (minimum 8
visit)
1) First visit as early as within 12 wks.
2) Upto 28 wks- monthly.
3) 28-32 wks- 2 weekly.
4) 32-36 wks- weeks.

14. MANAGEMENT OF 1ST ANC:-
a) Registration of the pregnant woman.
b) H/O present pregnancy: period of gestation, any other
problem.
c) Obstetric history: duration of marriage , parity & gravida.
d) Mensuration & contraception history.
e) Past medical and surgical history.
f) Immunological history mainly about TT.
g) Family history and personal history.
h) General examination and obstetrical examination.

15. i) investigation:-a) blood for Hb%, PBF, ABO grouping & Rh
typing, VDRL, Blood glucose, HBsAG, HIV.
b) urine for R/M/E & C/S.
c) USG of uterus & adnexa.
j) Advice:-
1) Diet- light, nutrition, easily digestible, rich in protein,
minerals & vitamins.
2) Rest-at least 10 hr (2 hr at noon + 8 hr at night).
3) Daily bath and wear loose garments.
4) Avoid physical labour.
5) Sexual abstinence at 1st & last trimester.

16. 6) Care of breast.
7) Avoid journey at 1st trimester and last 6 wks.
8) Drug:- avoid thalidamide, aspirin, tetracyclin,
streptomycin. Take folic acid in first 3 month and
then add iron+ calcium+vitamin after 3 month.
9) Report immediately in case of warning sign.
10) Radiation:- X-ray should be avoid 1st 4 month.
11) The art of child care has to be learnt.
12) Immunizations:- TT=1st dose at 5th month, 2nd
dose at 7 month. Rabies,hepatitis A & B vaccines,
toxoids can be given as in non-pregnant state.

17. WARNING SIGNS:-
1) Swelling of the feet.
2) Fits.
3) Headache(severe).
4) Blurring of vision.
5) Bleeding or discharge per vagina.
6) Any ususual symptoms like high fever.
PRINCIPLES OF ANTENATAL ADVICE:-
1) To impress the patient about the importance of regular check
up.
2) To maintain or improve, if necessary, the health status of the
women to the optimum level till delivery by judicious advice
regarding diet, drugs & hygiene.
3) To improve & tone up the psychology & to remove the fear of
the unknown by talking sympathetically to the patient &
explaining the principal changes & events likely to occur during
pregnancy & lactation.

18. NUTRITIONAL REQUIREMENTS DURING PREGNANCY:-
TREATMENT OF MORNING SICKNESS:-
1) Assurance and advice to move the limbs for a few minutes getting
out of bed.
2) Take small dry food(biscuit,dry toast) before rising from bed at early
morning and avoidance of fatty & spicy food and adviced to take
plenty of fluids(2.5L/day) with glucose or fruit juice.
3) If non controled with above measures then ante-emetic- tablet
prochlorperazine 5mg.
KILOCALORIES 2500
PROTEIN 60 gm THIAMIN 1.5 mg
IRON 40 mg RIVOFLABIN 1.5 mg
CALCIUM 100 mg NICOTINIC ACID 17 mg
ZINC 15 mg ASCORBIC ACID 70 mg
VITAMIN A 6000 IU FOLIC ACID 400 micro gn
VITAMIN D 400 IU VITAMIN B12 2 micro gm

19. MINOR PROBLEMS IN PREGNANCY:-
BACKACHE
CAUSES:- relaxation of pelvic joints, faulty posture, high heel
shoes, muscular spasm, UTI, constipations.
ADVICES:- improvement of posture, well fitted pelvic girdle,
adequate rest, avoidance of heavy & sternuous work.
TREATMENT:-
1) Rest
2) Back massage
3) analgesics

20. CONSTIPATION
CAUSES:- effect of progesteron
diminished physical activity
TREATMENT:-
a)Plenty of fruits,fluid,milk & leafy vegetables.
b)ispagula hash(2tsf at night)
LEG CRAMPS
CAUSES:- deficiency of diffusible serum calcium, elevation of
serum phosphorus.
TREATMENT:-
a) leg massage
b) application of local heat
c) tab calcium 500 mg daily
d) tab vitamin B1(30 mg daily)

21. ANKLE ODEMA
CAUSES:-
1) Physiological edema 5) severe anaemia
2) Orthostatic edema 6) hypoproteinaemia
3) Pre-eclampsia 7) nephrotic syndrome
4) Heart failure
TREATMENT:-
1) Physiological edema and orthostatic edema: rest and
slight elevation of the legs over one/two pillow during
sleep and no diuretics should be given.
2) If any pathological odema: if suspected then refer to the
higher center.

22. ACIDITY & HEART BURN
CAUSES:-
1) Excessive stress
2) Emotion
3) Pre-existing PUD & H. pylori infection
TREATMENT:-
1) Mild symptom: antacid
2) Moderated symptom: pantoprazole or rabeprazole
3) Severe symptom/H.pylori infection: triple therapy
(pantoprazole + amoxicillin + erythromycin or
clarithromycin).

23. VARICOSE VEIN
SITE:-
May appear for the time of pregnancy or may aggravate
during pregnancy in the later months in legs, vulva, or
rectum.
CAUSE:-
obstruction of the venous return by the gravid uterus.
TREATMENT:-
1) Leg varicosities: elastic crepe bandage during movements
& elevation of the legs during rest can give symptomatic
relief. Specific therapy is better to be avoided. Varicosities
usually disappear after delivery.
2) Haemorrhoids: regular use of laxatives, local application of
hydrocortisone & replacement of the piles(if prolapsed).
Surgical treatment is better avoided as the condition
sharply improves after delivery.

24. VAGINAL DISCHARGE
CAUSES:-
1) Lack of proper personal hygiene maintenance.
2) T. vaginalis
3) C. albicans
4) Other bacterial vaginosis
TREATMENT:-
1) Maintenance of proper personal hygiene.
2) Advice for local cleanliness.
3) Wearing of soft cotton made undergarments.
4) Vaginal application of metronidazole or miconazole.

25. HIGH RISK PREGNANCY
High risk pregnancy means pregnancy with added risk for
complications of mortality and morbidity to be faced by the
mother and her unborn baby.
1) Elderly primi(30 yrs and above)
2) Short statured primi(140 cm & below)
3) Mal prensentation like breech or transverse lie
4) Antepartum haemorrage & threatenend abortion
5) Pre-eclampsia or eclampsia
6) Anaemia
7) Twins
8) H/O of caesarean section or instrumental delivery
9) Pregnancy associated with general diseases- CVD, kidney
disease, DM, TB, liver disease etc.

26. METHODS OF ASSESSMENT OF ANTENATAL FOETAL WELLBEING:-
A) Foetal factor:
1) Size of the foetus
2) Lie, presentation & attitude of foetus
3) Auscultation of foetal heart sound
B) Maternal factror:
1) Maternal nutrition.
2) H/O maternal anaemia, jaundice.
3) H/O maternal HTN, DM.
4) H/O maternal infection especially TROCH.
5) Progressive maternal weight gain.
6) Progressive rise of height of uterus.
7) Abdominal circumference.
8) USG of pregnancy sac.