Raynaud's disease, also known as Raynaud's phenomenon or Raynaud's syndrome, is a condition that affects blood flow to certain parts of the body—usually the fingers and toes. In Raynaud's disease, smaller arteries that supply blood to the skin constrict excessively in response to cold or stress, limiting blood supply to affected areas (vasospasm). This can lead to numbness, tingling, and color changes in the affected areas, typically turning them white or blue.

1. Antenatal Care

2. Antenatal care
1. Diagnosis and presumptive manifestations
2. Pregnancy tests
3. Gestational age
4. Initial examination
5. Examination in subsequent visits
6. Drugs during pregnancy
• Contraindications for use of physical agents in pregnancy
• Medication usage in pregnancy

3. 1.Diagnosis and presumptive manifestations
• Presumptive signs and symptoms of pregnancy are those signs and
symptoms that are usually noted by the patient, which impel her to
make an appointment with a physician.
• These signs and symptoms are not proof of pregnancy but they will
make the physician and woman suspicious of pregnancy.

4. Early symptoms of pregnancy
Some symptoms of pregnancy are especially noticeable early on, including:
1. a missed period
2. feeling exhausted
3. urinating more than normal
4. sensitive, swollen breasts
5. Nausea & vomiting
• If you notice any of these symptoms, talk to your doctor, especially if
you’ve recently had unprotected sex.

5. Amenorrhea (Cessation of Menstruation).
(1) Amenorrhea is one of the earliest clues of pregnancy.
The majority of patients have no periodic bleeding after the onset of
pregnancy. However, at least 20 percent of women have some slight, painless
spotting during early gestation for no apparent reason and a large majority of
these continue to term and have normal infants.
(2) Other causes for amenorrhea must be ruled out, such as:
(a) Menopause.
(b) Stress (severe emotional shock, tension, fear, or a strong desire for a
pregnancy).
(c) Chronic illness (tuberculosis, endocrine disorders, or central nervous
system abnormality).
(d) Anemia.
(e) Excessive exercise.

6. Nausea and Vomiting (Morning Sickness).
1) Usually occurs in early morning during the first weeks of pregnancy.
2) Nausea and vomiting are unreliable signs of pregnancy since they
may result from other conditions such as:
(a) Gastrointestinal disorders (hiatal hernias, ulcers, and appendicitis).
(b) Infection (influenza and encephalitis).
(c) Emotional stress, upset (anxiety and anorexia nervosa).
(d) Indigestion.

7. Frequent Urination.
• Frequent urination is caused by pressure of the expanding uterus on
the bladder.
• Frequent urination is not a definite sign since other factors can be
apparent (such as tension, diabetes, urinary tract infection, or
tumors).

8. Breast Changes
In early pregnancy, changes start with a slight, temporary enlargement
of the breasts, causing a sensation of weight, fullness, and mild
tingling.

9. Fatigue.
• This is a common complaint by most patients during the first
trimester.
• Fatigue may also be a result of anemia, infection, emotional stress,
or malignant disease.

10. 2.Pregnancy tests
• Home pregnancy tests
• Clinical urine test
• Blood test

11. Pregnancy tests
• Pregnancy tests work by checking your urine for a hormone called human
chorionic gonadotropin (HCG).
• Your body only makes this hormone if you’re pregnant.
• HCG is released when a fertilized egg attaches to the lining of
your uterus — when pregnancy begins.
• If your pregnancy test results are positive, it means you're pregnant. If
they’re negative, it means you’re not pregnant.

12. Home pregnancy tests
• A home pregnancy test (HPT) can be used on the first day of your
missed period. Some very sensitive tests can be used even earlier.
• These tests work by detecting the hormone human chorionic
gonadotropin (hCG) in your urine.
• A chemical in the stick changes color when it comes into contact with
this hormone.

13. Blood test
Blood tests can detect hCG earlier than urine tests. Blood tests are usually more
expensive than home tests, and you have to wait longer for your results.
There are two types of pregnancy blood tests:
Qualitative hCG blood test: This test checks to see whether any hCG is being produced
in the body. It gives a simple yes or no answer as to whether you’re pregnant.
Quantitative hCG blood test: This test measures the specific level of hCG in the blood
Quantitative hCG blood tests are very accurate because they measure the exact
amount of hCG in the blood. They can detect smaller amounts of the hormone than a
qualitative hCG blood test or a urine test.

14. 3. Gestational age
• Gestational age, length of time that a fetus grows inside the
mother’s uterus.
• Gestational age is related to the fetus’s stage of growth as well as
its cognitive and physical development.
• For example, at the gestational age of 7 to 8 weeks, all the vital organs
have begun to form, along with the bones and cartilage.
• By the gestational age of weeks 9 to 13, the genitalia have formed, and
the entire fetus weighs about 1 oz (0.06 pounds).
• By weeks 21 to 23, the fetus’s eyes have developed, and the fetal
heartbeat can be heard by stethoscope
• By 40 weeks, fetal development is complete.
• Hence, a normal pregnancy has a gestational range of 38 to 42 weeks,
with 40 weeks generally considered full-term pregnancy

15. 3. Gestational age
First
Trimester
Week
1 2 3 4 5 6 7 8 9 10 11 12
1
3
Second
Trimester
Week
14 15 16 17 18 19 20 21 22 23 24 25 26
2
7
Third
Trimester
Week
28 29 30 31 32 33 34 35 36 37 38 39 40
4
1

16. 3. Gestational age
• Gestational age should be documented by the clinician as a numeric
value between 1-50. Gestational age (written with both weeks and
days, eg. 39 weeks and 0 days) is calculated using the best obstetrical
Estimated Due Date (EDD)

17. Duration of the gestation
• Duration of the gestation may be calculated using one of the
following methods
1. Menstrual History
2. Date Of Quickening
3. Hegar,s Sign
4. Pregnancy Test
5. Ultrasound Scanning

18. 1. Menstrual History
• Gestational Age (GA), or menstrual age, is a clinical term usually given in
weeks and days to describe human development timed from the first day
of the last menstrual period (LMP).
• In general, gestational age is measured by the number of weeks that have
passed since the first day of the mother’s last menstrual period
• Naegele,s rule: add 280 days ( roughly 9 months and 7 days) to the first day
of LMP
• For example:
• Date /LMP 1st September 2020
• EDD +7 +9
• EDD 8 June 2021

19. 2. Date Of Quickening
• The first natural sensation of quickening may feel like a light tapping, or
the fluttering of a butterfly.
• These sensations eventually become stronger and more regular as the
pregnancy progresses. Sometimes, the first movements are mis-attributed
to gas or hunger pangs
• Usually, quickening occurs naturally at about the middle of a pregnancy.
• A woman pregnant for the first time typically feels fetal movements at
about 18–20 weeks, whereas a woman who has given birth at least once
will typically feel movements around 15–17 weeks

20. 3. Hegar's sign
• Hegar's sign is a non-sensitive indication of pregnancy in women —
its absence does not exclude pregnancy.
• Pregnancy causes progressive softening of uterus, which typically
begins at the level of isthmus. This softening of isthmus occurs while
the body uterus and cervix still firm , make the cervix and body of
uterus to move independent to each other on bimanual examination
• This sign is demonstrable between 6th-8th weeks of pregnancy
• As before this isthmus is firm and after this softening of uterus is
more generalized .

21. Parts of uterus
The narrow portion situated between body
and cervix is known as the isthmus

23. 5.Ultrasound Scanning
• Ultrasound uses the size of the fetus to determine the gestational age
(the time elapsed since the the first day of the last menstrual period)
• The American College of Obstetricians and Gynecologists
recommends that ultrasound-established dates should take
preference over menstrual dates when the discrepancy between
ultrasound dating and LMP is exist

24. 1.Gestational sac:
• From start of pregnancy up to 9 weeks the gestation is calculated by
measurement of the size of gestational sac.
• the gestational sac is a fluid-filled structure surrounding an embryo
during the first few weeks of embryonic development. It is the first
structure seen in pregnancy by ultrasound as early as 4.5 to 5 weeks
of gestational age
• In early pregnancy, by 4.5 to 5 weeks gestation, the gestational sac
appears in the central portion of the uterine body, initially measuring
2 to 3 mm in diameter

25. • Gaestational sac diameter increases 1.13 mm per day. By 5.5 weeks
gestation, a thin-walled circular structure, the yolk sac, can be seen
within the gestational sac, which reaches approximately 6 mm by the
time the yolk sac is visible.
• By six weeks of gestation, a 1 to 2 mm structure within the yolk sac is
visible, which represents the embryo. Embryo size is measured using
crown-rump length (CRL) assessment, which is the most accurate
gestational age estimation tool in early pregnancy. By eight weeks of
gestation, the head, body, and limb buds become apparent

28. 2. Crown rump length (CRL)
• Crown-rump length (CRL) is an ultrasound measurement that is used
during pregnancy. The baby is measured, in centimeters, from the
top of their head (crown) to the bottom of their buttocks (rump). The
limbs and yolk sac are not included in the measurement.
• CRL is reliable between 9 to 12 weeks and measure the duration of
gestation with the range of +/- 3 days
• Fetal gender may reliably be determined when CRL ≥ 60 mm
(gestational age ≥ 12+2). Male gender may already be reliably
determined when CRL ≥ 55 mm (gestational age ≥ 12+0). If CRL < 50
mm (gestational age < 11+4) the gender cannot be reliably predicted.

30. 3. Measurements between 12-24 weeks
1. BPD (bi parietal dimeter )
2. FL ( femur length )
3. HC ( head circumference)
4. AC ( abdominal circumference)
• BPD, FL, HC and AC all can be use to calculate the duration of gestation
• BPD is more reliable

31. BPD
• Biparietal diameter (BPD) is one of many measurements that are
taken during ultrasound procedures in pregnancy. It is a
measurement of the diameter of a developing baby's skull, from one
parietal bone to the other. Biparietal diameter is used to estimate
fetal weight and gestational age
• The biparietal diameter measurement increases from roughly 2.4
centimeters at 13 weeks to approximately 9.5 centimeters when a
fetus is at term.

32. Determining the Estimated Due Date
• The estimated due date (EDD ) is the date that spontaneous onset of
labor is expected to occur. The due date may be estimated by adding
280 days ( 9 months and 7 days) to the first day of the last menstrual.

33. The Booking Visit
• A. HISTORY
1. General Information (name, age ,address, occupation year since married )
2. Past Medical And Surgical History (UTI, blood reactions, allergy,diabetes,HTN)
3. Family History (D.M, HTN, congenital and inherited disorders)
4. Past Obstetrical History ( most relevant topic of history taking)
5. Social history ( social habits, condition of home and work)
6. Gynecological history ( menarche, LMP, any abnormality of menses)
7. Current pregnancy

34. Past Obstetrical History
• Total Number of pregnancies and their progress is noted.
• In case of pregnancy loss , the type of abortion ,the need for evacuation, detail
about an ectopic or molar pregnancy are recorded.
• Molar pregnancies are caused by an imbalance in genetic material
(chromosomes) in the pregnancy. This usually occurs when an egg
that contains no genetic information is fertilized by a sperm (a
complete molar pregnancy), or when a normal egg is fertilised by two
sperm (a partial molar pregnancy)
• Pregnancy complication like pregnancy induced hypertension,, intrauterine
growth retardation, antepartum hemorrhage etc. are noted.
.

35. Current pregnancy
• Duration of gestation at booking visit is calculated (GA, EDD etc)
• The progress of pregnancy regarding vaginal bleeding , pregnancy
symptoms, general illness, drug intake and exposure to radiation etc
is noted

36. Initial examination
1. General physical examination
2. Abdominal examination

37. General physical examination
• Height and weight
• Hands for cyanosis, jaundice, anemia
• Anemia ( presence of pallor in palmer crease and koilonychias (spoon
shaped nails) and is feature of chronic anemia
• Pulse , temperature and Blood pressure
• Eyes are examined for pallor, jaundice and exophthalmos
• Teeth , gums and oral cavity are examined for general hygiene
• Neck examined for thyroid enlargement and lymphadenopathy
• Breast is examined for lump discoloration or secretion
• Legs are examined for varicose veins and oedema

38. Abdominal examination
• First empty urinary bladder
• Uterus is in pelvis abdominal contour is normal
• May seen previous abdominal scars( whitish or silvery marks)
• Percussion and auscultation is not required in first trimester at first
visit

39. Examination in subsequent visits
• How frequent they should be?
• What care is to be provided at each visit?

40. Frequency of subsequent visit
• We in Pakistan currently following the UK 1929 model of antenatal
care i.e.
• 4 weekly visit till 28th weeks
• 2 weekly visits till 36 weeks
• Weekly visits there after till birth
for all pregnant women irrespective of the parity

41. Care provided at each subsequent visits
• The usual protocol of Care provided at each subsequent visits
comprises of the following steps
• 1.History:
• Discussion about diet, sleep, fetal movements, vaginal bleeding or
discharge, feeling of fainting, GIT symptoms, headache or visual
disturbance.
• 2.Examination:
• General and abdominal examination
• General BP, weight oedema, pallor etc.

42. Abdominal examination at each subsequent
visits
1.Inspection
2.palpation
• A. Assessment of fundal height
1. Palpatory method
2. Measurement method
• B. Assessment of fetus
1. First Manoeuvre
2. Second Manoeuvre
3. Third Manoeuvre
4. Fourth Manoeuvre
3.Auscultation

43. Assessment of fundal height: Palpatory method

44. Assessment of fundal height:
Palpatory method

45. Assessment of fundal height:
Measurement method
• Fundal height is measured with a measuring tape from the top of
symphysis pubis along the midline over the uterine curve to the top of
uterine fundus. Measure this distance in centimetres from the symphysis
pubis to the top of the fundus. This is the symphysis-fundus height.
• Feel carefully for the top of the fundus and for the upper border of the
symphysis pubis. Place the tape measure on the symphysis pubis and,
using a tape measure with the centimetre marks face down, measure to
the top of the fundus.Turn the tape measure over and read the
measurement
• The mean fundal height measures approximately 20 cm at 20 weeks and
increases by 1 cm per week so that at 36 weeks the fundal height should
be approximately 36 cm.

46. Assessment of fundal height:
Measurement method
A large SFH raises the possibility of:
• A multiple pregnancy.
• Macrosomia.
• Polyhydramnios.
A small SFH raises the possibility of:
• FGR.
• Oligohydramnios.

47. B. Assessment of fetus: First Manoeuvre
• To determine the fetal part occupying the uterine fundus

48. Assessment of fetus: Second Manoeuvre
• Lateral palpation
• Determine the sides on which the fetal back lies
• The palm of the hand are placed on either side of the abdomen, on
one side smooth part of the back is felt, while other side nodular area
i.e limbs

49. Assessment of fetus: Third Manoeuvre
• This determine the presenting part
• Pawlike grip

50. Assessment of fetus: Fourth Manoeuvre
• Determine the attitude of the fetal head
• Head flexed or extended

51. Drugs during pregnancy
• Folic acid before and during pregnancy
• Vitamin D in pregnancy
• Iron in pregnancy
• Vitamin C in pregnancy
• Calcium in pregnancy (Calcium is vital for making your baby's bones
and teeth.)

52. Folic acid before and during pregnancy
• You should take a 400 micrograms folic acid tablet every day before
you're pregnant and until you're 12 weeks pregnant.
• Folic acid can help prevent birth defects known as neural tube
defects, including spina bifida.
• If you did not take folic acid before you conceived, you should start as
soon as you find out you're pregnant.