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ANTENATAL CARE Dr ShobaBembalgi

Introduction Embryo – upto 8 weeks Fetus –from 8 weeks upto delivery Getational age—is expressed in completed weeks and calculated from the lmp Fetal age– is from the day of implantation Gravida– total number of pregnancies Parity- number of pregnancies that as passed the period of viaility excluding the present pregnancy

Live birth-complete expulsion of products of conception from mother regardless of the gestational age which after such separation shows signs of life Preterm infant-one born prior to 37 weeks

Prenatal care Pregnancy is normal physiological event Complication is seen only in 5-20% Prenatal care aim is to identify and special care for the high risk pregnancy So as to ensure uncomplicated pregnancy and delivery of healthy infant Remember that mother emotional state during pregnancy effects the fetal outcome

Conclusion Importance of antenatal care is to identify high risk cases during preconceptional period at earliest and during antenatal period not the least so as to provide a healthy baby to the mother if she is at risk

Preconceptionalcounscelling is necessary Physician should establish history, physical examination and lab tests during this period Remember healthy women will bear a healthy child Stress regarding avoidance of cigarette smoking, drug abuse and teratogenic drug should be advised

PRENATAL CARE Prenatal care should be initiated as soon as there is a reasonable likelihood of pregnancy. The major goals are. To define the health status of the mother and fetus. To estimate the gestational age of the fetus. To initiate a plan for continuing obstetrical care

Reasons for inadequate prenatal care varied by social and ethnic group, age, and method of payment. woman did not know she was pregnant. lack of money or insurance for such care. inability to obtain an appointment. Fear or lack of confidence in health care profession

population-based study from North Carolina, Harper and co-workers (2003) found that the risk of pregnancy-related maternal death was decreased fivefold among recipients of prenatal care.

DEFINITION OF ANTENATAL CARE "A comprehensive antepartum care program that involves a coordinated approach to medical care and psychosocial support that optimally begins before conception and extends throughout the antepartum period." The content of such a comprehensive program includes (1) preconceptional care, (2) prompt diagnosis of pregnancy, (3) initial presentation for pregnancy care, and (4) follow-up prenatal visits. Health during pregnancy depends on health before pregnancy, preconceptional care should logically be an integral part of prenatal care.

Diagnosis of Pregnancy Signs and Symptoms Cessation of Menses---- Uterine bleeding somewhat suggestive of menstruation occurs occasionally after conception. One or two episodes of bloody discharge, somewhat reminiscent of and sometimes mistaken for menstruation, are not uncommon during the first half of pregnancy. Such episodes are interpreted to be physiological, and likely the consequence of blastocyst implantation.

Diagnosis of pregnancy Changes in Cervical Mucus cervical mucus is relatively rich in sodium chloride when estrogen, but not progesterone, is being produced. Progesterone secretion—even without a reduction in estrogen secretion—acts promptly to lower sodium chloride concentration to levels at which ferning will not occur. During pregnancy, progesterone usually exerts a similar effect, even though the amount of estrogen produced is enormous. .

Diagnosis of pregnancy Thus, if copious thin mucus is present and if a fern pattern develops on drying, early pregnancy is unlikely. From about the 7th to the 18th day of the menstrual cycle, a fernlike pattern of dried cervical mucus is seen After approximately the 21st day, a different pattern forms that gives a beaded or cellular appearance This beaded pattern also is usually encountered during pregnancy

Diagnosis of pregnancy Changes in the Breasts= the anatomical changes in the breasts that accompany pregnancy are quite characteristic during the first pregnancy Discoloration of the Vaginal Mucosa the vaginal mucosa usually appears dark bluish or purplish-red and congested—the so-called Chadwick sign (Chadwick, 1886). This appearance is presumptive evidence of pregnancy, but it is not conclusive

Diagnosis of pregnancy URINE PREGNANCY TEST Trophoblast cells produce hCG in amounts that increase exponentially following implantation. With a sensitive test, the hormone can be detected in maternal plasma or urine by 8 to 9 days after ovulation. The doubling time of plasma hCG concentration is 1.4 to 2.0 days. Levels increase from the day of implantation and reach peak levels at about 60 to 70 days. Thereafter, the concentration declines slowly until a nadir is reached at about 14 to 16 weeks

Diagnosis of pregnancy The sensitivity for the laboratory detection of hCG in serum is as low as 1.0 mIU/mL using this technique. With extremely sensitive immunoradiometric assays, the detection limit is even lower (Wilcox and associates, 2001). False-positive hCG test results are rare (Braunstein, 2002). However, some women have circulating factors in their serum that may interact with the hCG antibody. The most common are heterophilic antibodies, which are human antibodies directed against animal-derived antigens used in immunoassays

Diagnosis of pregnancy Transvaginal sonography imaging of early pregnancy and its growth and development. A gestational sac may be demonstrated by abdominal sonography after only 4 to 5 weeks' menstrual age By 35 days, all normal sacs should be visible, after 6 weeks, a heartbeat should be detectable. Up to 12 weeks, the crown-rump length is predictive of gestational age within 4 days

History Present pregnancy- symptoms, LMP to calculate the EDD Previous pregnancy-outcome, length of gestation, fetal presentation, type of delivery, length of labor, complications. If cesarean was done type of uterine incision Medical history- CVS ,GIT and endocrine disorder require carefull evaluation and councselling concerning possible deleterious effect on mother Current infection if present should be treated to avoid deleterious effect on fetus

Surgical history- ceaserean details, prior history of multiple induced abortions or mid trimester loss may suggest incompetant cervix Family history – diabetes, previous still birth and anomalous babies, twins

Nausea and vomiting-50% of pregnancies 2-12 weeks If excess suspect multiple pregnancy or molar pregnancy Protracted vomiting causes dehydration and ketonuria Rapidly rising HCG levels is the cause

Breast Mastodynia hormonal response of mammary ducts and alevolar system Enlargment of subceous glands of areola Colustrumsecetion begin at 16 weeks Quickening -18-20 weeks in primi and 14-16 weeks in multi

Urinary tract Increased frequency because of pressure of growing uterus Urinary tract infections to be detected and treated asympomaticbacteruria to be treated as it increases risk of miscarriage, preterm and iud

signs Increased body temperature for a period of 3 weeks suspect pregnancy Skin – chloasma mask of pregnancy skin on forehead bridge of nose or cheek bones Linea nigra—increased MSH stimulating the melanocytes Palmarerthyma and spider telengectasiaalso present Strech marks seperation of underlying collagen and appear as irregular scars

Physical examination Maternal height and weight rate of weight gain is important . Bmi to be calculated in the preconceptional period if wt is <45 kg one should encourage them to gain weight upto 11-15 kg Indequate weight gain reflects nutritional deficiency , materanl illness ,iugr

Abdominal enlargement Progressive enlargement from 7 weeks Uterine contractions painless contraction Braxton hicks contractions

Fundal Height Between 20 and 34 weeks, the height of the uterine fundus, measured in centimeters, correlates closely with gestational age in weeks Obesity, however, may distort this relationship. T he fundal height should be measured as the distance over the abdominal wall from the top of the symphysis pubis to the top of the fundus. The bladder must be emptied before making the measurment, fundal height was 3 cm higher with a full bladder.

Fundal height Just above symphisis pubis 12 weeks In between umblicus and symphysis 16 weeks Umblicus 22 weeks Just above umblicus 24 -26 weeks At xiphi 36 weeks Subsequent in between umblicus and xiphi can be divided into 3 parts four finger appart corresponding to 28, 32 and 36 weeks Orange line represents 40 weeks

subsequent prenatal visits has been scheduled at intervals of 4 weeks until 28 weeks, and then every 2 weeks until 36 weeks, and weekly thereafter. Women with complicated pregnancies often require return visits at 1- to 2-week intervals

At each return visit, steps are taken to determine the well-being of mother and fetus (see Table 8–3). Certain information—for example, assessment of gestational age and accurate measurement of blood pressure (Jones and associates, 2003)—is especially important. Fetal Heart rate(s) Size—current and rate of change Amount of amnionic fluid Presenting part and station (late in pregnancy) Activity

Pelvic examination Pelvic soft tissue any pelvic mass should be described accurately with help of scan Bony pelvis Pelvic inlet one as to measure diagonal conjugate from which obstetric conjugate can be calculated Mid pelvis note any prominence of ischial spine and distance between them curve of sacrum and side walls Outlet sub pubic angle and bi tuberous diameter Cervical length average around 3-4 cm tvs as upper hand over digital examination

Maternal Blood pressure— current and extent of change Weight— current and amount of change Symptoms—including headache, altered vision, abdominal pain, nausea and vomiting, bleeding, vaginal fluid leakage, and dysuria Height in centimeters of uterine fundus from symphysis Vaginal examination late in pregnancy often provides valuable information: Confirmation of the presenting part. Station of the presenting part Clinical estimation of pelvic capacity and its general configuration Consistency, effacement, and dilatation of the cervix.

INVESTIGATION Blood tests HB , blood group and typing , VDRL, HBSAG, HIV Women belonging to high risk group for GDM should get GCT done with 50 gm of glucose if that is positive one should do GTT with 100 gm of glucose Maternal HCG, alfafeto protein, inhibin, and unconjugatedestriol to be estimated as a part of quardaple test to look for fetal anomaly( 16 -18 weeks) First trimester test with PAPPA and free BHCG and nuchaltranslucany by scan is helpful to detect certain chromosomal anomaly

Genetic test should be offered for all women over 35 years of age and with abnormal pedigree chart and family history of inherited disease CVS at 10-14 weeks and amniocentesis at 16 -20 weeks can be offered

Urine for protein and culture Culture if asymptomatic bacteriuria treat accordingly Protein> 300 mg/dl of 24 hr is significant think preeclampsia Glucose in urine may be due to decreased renal threshold or because of GDM differentiated by blood glucose levels

Psychosocial Screening For barriers to care includes transportation facilities Child care Family support Unstable housing Unintended pregnancy Communication barriers Nutritional problems Ciggarate smoking Substance abuse

Cigarette Smoking spontaneous abortion, low birthweight due to either preterm delivery or fetal growth restriction, infant and fetal deaths, and placental abruption Suggested pathophysiological mechanisms for these adverse pregnancy effects include increased fetal carboxyhemoglobin, reduced uteroplacental blood flow, and fetal hypoxia Perinatal mortality reduces by 5 % if smoking is left

Drug abuse . Fetal distress, low birthweight, and drug withdrawal soon after birth are well documented

Domestic Violence Screening the majority of abused women continue to be victimized during pregnancy. With the possible exception of preeclampsia, domestic violence is more prevalent than any major medical condition detectable through routine prenatal screening

Recommended Consultation for Risk Factors Identified in Early Pregnancya Risk Factor Asthma Symptomatic on medication Severe (multiple hospitalizations) MFM Cardiac disease Cyanotic, prior myocardial infarction, aortic stenosis, pulmonary hypertension, Marfan syndrome, prosthetic valve, American Heart Association class II or greater MFM Other OBG Diabetes mellitus Class A–C OBG Class D or greater MFM Drug and alcohol use

High risk pregnancy MFM Epilepsy (on medication) OBG Family history of genetic problems (Down syndrome, Tay-Sachs disease, phenylketonuria) MFM Hemoglobinopathy (SS, SC, S-thalassemia) MFM Hypertension Chronic, with renal or heart disease MFM Chronic, without renal or heart disease OBG

High risk pregnancy Prior pulmonary embolus or deep vein thrombosis OBG Psychiatric illness OBG Pulmonary disease Severe obstructive or restrictive MFM Moderate OBG Renal disease Chronic, creatinine 3 mg/dL, ± hypertension MFM Chronic, other OBG Requirement for prolonged anticoagulation MFM Severe systemic disease MFM Obstetrical History and Conditions Age 35 years at delivery OBG Cesarean delivery, prior classical or vertical incision

High risk pregnancy Incompetent cervix Prior fetal structural or chromosomal abnormality MFM Prior neonatal death Prior fetal death Prior preterm delivery or preterm ruptured membranes Prior low birthweight (< 2500 g)

High risk pregnancy Second-trimester pregnancy loss Uterine leiomyomata or malformation Condylomata (extensive, covering vulva or vaginal opening) Initial Laboratory Tests Human immunodeficiency virus (HIV) Symptomatic or low CD4 count MFM CDE (Rh) or other blood group isoimmunization (excluding ABO, Lewis)

Advice regarding nutrition Certain prenatal vitamin–mineral supplements may lead to intakes well in excess of the recommended allowances. Moreover, the use of excessive supplements—for example, 10 times the recommended daily allowances—which often are self-prescribed, has led to concern about nutrient toxicities during pregnancy. Nutrients that can potentially exert toxic effects include iron, zinc, selenium, and vitamins A, B6, C, and D. Vitamin

CALORIE REQUIRMENT pregnancy requires an additional 80,000 kcal, which are accumulated primarily in the last 20 weeks. To meet this demand, a caloric increase of 100 to 300 kcal per day is recommended during pregnancy

PROTEIN protein should be supplied from animal sources, such as meat, milk, eggs, cheese, poultry, and fish, because they furnish amino acids in optimal combinations. 15 gram extra protein to be added diet Milk and dairy products have long been considered nearly ideal sources of nutrients, especially protein and calcium, for pregnant or lactating women.

IRON approximately 300 mg of iron transferred to the fetus and placenta and the 500 mg incorporated, if available, into the expanding maternal hemoglobin mass, nearly all is used after midpregnancy. During that time, iron requirements imposed by pregnancy and maternal excretion total about 7 mg per day

Scott and co-workers (1970) established that as little as 30 mg of elemental iron, supplied as ferrous gluconate, sulfate, or fumarate and taken daily throughout the latter half of pregnancy, provided sufficient iron to meet the requirements of pregnancy and to protect any preexisting iron stores The woman who is overtly anemic from iron deficiency responds well to oral supplementation with iron salts

Electrolyte and Mineral Metabolism), the pregnant woman retains about 30 g of calcium, most of which is deposited in the fetus late in pregnancy (Pitkin, 1985). This amount of calcium represents only about 2.5 percent of total maternal calcium, most of which is in bone, and which can readily be mobilized for fetal growth.

ZINC zinc deficiency may lead to poor appetite, suboptimal growth, and impaired wound healing. Profound zinc deficiency may cause dwarfism and hypogonadism. It may also lead to a specific skin disorder, acrodermatitisenteropathica, as the result of a rare, severe congenital zinc deficiency. zinc supplementation was not found to confer any benefits on developmental outcome (Hamadani and co-workers,

IODINE use of iodized salt and bread products is recommended during pregnancy to offset the increased fetal requirements and maternal renal losses. Despite this, iodine intake has declined substantially in the past 15 years, and it is probably inadequate for some populations

Trace elements Important role in enzyme functions. Deficiency of selinium manifests as cardiomyopathy

Vitamins The increased requirements for vitamins during pregnancy usually are supplied by any general diet that provides adequate calories and protein. The exception is folic acid during times of unusual requirements, such as pregnancy complicated by protracted vomiting, hemolytic anemia, or multiple fetuses. Supplementation with multivitamins reduce inidence of lbw and iugr

Vitamins more than half of these defects could be prevented with daily intake of 400 g of folic acid throughout the periconceptional nutritional sources alone are insufficient, however, folic acid supplementation is still recommended A woman with a prior pregnancy complicated by a neural-tube defect can reduce the 3-percent recurrence risk by more than 70 percent if she supplements her daily diet with 4 mg of folic acid for the month before conception and for the first trimester of pregnancy

Vitamins A small number of case reports suggest an association of birth defects with very high doses during pregnancy—10,000 to 50,000 IU daily. These malformations are similar to those produced by the vitamin A derivative isotretinoin (Accutane), which is a potent teratogen in humans Vitamin A deficiency, whether overt or subclinical, was associated with a significantly increased risk of both maternal anemia and spontaneous preterm birth. The former likely reflected the need for vitamin A to facilitate iron absorption, and the latter possibly reflected increased susceptibility to infection associated with vitamin A deficiency.

Vitamins Vit b 12– deficiency in first trimester increases risk of ntd Vit b6 –combined with doxylamine reduces incidence of nausea and vomiting of pregnancy The recommended dietary allowance for vitamin C during pregnancy is 80 to 85 mg/day, or about 20 percent more than when nonpregnant

Pragmatic Nutritional Surveillance Although the science of nutrition continues in its perpetual struggle to identify the ideal amounts of protein, calories, vitamins, and minerals for the pregnant woman and her fetus, those directly responsible for their care may best discharge their duties as follows. In general, advise the pregnant woman to eat what she wants in amounts she desires and salted to taste. Make sure that there is ample food to eat in the case of socioeconomically deprived women.

Pragmatic Nutritional Surveillance Monitor weight gain, with a goal of about 25 to 35 pounds in women with a normal BMI. Periodically explore food intake by dietary recall to discover the occasional nutritionally absurd diet. Give tablets of simple iron salts that provide at least 27 mg of iron daily. Give folate supplementation before and in the early weeks of pregnancy. Recheck the hematocrit or hemoglobin concentration at 28 to 32 weeks to detect any significant decrease

Common Complaints during Pregnancy Ptylaism --xcessive salivation cause unknown strongly associated with nausea and vomiting Pica ingestion of substance with no food value for eg clay and starch educating patient is important as they may neglect their nutrition as these substance substitute their food Excessive urination is due to pressure of gravid uterus and hormonal changes and vascular enlargement in the pelvis

INFECTIONS HSV topical acyclovir can be used oraly to be use dif pregnancy> 36 weeks If active lesion at time of delivery section to be done HIV viral load to be calculated by measuring cd4 count art to be started depending n viral load . If viral load > 1000 copies /ml section is to be done

Employment confirmed a 20- to 60-percent increase in preterm birth, fetal growth restriction, or hypertension associated with physically demanding work. In a prospective study of more than 900 healthy primigravida, Higgins and associates (2002) found that women who worked were about fivefold more likely to develop preeclampsia. Newman and colleagues (2001) reported the relationship between occupational fatigue and preterm birth in 2929 women with singleton pregnancies studied by the Maternal–Fetal Medicine Units Network.

Employment They found that occupational fatigue—estimated by the number of hours standing, intensity of physical and mental demands, and environmental stressors—was associated with an increased risk of preterm membrane rupture. For those women reporting the highest degrees of fatigue, the risk was 7.4 percent.

EXCERISE pregnant woman to severe physical strain should be avoided. Ideally, no work or play should be continued to the extent that undue fatigue develops. Adequate periods of rest should be provided during the work period. Women with previous pregnancy complications that are likely to be repetitive, such as low-birthweight infants, probably should minimize physical work

Common ConcernsExercise no exercise or to weight-bearing exercise beginning at 8 weeks. Exercise consisted of treadmill running, step aerobics, or stair stepper use for 20 minutes three to five times each week placental size and birthweight were significantly greater in the exercise group.

Absolute Contraindications FOR EXCERISE Hemodynamically significant heart disease Restrictive lung disease Incompetent cervix or cerclage Multifetal gestation at risk for preterm labor Persistent second- or third-trimester bleeding Placenta previa after 26 weeks of gestation Preterm labor during the current pregnancy Ruptured membranes Preeclampsia or gestational hypertension

Relative Contraindications Severe anemia Unevaluated maternal cardiac arrhythmia Chronic bronchitis Poorly controlled type 1 diabetes mellitus Extreme morbid obesity Extreme underweight (BMI < 12) History of extremely sedentary lifestyle Fetal growth restriction in current pregnancy Poorly controlled hypertension Orthopedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism Heavy smoker

EXCERSISE pregnant women should be encouraged to engage in regular, moderate-intensity physical activity 30 minutes or more a day. Each activity should be reviewed individually for its potential risk. Activities with a high risk of falling or abdominal trauma should be avoided. Similarly, scuba diving should be avoided because the fetus is at an increased risk for decompression sickness.

Travel pregnant women should be encouraged to wear properly positioned three-point restraints throughout pregnancy while riding in automobiles. The lap belt portion of the restraining belt should be placed under the woman's abdomen and across her upper thighs. The belt should be as snug as comfortably possible. The shoulder belt also should be snugly applied and positioned between the breasts the American College of Obstetricians and Gynecologists has concluded that pregnant women can safely fly up to 36 weeks.

Fish consumption Pregnant ladies are asked to avoid fish containing higher level of methyl mercury levels

Varicose Veins Varicosities may develop in the legs or in the vulva. A family history of varicosities is often present. Pressure by the enlarging uterus on the venous return from the legs is a major factor in the development of varicosities. The physician should warn the patient early in pregnancy of the need for elastic stockings and elevation of the legs if varices develop. Specific therapy (injection or surgical correction) usually is contraindicated during pregnancy. Superficial varicosities may rarely signal deeper venous disease. These patients should be examined carefully for signs of deep vein thrombosis.

Joint Pain, Backache, & Pelvic Pressure Although the main bony components of the pelvis consist of 3 separate bones, the symphysial and sacroiliac articulations permit practically no motion in the nonpregnant state. In pregnancy, however, endocrine relaxation of these joints permits some movement. The pregnant patient may develop an unstable pelvis, which produces pain. A tight girdle or a belt worn about the hips, together with frequent bed rest, may relieve the pain; however, hospitalization is sometimes necessary.

Improvement in posture often relieves backache. The increasingly protuberant abdomen causes the patient to throw her shoulders back to maintain her balance; this causes her to thrust her head forward to remain erect. Thus, she increases the curvature of both the lumbar spine and the cervicothoracic spine. A maternity girdle to support the abdominal protuberance and shoes with 2-inch heels, which tend to keep the shoulders forward, may reduce the lumbar lordosis and thus relieve backache. Local heat and back rubs may relax the muscles and ease discomfort. Exercises to strengthen the back are most rewarding.

Leg Cramps The cause of leg cramps in pregnancy is unknown but may be the result of a reduced level of diffusible serum calcium or elevation of serum phosphorus. Treatment for this includes curtailment of phosphate intake (less milk and nutritional supplements containing calcium phosphate) and an increase of calcium intake (without phosphorus) in the form of calcium carbonate or calcium lactate tablets. Alternatively, a randomized trial showed that magnesium citrate, 300 mg/d, reduces leg cramps. Symptomatic treatment consists of leg massage, gentle flexing of the feet, and local heat. Tell the patient to avoid pointing toes when she stretches her legs (eg, on awakening in the morning) as this triggers a gastrocnemius cramp. She should also practice "leading with the heel" in walking.

BREAST Soreness Physiologic breast engorgement may cause discomfort, especially during early and late pregnancy. A well-fitting brassiere worn 24 hours a day affords relief. Ice bags are temporarily effective. Hormone therapy is of no value

Discomfort in the Hands Acrodysesthesia of the hands consists of periodic numbness and tingling of the fingers (the feet are never involved). It affects at least 5% of pregnant women. In some cases it is thought to be a brachial plexus traction syndrome caused by drooping of the shoulders during pregnancy; carpal tunnel syndrome is a common cause of a similar symptom complex. The discomfort is most common at night and early in the morning. It may progress to partial anesthesia and impairment of manual proprioception. The condition is apparently not serious, but it may persist after delivery as a consequence of lifting and carrying the baby

Bathing Bath water does not enter the vagina. Even swimming is not contraindicated during normal pregnancy. Diving should be avoided because of possible trauma. A woman in the last trimester of pregnancy may have impaired balance. For this reason, she should be cautioned about slipping and falling in the tub or shower.

Immunization Killed virus, toxoid, or recombinant vaccines may be safely administered during pregnancy, and patients should be vaccinated appropriately for both maternal and fetal benefit. The American College of Obstetricians and Gynecologists recommends that all women who are pregnant in the second or third trimester during the flu season (October to March) should receive the influenza vaccination. Diphtheria and tetanus toxoid may be administered in pregnancy if a woman has not received a booster in 10 years, or if no primary series had been received. The hepatitis B vaccine series and killed polio vaccine may be given during pregnancy to women at risk.

IMMUNIZATION Live, attenuated vaccines, including those for varicella, measles, mumps, polio, and rubella, should be given 3 months prior to pregnancy or immediately postpartum. These vaccines are contraindicated in pregnancy secondary to the potential of fetal infection. Viral shedding occurs in children receiving vaccination, but they do not transmit the virus; consequently, vaccination may be safely given to the children of pregnant women. Secondary prophylaxis with specific immune globulin is recommended for pregnant women exposed to measles, hepatitis A, hepatitis B, tetanus, chickenpox

Douching Douching, which is seldom necessary, may be harmful during pregnancy.

Dental Care There may be generalized gum hypertrophy and bleeding during pregnancy. Interdental papillae (epulis) may also form in the upper gingivae, and these rarely resorb and must be excised. Normal dental procedures under local anesthesia (ie, drilling and filling) may be carried out at any time during gestation. Lengthy procedures should be postponed until the second trimester. Antibiotics are given for dental abscesses and in cases of rheumatic heart disease and mitral valve prolapse. Periodontal disease has been associated with an increased risk of preterm birth but there have been no trials of treatment during pregnancy.

coitus Can be practised Few condition in which abstience is advised r If cramps or spotting following intercoures Late in pregnancy in women with previous history of preterm delivery or in present pregnancy with pv bleeding

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