Ante Natal Care in office
Before you get pregnant
It is good idea to talk to your doctor when you are thinking of, or planning to get pregnant. It is recommended that you take Folic Acid for at least three months before you do get pregnant. This will prevent some problems from happening to your developing baby. The dose needed is usually higher than what you will find in your regular prenatal vitamins. Also, if you are diabetic, you should be switched to a medication that is safe to take during pregnant, usually insulin. The same is true if you are on a blood thinner, you may need to switch to heparin or mini-heparin. Some blood pressure medicationss are better avoided during pregnancy.
If you are planning to get pregnant, we recommend that you act like a pregnant woman. So, avoid alcohol, try to quit smoking, and do not take any medication that is not really needed at this point in time. Examples can be as simple as Advil. You can still take Tylenol, though. Anyway, if in doubt, please see your physician.
First we need to make sure you are pregnant. You need to do a urine pregnancy test. Please do NOT do a pregnancy test if you have not yet missed your period. You cannot be pregnant if you have not missed a period. A positive pregnancy test BEFORE you miss a period does not mean you are pregnant! -We can talk about this for a long time). If you have missed your period for 3-4 days and you have done a urine pregnancy test, then we need to see a doctor. Your physician will then order a blood pregnancy test (hCG titre). Usually they will also ask for some other blood tests including your blood type, etc. An ultrasound will be arranged as well, best done NOT BEFORE 6 weeks. Any ultrasound done sooner will create more confusion than give you answers.
In the first visit after you have confirmed pregnancy, ou will be asked to fill in an antenatal form, or pregnancy follow up form. Your health care provider will then go through the questions that are on the form, and update any details that need clarification about your past medical and obstetric history. Following this, they will discuss interventions that may be offered to you and what they mean.
On the first visit you will probably be offered an ultrasound and some blood work, if not done before. We will also take your weight and dip your urine for sugars and protein. On each visit we will measure you blood pressure and check how big or small your baby is. We will also check your baby’s heart rate. There are visits when we may arrange some more stuff, like ultrasound or blood work, and there are other visits when we only check you and your baby. In all visits, we will ask you how are were and if your baby is moving well.
The first ultrasound is usually done at around 6-7 weeks or so. It is done to confirm that you are pregnant, that the baby is inside the uterus, and that the baby is developing well. Many millions of ultrasounds and thousands of research papers all confirm that ultrasounds are safe. They consist of high frequency sound waves, and there is no radiation exposure associated with them.
Its value is that it confirms that the baby is developing inside the uterus. About 1 in 200 pregnancies occur outside the uterus, usually in the fallopian tubes, and are called Ectopic Pregnancies. The tubes are not capable of carrying a baby till it is delivered. If an ectopic pregnancy is diagnosed early, the treatment can be a medical treatment (a shot called methotrexate) or a surgical treatment through a laparoscope (a camera that goes through your belly button). If done early enough the tube may not be totally damaged, and you can get pregnant through that tube again. If an ectopic pregnancy is not diagnosed until later, the tube may burst, leading you to bleed internally. You may then need a surgery that usually involves removing the tube. This surgery may be done through an open cut or may be done through a laparoscope, depending on the situation.
Another great value of the early ultrasound is that it confirms your dates. It is important to confirm the due date we calculated by your last menstrual period date. This date is important to guide us when we perform the genetic testing (or IPS-eFTS) early in pregnancy and the anatomy scan later on, and to know when to plan an intervention if you have passed your due date.
These are meant to check for your hemoglobin or iron levels, and your blood group. You may also be tested for your thyroid gland functions.
Genetic Testing, IPS, eFTS and NIPT
We all want to have a healthy baby. Chances are, most pregnant moms will end up happy with a healthy baby. Rarely, things do not turn out the way we wished them to. Women who were 35 years or older are at a higher chance of developing some genetic problems with their babies, mainly Trisomy 21 or Down’s Syndrome. In the old days, the test to check for this was to get some fluid from around the baby, usually by way of a needle through mum’s tummy. This is called Amniocentesis, or simply ‘Amnio’.
With the scientific advances in both lab and ultrasound technology, we can predict with a good amount of accuracy whether this baby is OK or not. There a few ways of doing these tests, the most commonly done test, as we do it in Ontario used to be the two step IPS, now replaced by the one step eFTS.
IPS: This is basically one ultrasound test and 2 blood works. You do the first part of the testing when you are 11-14 weeks. We will calculate your exact dates, and then book you for ultrasound. The day you get the ultrasound is the day you have to do the blood work. The ultrasonographer will have to write the results of the findings on the requisition (paper) for the lab. You then take all the lab papers to the lab, they take a blood sample form you. They should then book you for the second set of blood work which is between 15 and 19 weeks, or 4 weeks after the first blood test. There is no second ultrasound for the IPS. You need to do both lab tests at the same lab. You actually have to make sure that the first physician who discussed IPS with you actually gave you all the needed paperwork. We cannot help you half way through. The way it needs to be arranged can most easily be done through one person, and as mentioned above.
eFTS: because of the complexity of arranging IPS, and with some advances in research, eFTS has largely replaced IPS. eFTS is a one step ultrasound and blood test. It is usually done around 12-13 weeks. It is as accurate, if not more accurate than IPS, with faster results. You still need to do the Anatomy US around 20 weeks.
The results will usually come back saying the screening is negative, which means that probably baby is OK. The odd time the results may come back saying that screening is positive for “spina bifida’ or ‘neural tube defect’. These are things that can be picked up by ultrasound. This is arranged, and if baby is cleared by ultrasound, chances are, baby is alright.
If the results come back saying screening positive for Down Syndrome, you will be offered NIPT (blood test, may be called Harmony or Panorama, depends on which lab you went to). These tests are very accurate. If you want even more confirmation, you will then be offered an ‘Amnio’. Again, this is a test where a small amount from around the baby is collected though a needle through mum’s tummy. It is actually not too complicated, and you get freezing, so it is not painful. The baby’s cells that are collected are then grown in the lab, and tested for their chromosomes.
eFTS not a diagnostic test, it is a screening test. This just means that it fairly accurate, but may over call at times, and miss a problem on other occasions. Although these are rare, they do happen at times. More importantly maybe is that it does not test for everything.
One of the questions you need to ask yourself actually before you start the eFTS testing is what will you do if your baby tests positive for a major problem, and this has been confirmed by the NIPT or ‘Amnio’. Will you chose to continue the pregnancy? Do you think you will keep the pregnancy anyway, and there is no need for the test as it is not going to make you do anything different anyway? Or does it matter a lot for you to know early enough because may be you will choose not to continue a pregnancy when you know the baby may have this problem or that.
NIPT is a non invasive test for genetic screening. It is a test from mom's blood and looks for fetal genetic material.It is more accurate than IPS, but off course, more expensive. There are certain situations when the ministry will pay for your NIPT test, including advanced maternal age and failed eFTS testing. If you chose to do it yourself, the price is about 400 dollars, or so.
Communicable disease testing
This includes Hepatitis B, Syphilis, and HIV/AIDS testing. The reason you are tested for these infections (among others) is the fact that there are treatments that can prevent or reduce the chance of the infection reaching the baby and reduce the harm to the mother. We recommend it for all pregnant women, but you can choose to opt out of HIV/AIDS testing if you feel strongly against being tested. Another option is that you can ask for your tests to be sent without your identification, allowing you to know your results without notifying public health. If you feel strongly against being tested or if you have concerns about the testing, make sure you communicate this to your health care professional.
For Hepatitis B, the baby will get Immunoglobulins at birth, and will be vaccinated. With Hepatitis B you will probably be able to breast feed if this is your wish.
If you test positive for HIV/AIDS, you will undergo more testing to detect the level of virus in your blood, as well as other tests of your health in general. Depending on the results of these tests, you will start treatment, and may be allowed a vaginal birth. Your health care provider may consult with physicians who specialize in infectious diseases and HIV/AIDS for your treatment.
You will also be tested for immunity against Rubella. Rubella is rare but can cause serious problems to the developing baby, including loss of hearing, eye and heart problems as well as developmental delays.
Most women have been vaccinated (with the MMR vaccine) during their childhood years and have retained their immunity, in which case the result of testing will be “immune” and there will be no risk to any pregnancies.
However, some may not have had the childhood vaccine and occasionally others may have been vaccinated but lost their immunity. If you fit one of these cases, the result will come back “non-immune”, and you will need an MMR vaccine after delivery, usually before you leave the hospital. This vaccine will protect you in future pregnancies. MMR vaccines should not be given to pregnant mothers; they may cause deformities to the developing baby. The vaccine itself, like other vaccines, may be associated with some side effects. Most vaccines may result in a local irritation at the injection site, as well as may be a low grade fever and feeling unwell. Rarely they may be associated with an allergic reaction that makes you swell, called angioneurotic edema. Some report a paralysis like disease after vaccines (Guillain-Barre syndrome); the exact incidence of these are not known, but they are generally quite rare.
As you can see from the above information, you and your baby will benefit from these tests. You cannot be forced to undergo any of these tests, but as you can see, there is an advantage to being tested. You are either reassured that you do not have the disease or you are given the opportunity to be started on treatment for the benefit of both yourself and your baby.
Just a bit of info, these tests are done in the public health labs. The results may take up to 14 days to come back. If we actually miss one of them, I get a letter from the office notifying us that there was some test that was not done.
Also see swabs at the bottom of the page.
Blood group and RH testing
We all have Red Blood Cells or RBC’s in our blood. They are the cells that carry oxygen from the lungs to other organs and tissue. These cells have ‘tags’ on them: either A, B, both A and B, or none, and hence the A, B, AB or O blood groups as we know them. Most people also have a tag called Rhesus or Rh. Those who have it are Rh positive, those who do not are Rh negative.
If you are, for example, blood group A, and get a blood transfusion containing blood of type B, your body has antibodies against those B cells, sees those cells as foreign, or as invaders, and destroys them. This is why you should only receive blood from a donor with a similar blood type to yours.
When you are Rh negative, the story is a bit different. You normally do not have antibodies against the Rh tag initially. However, if you get a blood transfusion containing Rh positive blood, your body will then start an immune reaction. You will then produce antibodies against the Rh positive blood cells. You will not feel anything different.
Similarly when you are pregnant, if you are Rh negative and the baby is Rh positive (this will likely happen if the father of the baby is Rh positive) you can get exposed to the baby’s Rh positive blood. Any time you bleed in relation to a pregnancy (either during pregnancy or during delivery), some of your baby’s blood will enter into your blood stream, and start a reaction. You will then produce antibodies against Rh blood cells. If this happens, you do not feel anything different yourself, and it does not affect you in any way.
But when you get pregnant a second time, and if your baby is again Rh positive, your body will produce antibodies and attack and destroy baby’s blood cells. This may be mild and only cause anemia to the baby, or may be severe enough to cause the baby to swell and may be even develop heart failure. In really severe cases we may even lose the baby. It can be very difficult to treat and will often require the assistance of specialists.
As you see, this is a significant problem if it develops. Therefore the best option is to prevent all this from happening in the first place. The prevention is through a shot, which has different names but is most commonly referred to as Rhogam or WinRho shot. This shot should be given any time you bleed during pregnancy and within 72 hours of giving birth. That is, if you have bleeding in early pregnancy, in the form of spotting, an abortion, or an ectopic pregnancy, or if you deliver a baby vaginally or by cesarean section, you should get this shot.
In addition, you will also be tested and receive the shot at 28 weeks of pregnancy even though you did not bleed. This is an extra precaution as some women are affected even when no bleeding has occurred.
This shot is formed from a pool of blood donors. It is regarded as a blood product and theoretically may carry the same risks as a blood transfusion. These may include a local reaction at the injection site, with swelling and pain. Rarely some individuals may have a systematic allergic reaction. There is also the risk of transmission of diseases like HIV/AIDS, Hep B, Hep C, syphilis, HTLV and others. The risk of transmission of these infections is very small, from between 1 in 100,000 to 1 in 3-4 million. Blood is tested and screened to exclude the possibility of transmission of these diseases.
Since the side effects of the shot are very small, and since the consequences can be very significant for future pregnancies, the best option is to have this shot for prevention. We advise this even if you are planning on tying the tubes and have no wish for future pregnancies. This will keep all options open.
In summary, if you are Rh negative you can form antibodies during pregnancy that will cause harm to future pregnancies. If you get the shot at 28 weeks, and within 72 hours of any type of bleeding in pregnancy (including early pregnancy and at delivery), this process of antibody formation is blocked, and no harm will be done. You will need this shot with each and every pregnancy.
Anatomy Scan (Ultrasound at 18-20 weeks)
This is a detailed ultrasound where they count the fingers and the toes. They actually will have a detailed look at the baby by ultrasound to make sure that organs look the way they should and that they are measuring within normal. It is at this ultrasound that you may know if you are having a boy or a girl. If you do want to know, please make sure that you tell us of your wish at the time of arranging this ultrasound. We have to mention this on the form.
Now this ultrasound looks at form and not function. So, it may say that the baby has a normal looking liver for example, but it cannot say if baby may have lactose intolerance.
There are some situations where the ultrasound may recommend a repeat scan. This may be due to the fact that they could not see everything clear enough the first time, usually because of the way baby is sitting in there. Another reason would be if they see something that does not look normal, but may be just slightly so. A repeat scan will usually clear this.
Sometimes the report comes back saying that you have a low placenta. This is not uncommon. We repeat the ultrasound at about 30-32 weeks, and usually the placenta has cleared or ‘moved up’. If the placenta is covering the cervix it is not likely to move upwards. Read more about this in Placenta Previa. A low lying placenta on its own should not make you worry too much, nor is it a reason for any extra precautions.
We recommend you have your ultrasound closer to 20 weeks. The baby will be a nit bogger, and this will help in better assessment. Also, it is easier if you wnat to know if baby is boy or girl at 20 weeks.
3D ultrasound and 'Social Ultrasounds'
At any time in your pregnancy, you can, if you wish, have anultrsound scan on yoru baby. There are private clinics out there that will arrange for you to have a 3D ultrasound for a cost. These are not covered by OHIP, and you do not need a referral.
There are some issues around this, though. First, due to some cultural practices, these centers have self regulated themselves and might not disclose if the baby is boy or girl before 20 weeks.
Also, there have been some reports in the media of certain practices in an ultrasound place, I am sure you all heard about them. Your best options is to research them well, and go to a place that has a good reputation and favourable reviews.
There has bot been any evidence showing any issues with babies who had these ultrasound scans.
Blood Sugar Testing
Yes, it is this famous orange pop your heard women talk about. Fact is, when you are pregnant, pregnancy hormones put some stress on your body that may cause you to show diabetes. These changes are maximum after your 24th weeks of pregnancy. So, we arrange this test between 24 and 28 weeks.
You got to the lab, you do not need to be fasting. They give you this very sweet orange thing to drink. You stay with them for one hour, then they take your blood sample and send you home. If you test positive for this test, it does not mean you are diabetic. At least not yet. You will then have to do the test again, with more sugar load and more blood testing. This second test can come saying there is nothing wrong, or can say you are diabetic.
So, why do we not go ahead and test everyone with the real test? Good question. Because most moms will pass the easier one. So, they get away with only one poke.
If you come back with GDM, or diabetes with pregnancy, we will refer you to a diabetes program. You see a physician, a diabetic educator, and we also book you for an NST, or Non Stress Test in the hospital.
You may be tested again after delivery to make sure that this is not a true diabetes that has come to stay with you. You are more likely to test positive in coming pregnancies again, and if you do not follow the recommendations of the diabetic program, you may end up with diabetes later on in life.
This is a swab that we usually do between 35 and 37 weeks of pregnancy. GBS is a bacteria (stands for Group B Strept) that is commonly found in the vagina of some women. It is not a disease in and of itself. You may test positive on one day and negative on a later date. We do not test you if you are not pregnant. We do not test you early in pregnancy, because there is not too much of a concern. Now baby has no immunity, and if baby catches the GBS form mom at the time of delivery, baby may catch an infection that at times may be serious.
If you tested positive for GBS you will be given an antibiotic (penicillin every 4 hours IV, or clindamycin every 8 hours if you are allergic to penicillin). So, if you think you are in labour, or if you broke your waters, go to the hospital, labour and delivery. You will be started with an IV, and an antibiotic started. This will continue until the baby is delivered, and then stopped.
If you tested positive in one pregnancy, you may test negative on following pregnancy. This is wht we test you with each pregnancy. If you are booked for a C Section, you may not be tested for it, as there is no concern. If you tested positive for GBS in urine during this pregnancy, or if you had a baby that was infected in a previous pregnancy, you will probably be given the antibiotic anyway.
If you have not been tested, you will receive the antibiotics if you are preterm, or less than 36 weeks. If you are not tested and you are more than 36 weeks, you will not automatically be given the antibiotic. Only may be if you are feverish or have been labour for a long time.
Monitoring your baby’s movements
Your baby should be active and lively. You can expect the baby to behave in a way similar to a new born baby. They are awake at times and sleeping on other times. But baby should be generally active. If you notice a significant change from previous movements, you may want to check baby. This is usually done in the hospital, with what we call an NST, or Non Stress Test.
In general baby should move at least 6 movements every two hours. If you think baby has moved less than that, drink something sweet (like juice) and pay attention to baby’s movements for the following two hours. If it did not move 6 times, go to labour and delivery to get checked.
We know that towards the end of pregnancy there is less space inside the uterus, so baby’s movements become different. So may be there are no kicking as before, but still the body movements, or rolling movements should be there. And these count as baby’s movements.
There are some recent recommendations to get vaccinated during pregnancy. Do remember that some vaccines are not allowed during pregnancy eg MMR.
Influenza can be a bit nasty if you get infected during pregnancy. You can become mreo sick than non pregnant women. Also, it can result in more complications. So, the recommendation if for pregnant moms to get vaccinated against Influenza as needed.
Tetanus vaccine is safe during pregnancy. If you are due for Tetanus booster dose, there is no reason to delay it only because of pregnancy.
Typhoid vaccines can be taken during pregnancy.
Whooping cough or Pertusis: may be useful to pregnant women.
The "PAP" test, medically, is a test that is done using a vaginal speculum to collect cells from your cervix. It checks for Cancer cervix or precancer cells. It is indicated after age 21 and if normal, is only needed every 3 years. Bing pregnant or not is irrelevant. To say it in another way, you just do not automatically need a pap test only because you are pregnant. And pregnancy is not a reason to do the test, or delay the test.
These are also tests done using a speculum, and done by taking a sampl eof fluid from your cervix. To the patient, you feel it is the same thing like a pap test. Many women actually use the term pap test to mean swabs. Technically they are different tests, actually.
Swabs are done to check for STI's, namely Chlamydia and Gonorrhea.
Recently, with a new advance in lab techniques, we check for STI's by doing a urine test. So, 'swabs' may be obsolete soon.