ABC of Pregnancy

First visit: 6-8. week

First of all, pregnancy is diagnosed with β-HCG in the blood or the positive pregnancy tests in urine. At the first pregnancy visit, the mothers are passed through a check-up.

  • Ultrasound (preferably through the vagina)
  • Blood type, Rh
  • Complete blood count
  • Blood biochemistry
  • TORCH scan
  • Complete urinalysis, urine culture-antibiogram, if necessary
  • Cervicovaginal smear test (PAP smear test)
  • Bleeding profile
  • Hepatitis B, Hepatitis C, AIDS screening

Visit 2: 10-13. week

  • Nape thickness (Nuchal Translucency, NT)
  • I. Trimester screening test

Visit 3: 16-18. week

  • Ultrasound (anomaly scan)
  • II. Trimester screening test (Triple Test, Triple Test)
  • Amniocentesis (if necessary)

Visit 4: 22-24. week

  • Ultrasound (anomaly scan)
  • Cervical culture and fresh tests.

Visit 5: 24-28. week

  • Complete blood count
  • Complete urine test
  • 50 gram glucose tolerance test
  • Indirect Coombs Test at 28th week (in those with blood incompatibility)

Visit 6: week 32

General ultrasound reviews

Visit 7: Week 34

General ultrasound reviews

Visit 8: week 36

General ultrasound reviews

Visit 9: week 38

  • Ultrasound (biophysical profile if necessary)
  • NST (Non-Stress Test)
  • Doppler ultrasound (if necessary)
  • Blood biochemistry, Complete blood count, Complete urinalysis, Hbs Ag, Anti Hbs, HCV, HIV, repeat TORCH tests if necessary

39-42. monitoring between weeks

  • Ultrasound (biophysical profile if necessary)
  • NST (once a week between 38-40 weeks, every 3 days after 40 weeks)
  • Vaginal examination (touch)
    Pregnant is informed about birth marks and detailed information about birth is given to the expectant mother.

After the 40th week, it is useful to evaluate the pregnant woman twice a week until the birth.

Pregnant women who have not started their birth until the 42nd week should be hospitalized and the birth should be started.

Pregnancy Follow-Up (Detailed)

First visit: 6-8. week
The most frequently requested period is the first visit. In this period, expectant mothers are passed through a check-up in terms of diseases they already knew or did not know.

Ultrasound
In ultrasound, it is possible to see the embryo with a heart rate above 100 / min in the proper gestational sac and the sac (yolk sac) that feeds the embryo.

The presence of any mass of myoma in the uterus and any cyst in the ovaries is also investigated on ultrasound. The length and shape of the cervix (cervix) is also evaluated.

In these weeks of gestation, it is clearer than the ultrasound (transabdominal) done through the vagina (transvaginal way) and is the reason for preference.

It is possible to see heart beats with an embryo at the transvaginal way ultrasound at 5 weeks and 4 days according to the last menstrual period, and at the transabdominal way at 6 weeks.

Blood type, Rh:

If the pregnant's blood group is Rh negative, and her partner's blood group is Rh positive, “Blood incompatibility” (Rh / rh) is mentioned. The "Indirect Coombs test" should be performed to see if the baby in the womb is affected by blood incompatibility.

Pregnant women who are negative for the indirect coombs test are followed up by understanding that there is no affect in the baby due to blood incompatibility. In case of continuation of the indirect coombs test negativity at week 28, an injection of “Anti D Immunglobulin” is applied to protect the baby from blood incompatibility until the last months.

Again, in pregnant women with blood incompatibilities, the blood group of the baby is checked after birth. If the blood group is Rh positive, Anti D Immunglobulin application to the mother is repeated.

There is no blood incompatibility in all possibilities except that the mother-to-be blood group is Rh-negative and the father-to-be is Rh-positive.

Complete blood count:

The presence of any “blood deficiency (anemia)” condition at the beginning of pregnancy is investigated with a complete blood count.

Blood deficiency may be related to iron deficiency, but may also be a symptom of Megaloblastic anemia, Pernicious anemia, Sickle cell anemia, Thalesemia states, malignancies and some systemic disorders.

Blood biochemistry:

Fasting blood sugar (FBS), Urea (BUN), SGOT, SGPT, Creatinine. Detection of liver and kidney diseases at the very beginning of pregnancy is important for follow-up. Indeed, the burden of these organs will increase during pregnancy.

Pregnancy may be terminated in severe kidney or liver problems. Especially in the presence of systemic conditions such as diabetes, high blood pressure (hypertension), these tests increase in importance. In these cases, physicians may also request some tests.

TORCH scan:

Toxoplasma, Rubella (Rubella), CMV (Cytomegalovirus), Herpes Type 2 infections are scanned for Ig M and Ig G antibodies.

While such infections do not cause any problems when they are spent outside of pregnancy, they may cause some disabilities in the baby, especially in the first three months of pregnancy.

Toxoplasma is taken from the foods eaten especially with cat and dog droppings. Especially raw meat and unwashed fruits and vegetables play a role in passing Toxoplasma parasite. The fact that both Ig M and Ig G antibodies are negative in the antibody screening tests performed at the beginning of pregnancy indicates that the body never encountered toxoplasma parasite. In this case, protection from toxoplasm is essential until the end of pregnancy.

In order to protect from toxoplasm, it is necessary to stay away from cat and dog animals during pregnancy, to have vaccinations if they are fed at home, to cook edible meat well, not to eat raw meat, to wash hands well before meals and to wash fruit and vegetables with plenty of water.

Rubella (Rubella), CMV (Cytomegalovirus), Herpes Type 2 infections are the diseases that are transmitted through contact with mostly sick people. Pregnancy should definitely be evacuated in people who encounter Rubella (rubella) microbe in the first trimester of pregnancy and pass the disease.

Complete urinalysis, urine culture-antibiogram, if necessary

Urinalysis performed at the first visit is an indirect indicator of kidney function as well as informs about the presence of hidden or obvious urinary tract infection. Urinary tract infections in the first months increase pregnancy-related nausea and vomiting, and may cause burning and / or inguinal pain in the urine.

Secret or overt infections in recent months can lead to preterm labor.

Cervicovaginal smear test (PAP smear test)

As a result of hormones secreted during pregnancy, cervix cancers increase. Therefore, the presence of such a condition should be investigated by applying a smear test to pregnant women in the first months.

While most of the pregnant women in our country believe that they will harm their babies with a false belief, they do not accept this kind of procedure, and their doctors usually neglect this procedure since they do not want to frighten their patients in the first month.

Bleeding profile

Bleeding profile tests include aPTT, PTT, INR, Fibrinogen, Platelet count. It is a process with both normal delivery and cesarean bleeding. The "bleeding tendency" of pregnant women should be determined at the first visit. In addition, patients are questioned whether they have a condition that is prone to bleeding, which is earlier than their own testimony.

Hepatitis B, Hepatitis C, AIDS screening

Hepatitis B, Hepatitis C, AIDS screening

Such viral diseases are transmitted through sexual intercourse, blood or childbirth and can often cause carriage (portering) for a long time in individuals.

The carrier (porter) means "able to transmit the disease even when there is no patient". Although the viruses that these people have in their bodies pass through the placenta to the baby during pregnancy, they do not cause any disability in the baby, and since the immune resistance (immunity) of the newborn babies is less than that of the adults, they may cause some problems after birth. These problems can be in the form of getting sick or carrying the disease in infants.

The infants of the hepatitis B carrier mothers are given serum with postpartum vaccination and the vaccine treatment continues at certain intervals. In this way, the baby is actively immunized. Unfortunately, there is no effective disease-saving treatment for babies born to pregnant women who have Hepatitis C and AIDS virus.

Visit 2: 10-13. week

Nape thickness (Nuchal Translucency, NT)

The anatomical organs and size of the fetus are evaluated between these weeks.

The fetus should be between 11 and 13 weeks and 6 days according to the last menstrual period and head-butt distance between 45-84 mm in order to measure the nape thickness properly.

Nape pleat thickness; It increases in chromosomal disorders such as trisomy 21 (Down syndrome, mongolism), trisomy 18 and problems of some organs of the baby, especially the heart. The reason for this increase is the accumulation of fluid (edema) in the nape area of the baby and it is possible to catch it with ultrasound.

Normally, the nape thickness of the baby increases as the gestational week progresses. Generally, over 3 millimeters is considered pathological and in this case, the fetus is evaluated further in terms of “Down syndrome”.

Neck thickness measurement is a method that has been used in pregnancy follow-up in recent years. It also requires a certain experience to be done.

I. Trimester screening test (Dual test)

The aim of the first trimester screening test, which has become widespread in the world in the last decade and in our country in the last 4-5 years, is to catch Down syndrome in the early weeks of pregnancy.

9-13 according to the last menstrual date. Free β-HCG and PAPP-A biochemical values are examined by taking blood from the mother candidate in the test applied between weeks of gestation.

In Down syndrome, while the free β-HCG values are twice as high in mother blood, PAPP-A values are 2.5 one (40%) of the normal. In the process called "double test", both biochemical values are evaluated in the computer program and a risk rate arises. Having a risk ratio above 1/250 requires further investigation in terms of Down syndrome.

If the test is positive, the next step is to obtain a diagnosis by chromosome analysis by taking a small piece from the baby's part of the placenta called "chorionic villus biopsy".

The test was named as "triple test" by evaluating the "Nuchal Translucency (NT, nape thickness, nape pleat thickness)" measurements added to the bilateral test in recent years.

Visit 3: 16-18. week

Ultrasound; the fetus as a whole is evaluated for anomaly screening.

II. Trimester screening test (Triple Test, Triple Test)

Purpose in triple test application; It is the screening of some abnormalities called “Neural tube defects” together with chromosome disorders such as Down syndrome and trisomy 18 belonging to the baby.

Triple test; 16-19 of pregnancy. In the sample taken from the mother's blood between weeks of, β-HCG is done by measuring three biochemical substances called alpha feto protein (AFP) and unbound estriol (uE3). These measurements are evaluated together with the age, body weight, race, diabetes mothers, whether they smoke or not, and the characteristics of previous pregnancies in the history according to the week of gestation. The risk of encountering neural tube defects and some chromosomal abnormalities (Down syndrome and trisomy 18) in the growing baby is calculated.

The triple test is not a diagnostic test but a "screening test". The purpose of the test is to determine the risk of anomaly in the baby without using risky methods for the baby and mother. If the risk rises above a certain level as a result of the test (in general if it is more than 1/270), a definitive diagnosis is made by performing the procedure called “amniocentesis”. In other words, amniocentesis is a diagnostic test.

In the process of amniocentesis, amniotic fluid is taken from the mother's womb with a thin and long needle. When done with experienced hands, it is quite painless and has little risks for the baby.

There are living cells that are shed from the baby in the fluid taken. These cells are produced by keeping them in a special culture medium. The produced cells are collected at a certain stage and their chromosomes are separated and viewed under a microscope, the chromosomes are analyzed.

Since the cells displayed in the chromosome analysis belong directly to the baby, it shows the chromosome spread of the baby. In this way, problems with the baby's chromosomes can be easily seen, and at the same time, the sex of the baby is revealed by examining the sex (sex) chromosomes. In the picture below, you can see the amniocentesis procedure.

Enter the amniotic sac with ultrasound guidance with a fine needle from the abdomen. Approximately 20 cc amniotic fluid is aspirated with an injector and sent to the genetic laboratory.

Neural tube defects (NTD) rank first among the anomalies (defects in the baby) seen in infants. There are several different types. One of them is that the baby's brain tissue does not develop as a whole, this heaviest form called “anencephaly” is fatal.

Other types of neural tube defects are related to the spinal cord. As the spinal cord develops, the spinal bones surrounding it do not close completely, resulting in the spinal cord tissue coming out of a cleft on the baby's back; this condition is called “spina bifida”. This nerve tissue, which is very sensitive to external factors, is damaged over time and the baby performs neural functions below a certain level maze. As a result, it is a congenital anomaly that can be fatal for the baby. Slightly spina bifida has a chance to improve with some operations after birth.

In these anomalies, “alphafetoprotein” (AFP) passes from the exposed tissue to amniotic fluid and from there to the mother's blood. In tests made from mother's blood, higher amounts of alphafetoprotein are detected in these pregnant women than in normal pregnant women.

85% of pregnancies with spina bifida can be caught with this test. However, although everything is normal in 3-4% of the pregnant women tested, it can give high results. Therefore, it is not diagnosed with test results alone.

In the triple test, if AFP is high, brain tissue and spine are evaluated with detailed ultrasound. In the presence of a condition that cannot be detected by ultrasound, an accurate diagnosis can be made by performing amniocentesis by measuring the amount of AFP in the amniotic fluid. In addition, the amount of "acetylcholine esterase enzyme" in the amniotic fluid can be observed.

In pregnancies with high AFP value but without anomaly in amniocentesis and detailed ultrasonography, it is recommended to follow the growth and development of the baby more closely.

The risk of trisomy 18 along with Down's syndrome can be calculated with triple test in mother's blood. The 21st chromosome, which should normally be two in a baby with Down syndrome, is three.

In trisomy 18, the same problem is on the 18th chromosome. Babies with trisomy 18 are incompatible with life and generally die in the womb or immediately after birth. The incidence of trisomy 18 is very low compared to Down syndrome.

Down's syndrome (Trisom 21, mongolism) occurs approximately once in 850 births. In this chromosome anomaly without treatment, there are babies with physical and mental retardation.

The chance of having Down syndrome increases depending on age. Especially over 35 years of age, risk reaches an important dimension. However, while 25-35% of all Down syndrome patients are only pregnancy products over 35 years old, they are in young pregnancies up to 70-80%. Almost 60% of babies with Down syndrome (5% false positivity) can be caught with triple test.

In order to increase the chance of triple test to catch Down syndrome in recent years, the studies carried out to transform the test into a "quad test" form by measuring and adding the biochemical value called "Inhibin A" in the test.

In order to make a definitive diagnosis in pregnancies with a high risk of Down syndrome, it is necessary to perform genetic amniocentesis as described. The main purpose of the triple screening test is to catch babies with Down syndrome that can be compatible with life and have a mental retardation. Babies with Down syndrome who are caught as a result of amniocentesis are evacuated by the decisions of the health committee issued.

It is possible to detect some other anomalies with triple test. Test results can be high in the abdominal wall anomalies of the baby (gastroschisis, omphalocele) and kidney anomalies. Therefore, before performing amniocentesis to pregnant women with increased risk in triple test, detailed ultrasonographic evaluation (2nd stage ultrasonography) should be performed for all these anomalies.

Visit 4: 22-24. week

Ultrasound; cervical (cervical) length and shape are measured. The baby is especially evaluated for the heart, brain and other internal organs.

Cervical culture and fresh tests

It is performed to investigate hidden vaginal infections. Some vaginal infections, which are called “opportunistic infections” may develop during pregnancy, especially due to decreased cellular type body resistance. Among these, especially fungal infections (candida), as well as Trichonomas and Gardnerella infections.

Generally, these relapsing disorders after treatment may require repeated treatment in the weeks of gestation.

Visit 5: 24-28. week

Complete blood count

The mother candidate's blood count is performed to see if anemia has developed in these later weeks of pregnancy.

Complete urine test

The presence of hidden infections in the urine is investigated. Especially in pregnant women, secret urinary tract infections (asymptomatic bacteriuria), which are characterized by the appearance of bacteria and lococytes only in urinalysis without causing any complaints, can lead to preterm and kidney infections (pyelonephritis).

If such a situation is detected in the full urine test, urine culture-antibiogram test should be performed and antibiotics should be started according to the type of microorganism reproducing.

50 gram glucose tolerance test

During this gestational week, 50 grams of powdered glucose is diluted with fasting in the morning and the blood is taken for an examination after one hour. If the blood glucose value in the blood sample taken is 140 mg / dl and above, the test is accepted as positive and 100 grams standard glucose screening test is passed after a day in these pregnant women.

Some pregnant women may have trouble drinking this rather sweet juice, for example, nausea and vomiting. In this case, when going to the laboratory, his complaints will be generally resolved by taking "lemon" with them and squeezing them into fresh water.

In the 100 gram standard screening test this blood is taken from the pregnant women in the morning with an empty stomach and 100 grams of powdered glucose is diluted immediately afterwards. 1 hour, 2 hours and 3 hours later, blood is drawn for examination. Thus, 4 different blood glucose values are obtained together with fasting blood glucose. If 2 or more of these 4 values are above the standard values, pregnant women are diagnosed with gestational diabetes (diabetes due to pregnancy, hidden diabetes) and sent to the dietitian for consultation for calorie restriction.

If pregnant women with gestational diabetes are not restricted from diet, as a result of the high blood sugar values of the mother; conditions such as baby's being bigger than normal, birth difficult, amniotic water more than normal and related preterm risks. In addition, metabolic problems related to blood values after birth may occur in babies born.

According to normal, large babies (macrosomia) are referred to as “squish” among the people.

Indirect Coombs Test

This week only pregnant women with blood incompatibility are evaluated again by looking at the Indirect Coombs test, if the result is negative, it means that the baby is not affected. In this case, "Anti D Immunglobulin" needle is applied to the pregnant woman in order to protect it from being affected until the end of the pregnancy (immunization).

Visit 6: week 32
Ultrasound; The development of the fetus, its internal organs are evaluated in detail. In addition, amniotic fluid, baby's posture, location and appearance of the placenta, active movements of the baby in the womb are examined.

Visit 7: Week 34

The operations in the 6th visit are repeated. In the presence of risky situations, additional examinations such as Doppler ultrasonography and NST may be requested.

Visit 8: week 36

In the ultrasound, especially the baby's posture, amniotic fluid, the appearance of the placenta and the active movements of the baby are examined.

Visit 9: week 38

We use many methods to determine the health of babies. It should be noted that no method alone has 100% sensitivity.

Most of the researches performed during pregnancy follow-up are to make the environment of the mothers and the fetus healthy or to determine the health level of this environment. It is an advantage to use the possibilities of technological developments and information age in the detection and follow-up of risky pregnancies, as in every field of medicine.

In the last weeks, there are three different methods that show the well-being of the baby. These:

Ultrasonographic evaluations; NST and baby movements.

While the first two of these are examined by the physician, the baby's movements should be evaluated by the expectant mother. In the event of a sudden decrease in the baby's movements, this may be an expression that the baby is in trouble. In this case, he should inform the pregnant physician.

In addition, the baby's “biophysical profile scoring” is done. Biophysical scoring; In the ultrasound, some active movements of the baby in the uterus and the amount of amniotic fluid, as well as the evaluation of NST findings, are scored together. It is an important criterion that shows the health of the baby.

In summary, biophysical profile scoring; These are the evaluations of ultrasound imaging of pregnancy and NST findings. In diagnosis, the decision should be made by considering it as a combination rather than a single method.

NST (Non-Stress Test, Cardiotocography)
NST has become an indispensable method in pregnancy follow-up especially in recent years.

It is a test that evaluates the baby's well-being based on the course of the baby's heartbeat, the relationship between the baby movements and the contractions, if any, with a device called cardiotocography (cardio = heart, toco = uterine contraction) or for short. It is used for the same purposes during labor.

There are two receiving tips, called "probes" and fixed on the belly of the pregnant woman. One of the probes perceives the contractions of the uterus (uterine contraction) and the other senses the baby's heart sounds. Perceived contractions and heart sounds are transferred by the device onto a graph paper.

During this process, which takes about 20 minutes, pregnant women are asked to press a small button given to their hands whenever they feel their movements. Thus; The baby's heart rate and reactivity (variations in the beat rate), contractions in the uterus and the responses of the baby's heart to these contractions are evaluated by the physician and indirect information about the health of the baby is obtained.

NST, especially in the last months of pregnancy, demonstrates the health of the baby and is also very important in monitoring (monitoring) during delivery.

In non-risk pregnancies, it is recommended to repeat the NST application once a week after 37 weeks of gestation and every 3 days after 40 weeks of gestation.

Before the NST procedure, it is recommended that the mother be satiated by eating a carbohydrate-rich diet. The application has no negative effect on the baby.

Valuable information is used when NST is used in situations where the expectation of contractions is suspected, especially in cases where the expectant mother indicates a decrease in infant movement.

Color doppler ultrasound

Color doppler ultrasonography has been increasingly used in recent years.

It is especially used to determine the risks of the expectant mother and to evaluate the health of the baby.

In the Doppler ultrasound, the blood flow to the baby is examined briefly. In the picture above, the blood flow color that goes to the baby in an early pregnancy is monitored by doppler ultrasound.

In cases of impaired blood flow (decrease or backward), the baby's life is at risk. The increase in resistance in the vessels refers to the decrease in blood flow.

In addition, the umbilical artery within the umbilical cord between the baby and the placenta, umbilical vein, and waveform disorders in the baby's brain vessels can determine the severity of circulation in the baby as well as its severity.

When circulatory disorder is detected on Doppler ultrasound, the risk of worsening in the condition of the baby is increased in later periods. Especially in cases such as preeclampsia (pregnancy poisoning) or the baby's low intrauterine development (IUGR), the increase in resistance in the vessels indicates that the trend is negative.

12-14 of pregnancy. The “Ductus venosus doppler” performed in the weeks of pregnancy gives hope in the early diagnosis of a number of chromosome disorders such as Down syndrome, especially heart anomalies, in the baby.

Blood biochemistry, Complete blood count, Complete urinalysis, Hbs Ag, Anti Hbs, HCV, HIV, TORCH tests are repeated. These tests are revised to prepare for prenatal birth or possible cesarean delivery.
If cesarean is planned, these examination results are also important for anesthesia.

Information about birth

Detailed information about birth is given to the expectant mother.

39-42. monitoring between weeks
Ultrasound (biophysical profile if necessary)
NST

38-40. It is recommended to apply once a week between weeks and every 3 days after 40 weeks.

It was observed that 997 of 1000 pregnant women with NST normal (reactive) had no problems in the first three days. NST has an important place in monitoring fetal well-being.

Vaginal examination (touch)

Vaginal (pelvic) examination is called "touch". The aim is to evaluate the hip bone (pelvis) and cervix. In this way, pelvic invasion, bone protrusions and pelvic roof are evaluated in detail. In addition, the cervix is also checked.

Pregnant is informed about birth marks.

After the 40th week, it is useful to evaluate the pregnant woman twice a week until the birth.

After the 40th week, it is useful to evaluate the pregnant woman twice a week until the birth.

Pregnant women who have not started their birth until the 42nd week should be hospitalized. Because, after this week, it is considered as “Day-out (Surmaturation, posterm)” pregnancy and the risk of the baby getting bored inside is considerably increased.

Depending on the risks of pregnancies, these tests may be displaced, follow-ups may be more frequent or more detailed tests may be requested.

Op. Sibel Malkoç, MD

Gynecology and Obstetrics Specialist

Dr. Sibel Malkoç attended many domestic and international training seminars and congresses during 25 years of specialised physician service.

Pregnancy follow-up, urinary incontinence surgery and laser treatments, genital aesthetic surgery and laser applications and vaginismus treatment are of special interest.

It serves its patients especially in surgical and laser-assisted Vagina aesthetics.

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