Pregnancy monitoring

Monitoring a pregnancy is a serious task and a great responsibility for every perinatologist. The philosophy of the practice is that there is no generalisation: every patient is an individual, and the way her pregnancy is managed, the tests and the follow-up are adapted to her specifically.

Only by individual adaptation is it possible to act on risk factors in time and keep them under control. The aim is a healthy child, both at delivery and later in life.

Our approach to pregnancy care

The woman

A woman’s body provides the conditions in which a “little person” forms from the initial two cells, one from the mother and one from the father. The speed of development over nine months seems almost unbelievable.

The conditions in which a fetus forms are easy to understand if we compare them with those in which a small child grows: food, oxygen and every prerequisite for healthy development. What matters most is that the genetic potential received from the parents can be fully expressed and is not damaged by the way the pregnancy is managed.

The partner

As a future or existing parent, the partner supports the mother and helps her to feel at ease, to understand advice more clearly and to enjoy the pregnancy, which nevertheless requires supervision and caution.

Cooperation and trust

Cooperation, understanding and mutual trust between doctor and pregnant woman are important, as are empathy, the support of the family and support for the family. This includes the relaxation of both partners and of the children, the future brothers and sisters.

Good results in pregnancy care arise when the doctor shows empathy and both patient and doctor share understanding, communication and trust. Sometimes an exchange of thoughts and answers to questions are enough to give a woman peace of mind in pregnancy.

Care

Care is an acceptable term for supervising the development of the fetus and placenta and the overall condition of the mother. It is also help for a woman to keep her body stable and healthy, so that pregnancy does not expose her to the complications it can potentially cause.

Pregnancy as an extra load

Pregnancy, which we call the “other state” (drugo stanje), places an additional load on the body, because all organs are exposed to an extra, albeit physiological, dose of effort. Outside pregnancy, organs work on “some reserve” that we do not notice because we are healthy, whereas in pregnancy a problem can become apparent.

If a woman already has a medical condition, its progression must not be allowed. The aim is a healthy child and the preserved health of the mother.

Prevention

In perinatology it is largely possible to ensure that problems are prevented, so it is always better to stay “a step ahead of the problem”. One important step, where possible, is a complete check-up and assessment of the woman’s whole body before pregnancy.

If the pregnancy occurs without a previous check, it is better to gain an overview of the overall condition as early as possible and correct the fine details that often prove important over time. It is simpler to take care than to bear the consequences of spontaneous miscarriages and of complications for mother and child, which later burden the whole family.

The child

The predispositions for good fetal development come from the combination of the future parents’ genetics and should be preserved by correct and precise pregnancy care. Inadequate supervision should not be allowed to damage the genetic potential that nature has given.

Changes that occur in the womb can also affect the child’s health later in life. More on this in the section on fetal programming.

Confirming the pregnancy and the first visit

Confirming the pregnancy

Pregnancy is confirmed by positive values of the hormone beta HCG after a missed period. The viability of the pregnancy is confirmed by seeing the heart activity from the 6th week of gestation.

Weeks of gestation are counted from the first day of the last menstrual period, that is, from the point when the beta HCG level reaches 1000 IU.

The first visit

At the first visit it is advisable to record any chronic diseases, previous gynaecological conditions and operations. Where needed, specialists are consulted, so that the pregnant woman receives an integrative, individual and multidisciplinary approach.

Pregnancy is a test of the capacity of organs and organ systems. Knowing their condition in good time means being “a step ahead” of possible problems and preventing complications in both mother and fetus.

Check-ups during pregnancy

The pregnancy must be checked at least once in every trimester. The details of further tests are planned individually.

gynaecological examination
ultrasound examination
basic laboratory tests
measurement of arterial blood pressure
monitoring of weight gain

Advice for the pregnant woman

Mothers are given advice about available vaccination and immunisation, and about the benefits of exercise and of a healthy, personally adapted diet.

Screening and diagnostics

Screening tests show a statistical probability and do not give a definitive diagnosis. A definitive diagnosis is given by invasive diagnostics.

DOUBLE test in the first trimester

The DOUBLE test is a first-trimester screening test. It is offered to parents within the first 13 weeks of pregnancy, and its result shows the statistical probability that the fetus has one of the most common trisomies (genetic aberrations associated with anomaly syndromes).

The test takes into account the ultrasound finding, which covers several aspects of a precise subspecialist examination, and two biochemical parameters from the mother’s blood, hence the name (double).

TRIPLE test in the second trimester

The TRIPLE test is a second-trimester screening test. It is offered to parents between the 14th and 20th week of pregnancy, and its result shows the statistical probability that the fetus has one of the most common trisomies.

The test takes into account the ultrasound finding and three biochemical parameters from the mother’s blood, hence the name (triple).

NIPS

NIPS, or non-invasive prenatal screening, is a test that is safe for mother and fetus. It involves taking the mother’s blood, which contains fetal cells, and analysing it for chromosomal aberrations.

It is best performed at around the 10th week of gestation. Its advantages are that it can be done early and requires only a blood sample, but it is also a screening method and does not give a definitive diagnosis.

Invasive diagnostics

Unlike screening methods, invasive diagnostics (amniocentesis, cordocentesis, chorionic villus sampling) give a definitive diagnosis. The drawback of these methods is that they are performed later in pregnancy than screening and may have complications that are dangerous for the mother and fetus, that is, for the pregnancy:

infection
bleeding
haematoma
miscarriage

A well-prepared maternal body and a skilled perinatologist significantly reduce the likelihood of complications.

Monitoring the fetus

Fetal growth

Fetal growth is monitored throughout the pregnancy. Before a doctor comments on growth and progress, they must know how accurately the pregnancy has been dated, which is established from the first-trimester ultrasound.

Fetal growth depends on several factors: the condition of the mother, the condition of the placenta and the condition of the fetus itself.

The placenta

The placenta is the only organ built from the tissue of two different organisms. It delivers nutrients and oxygen to the fetus. The maturity of the placenta is assessed by ultrasound.

Doppler blood flows are also monitored through the uterus, between the uterus and the placenta, then through the umbilical cord and within the fetus itself.

The fetus is in effect a little person inside the mother’s body, so the circulations we follow in adults can also be followed in the fetus. The priority in the diagnostic cascade is blood flow through the fetal brain, in order to prevent complications in the later physical, mental and overall development of the baby.

Amniotic fluid

Amniotic fluid fills the amniotic cavity and is familiar to everyone from the breaking of the waters. It is rich in nutrients and also contains fetal cells, so it can be sampled for genetic analysis.

It is first formed from the mother’s plasma, and once the fetal kidneys have developed it also consists of excreted fetal urine. As the gastrointestinal system develops, the fetus swallows and inhales the fluid, which keeps its volume at an optimal level. The amount of fluid is assessed by ultrasound.

Fetal heart echo

A fetal heart echo is a detailed examination of the baby’s heart that can diagnose heart defects or disorders of heart position and rhythm.

It is best performed between the 22nd and 24th week, when the heart structures are most visible. It takes about half an hour, is painless, and the ultrasound image is obtained with an abdominal probe.

Growth restriction and excessive growth

If the doctor finds that fetal growth has stalled, that is, growth restriction (IUGR), or that the fetus is growing excessively (macrosomia), diagnostics are carried out first to establish why this is happening.

It is better not to let such changes occur, because they can later affect the child’s health once he or she is an adult. Correct pregnancy care therefore prevents complications not only in the newborn, but also those that appear later in life. In modern medicine this is called fetal programming, that is, the prevention of adult-life diseases.

Fetal condition and timing of delivery

On the basis of ultrasound parameters, Doppler examinations and, later, CTG (cardiotocography), the “condition of the fetus” is monitored and the right moment for delivery is planned. Sometimes it is safer for the fetus if the pregnancy ends with delivery.

Understanding the state of the fetus, that is, interpreting what the baby “tells us about itself”, is based on monitoring several parameters:

fetal growth and weight gain
amount of amniotic fluid
fetal movements
breathing pattern
muscle tone
biophysical profile
a series of Doppler flows and monitoring of the circulation that carries nutrients and oxygen

Artificial fetal maturation

If the health and life of the mother are at risk, from the 24th week therapy can be given that makes it possible for the baby to be born and then monitored in neonatology, which protects the life of mother and fetus.

In this way the aim is to secure a healthy child from pregnancies that end early, when miscarriages or premature births occur, when the mother’s health is at risk or her life is in danger. This approach is medically called artificial maturation of the fetus.

Preventing complications

Spontaneous miscarriage

Miscarriage is defined as the spontaneous loss of a pregnancy before the 24th week of gestation, although the literature also cites the 20th week.

By the 24th week of gestation the type 2 pneumocytes of the fetal lungs are anatomically formed, and with adequate therapy a healthy child can be secured without complications.

Causes and prevention of miscarriage

The causes of spontaneous miscarriage are numerous:

genetic aberrations
infections
anatomical anomalies
hormonal causes
thrombophilias

With a precise, individual approach to the patient, the causes are usually found and their recurrence is prevented. It is also advisable to show the pregnant woman how to “listen” to her body without strain.

Signs of miscarriage and therapy

Sometimes signs of miscarriage appear, such as pain or bleeding. The pregnant woman is then most often prescribed progesterone therapy in various forms.

If the cause is known, therapy is given accordingly, for example thyroid hormone replacement or anticoagulant therapy. Doses and ways of administration require precision, because these fine details can make the difference for later complications.

Complications in the mother

Complications in pregnancy can arise from internal causes, related to the mother’s health and the pregnancy itself, and from external factors. Some of them are preventable and can be corrected, such as lifestyle habits.

That is why the doctor should already be aware at the first check-up of the mother’s chronic diseases and any previous operations, and the pregnancy must be checked at least once in every trimester.

Timing and mode of delivery

Timing of delivery

The timing and mode of delivery depend on obstetric and non-obstetric, perinatal indications. A delivery between the 37th and 42nd week is considered full term, although in practice a pregnancy is rarely allowed to go more than a few days past term.

From the 36th week at the latest, the pregnant woman should be referred for CTG checks, which monitor uterine contractions and the regularity of the fetal heart rhythm. If complications arise, the condition of mother and fetus is followed through several methods which together, as an algorithm, give a more precise picture and the possibility of avoiding an emergency and complications.

Mode of delivery

The way the pregnancy is ended is guided by the condition of the mother, the condition of the fetus and obstetric indications. In a pregnancy without complications, where the mother’s pelvic measurements, her general condition and the fetal condition allow it, priority is given to natural, vaginal delivery.

If there is a need, an operative delivery, better known as a caesarean section, is planned in good time. If complications arise during natural delivery, the delivery is completed by an emergency caesarean section.

Anaesthesia and epidural

The use of anaesthesia in labour and of an epidural to prevent labour pain involves adapting the doses, so that the delivery is of good quality and successful.

Preparation for delivery

Besides the primary monitoring of the mother and fetus, preparation for delivery includes conversation with the pregnant woman, explanations, advice and a detailed description of the mode of delivery, whether natural or operative, that is, a caesarean section.

A healthy lifestyle in pregnancy

A healthy lifestyle in pregnancy means concrete advice adapted to each pregnant woman and her partner. Support for a woman comes from her partner, family and gynaecologist, and in modern, fast-paced life it also calls for the advice of an experienced doctor.

This covers exercise, nutrition, body care and the ways a woman’s body is looked after in pregnancy and prepared for delivery, as well as the psychological and emotional state of the future mother and her partner.

Nutrition and body weight

Nutrition is adapted to existing habits, respecting the metabolism the woman is used to, including vegan and vegetarian diets. To give the baby good development and growth, and the mother the chance to keep her shape and fitness, the diet has to be adapted individually to each woman.

The aim is to maintain body weight and adequate weight gain (BMI, body mass index), so that the fetus receives everything it needs and the mother’s body functions well. Advice adapted to the woman’s needs and her usual diet affects both her physical and her psychological state.

Physical activity

Moderate physical activity is recommended in all conditions that do not limit it. Circulation ensures the flow of blood, nutrients and oxygen through the uterus and placenta to the baby, and this is monitored professionally through the utero-placental, feto-placental and fetal blood flow.

Women who are used to physical activity can continue it in pregnancy, with the gynaecologist’s advice. For many pregnant women activity has not previously been part of life. In that case a certain amount of activity is advised for adequate blood circulation, and thereby for preventing uterine contractions.

The type and amount of activity depend on the person, her previous BMI, the stage of pregnancy and gynaecological findings, and are adapted by a qualified professional.

Vitamins and minerals

Modelling the metabolism and adapting exactly which minerals and vitamins a woman needs is important for preventing spontaneous miscarriages and premature births, for the growth and development of the fetus and for avoiding complications that lead to hospitalisation.

The amount of minerals and vitamins in tablets is not the same for everyone. It is not uncommon for liver enzymes to rise, for the day-night sleep rhythm to be disturbed, and for digestion and bowel problems to occur.

Example: vitamin D

Vitamin D is a vivid example. Doses and types of preparation that are not adapted cause nausea and do not achieve the effect needed for the health of the mother’s bones and teeth and the quality of her hair. Nor is any effect achieved on the development of the fetus.

By carefully determining the dose and type of preparation, it is possible to prevent problems with bones, skin and teeth, and also to regulate sugar metabolism and prevent gestational diabetes. Patients often receive vitamins that are not adapted to the individual, yet our bodies are not all the same.

Sexual life

Sexual life is part of a couple’s life and is adapted to the stages of pregnancy and the partners’ habits, if they so agree. Sexology is a scientific and professional part of gynaecology, and with professional advice it provides measures of prevention and protection from complications in pregnancy.

When sexual activity is not advisable in pregnancy, partners are given advice on how to preserve their mutual psychological, emotional and intellectual closeness.

Psychological preparation

Psychological preparation of the pregnant woman and the new mother requires a multidisciplinary approach, which a doctor, psychologist and midwife can provide, together with the support of the partner, family and society. Education is the first step in empowering women to be proactive in their pregnancy.

It is better to seek professional advice and avoid “advice” which, however well meant, reflects the personal experience of people who want to help. Every body is an individual, so protocols and guidelines are subordinated to the individual approach. Any schematisation in medicine carries risk, because a “mathematical approach” to pregnancy care does not bring good results.

Creating a new life is a major part of a woman’s life, but also a responsibility that is better shared with a gynaecologist she trusts, as well as with her partner and family.

Individualised therapy

A pregnant woman should be able to enjoy her pregnancy, and for that she needs calm and peace of mind. That is why we think not only of prescribing medicines, but of individualised therapy, an approach to each woman separately.

Therapy has to be measured correctly: it is not enough to give a medicine without choosing an adequate dose.

Preparing for delivery and breathing

This approach aims at an easier delivery. For a natural delivery the pregnant woman should know the details of labour, cooperate and go through what is called breathing school.

Breastfeeding and breast care

The period after delivery, whether operative or vaginal, is delicate and begins with the body adapting to a new metabolism, breastfeeding and lactation.

The aim is to preserve the quality of the milk, prevent complications such as inflammation of the breasts and detect ultrasound changes in the breasts in good time. For women with implants, the woman’s wishes are respected and complications are prevented. The intention is to make things easier for both mother and baby.

Fetal programming

The aim of fetal programming is for the genetic capacity of the fetus to be expressed as fully as possible.

What fetal programming is

Many diseases later in a child’s life, through adolescence and adulthood, originate in changes to the cells and tissues of the fetus in the womb. This is professionally called fetal programming.

Correct monitoring of the pregnancy aims to ensure that the growth, development and function of the fetal organs are normal, and thus to prevent diseases of the adult.

A healthy environment for the fetus

By regulating the risk factors that make a pregnancy pathological, we act on fetal programming and reduce potential diseases in the child’s adult life. The fetus then has the chance to develop in a “healthy” environment provided by the mother.

To put it more vividly, a newborn child living in clean air, light and good food develops better than a child exposed to darkness, pollution and poor nutrition. The same applies to the fetus inside the womb.

Epigenetic changes

Fetal programming involves epigenetic changes that take place in the fetus in response to various external or internal factors.

Epigenetic changes mean that different genes are activated in the exposed fetus so that it can adapt to the environment in which it finds itself.

external factors, for example smoking
internal factors: gestational diabetes, hypertension, long-standing diabetes, thyroid disorders, metabolic disorders

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