Normal Pregnancy

The first lecture that I presented at McMaster University I gave the title “What is normal?” This was about research and laboratory data. A paper had been published by an English university which I disagreed with. The paper was on infertility in patients with “normal Prolactin levels”. In this study the patients had blood samples taken on one occasion in a morning. Prolactin has a diurnal variation (the level changes from morning to night). We had demonstrated marked variations in the same patient at different times of the day, with levels up to five times higher in the evening. The laboratory reports a level against a normal value. However it is never stated if this is an internationally recognised normal, normal for the equipment used, normal for the assay established by that laboratory or normal for that patient. All laboratories have reference levels for healthy men and women but although it is known that levels for most routine laboratory tests change during pregnancy, many laboratories do not show ranges for pregnant women.
There is no such thing as a normal pregnancy – every mother and baby is unique. There are however some common features.
Symptoms of pregnancy
A missed period is usually the first signal of pregnancy, although women with irregular periods may not recognize this. During this time, many women experience a need to urinate frequently, extreme fatigue, nausea and/or vomiting, and increased breast tenderness. Most over-the-counter pregnancy tests are sensitive 9-12 days after conception. During early pregnancy, most women experience an increased appetite.
Weight gain during pregnancy
Weight gain during pregnancy consists of the products of conception (fetus, placenta, amniotic fluid) increase of maternal organs and tissues (uterus, breasts, blood, extracellular fluid, maternal fat stores). The rate of weight gain varies with the trimester. Although weight should be gained throughout pregnancy, it is most critical in the second trimester. The appropriate gestational weight gain depends upon the pre-pregnancy Body Mass Index (BMI). The Institute of Medicine’s 2009 pregnancy weight gain recommendation guidelines for singleton pregnancies are
Underweight (BMI less than 18.5) – 28-40 lbs
Normal weight (BMI of 18.5-24.9) – 25-35 lbs
Overweight (BMI of 25-29.9) – 15-25 lbs
Obese (BMI that exceeds 30) – 11-20 lbs
Women with a low BMI need to gain more weight to produce babies with birth weights comparable to women with a normal BMI. Women with a high BMI can deliver babies with higher birthweights with lower gestational weight gain.
Fetal movement
Most women start to feel fetal movement by 18 to 20 weeks gestation in a first pregnancy, in following pregnancies it can occur as early as 15-16 weeks’ gestation. Early fetal movement is felt most commonly when the woman is sitting or lying quietly. The time at which a woman first feels the baby move is termed quickening.
Breast changes during pregnancy
Pregnancy-related breast changes include growth and enlargement, tenderness, darkening of the nipples, and darkened veins due to increased blood flow. In addition, small raised bumps (Montgomery tubercles) appear around the areola in mid-pregnancy. Colostrum is a yellowish fluid secreted by the breast that can be expressed as early as the 16th week of pregnancy. It is replaced by milk on the second postpartum day.
Skin changes during pregnancy
Pigmentation changes are directly related to melanocyte-stimulating hormone (MSH) elevations during pregnancy. Increased pigmentation of some form affects 90% of pregnant women but is more obvious in women with darker skin. This is typically evident in the nipples, umbilicus, axillae and perineum, the linea alba darkens to a brown line called the linea nigra on the midline of the abdomen. Pre-existing moles, freckles and recent scars also become darker. Melasma (also known as chloasma or the mask of pregnancy) is a tan or dark skin discoloration. These are seen in 75% of pregnant women and are commonly found on the upper cheek, nose, lips and forehead. Most of these changes regress after delivery but may recur in future pregnancies.
Striae gravidarum (stretch marks) occur in most pregnant women, usually by the end of the second trimester. In Caucasian women the incidence is reported as 90%. Stretch marks usually occur when weight is lost or gained quickly and the degree to which a woman experiences stretch marks is determined genetically. They usually fade and pale with time.
Hair changes in pregnancy are very common both scalp and body hair. Hirsutism (excessive growth of body hair) is seen in many pregnant women. Thickening of scalp hair during pregnancy is usually followed by increased hair shedding one to four months after delivery.
Sebaceous gland activity is increased during the second half of pregnancy causing greasy skin and possibly acne.
Haemorrhoids and varicose veins
As pregnancy progresses the combination of increased blood volume, circulating progesterone effect on blood vessels and pressure of the growing uterus result in haemorrhoids being more common during pregnancy.
Varicose veins may also appear for the first time during pregnancy due to the relaxant effect of progesterone on blood vessel walls and stasis in leg vessels caused by pressure of the uterus.
Labour
The onset of labour is regular contractions resulting in progressive cervical changes. A “show” (blood stained mucus discharge) or spontaneous rupture of the membranes (waters breaking) do not of themselves define the onset of labour. Despite the prevalence of “waters breaking” heralding the start of labour in films and TV dramas, this occurs before regular contractions in less than 8% of pregnancies.
The duration of labour varies with different populations and management practices. A general guideline would be that in most first pregnancies labour lasts less than 12 hours and this is reduced to less than 8 hours in subsequent pregnancies.
Most blood loss related to childbirth occurs within the first hour after birth. In vaginal deliveries up to 500ml of blood may be lost from the genital tract within 24 hours after birth, some of which may appear as clots.

Acupuncture during pregnancy

In recent years there has been increased interest in the use of acupuncture in obstetrics, since it offers a drug-free alternative to conventional treatments for common pregnancy-related complaints.
A study to review the effectiveness of needle acupuncture in treating the common and disabling problem of pelvic and back pain in pregnancy was reported in the American journal of obstetrics and gynecology198.3 (Mar 2008): 254-9, although not a large study supported its use.
Other studies on back pain in pregnancy include –
Acupuncture relieves pelvic and low-back pain in late pregnancy
Kvorning, Nina; Holmberg, Catharina; Grennert, Lars; Aberg, AndersView Profile; Akeson, Jonas; et al. Acta obstetricia et gynecologica Scandinavica83.3 (Mar 2004): 246-50.
Conclusion – Acupuncture relieves low-back and pelvic pain without serious adverse effects in late pregnancy.

Acupuncture for low back pain in pregnancy – a prospective, quasi- randomised, controlled study
Bosco Guerreiro da Silva J; Uchiyama, Nakamura M; Cordeiro JA; Kulay, Acupunct Med22.2 (Jun 2004): 60-7.
Conclusion – results indicate that acupuncture seems to alleviate low back and pelvic pain during pregnancy, as well as to increase the capacity for some physical activities and to diminish the need for drugs, which is a great advantage during this period.

Other studies in pregnancy have shown acupuncture to be effective for stress, morning sickness, hip and low back pain, breech position, mild to moderate depression, labour induction, and shortening the length of labour. Acupuncture therapy may offer some advantage over conventional treatment in the management of hyperemesis gravidarum and post caesarean section pain.
Acupuncture for insomnia in pregnancy -da Silva JB; Nakamura, MU; Cordeiro JA; Kulay, L J. Acupunct Med23.2 (Sep 2005): 47-51.
The results of this study suggest that acupuncture alleviates insomnia during pregnancy.

A 2002 study conducted at the Women’s & Children’s Hospital at Adelaide University in Australia on the safety of acupuncture for nausea in early pregnancy verified that there is no increased risk of congenital anomalies, miscarriage, stillbirth, placental abruption, pregnancy-induced hypertension, preeclampsia, premature birth, or normal measures of neonatal health (such as maturity or birth weight) when women receive acupuncture during pregnancy. The study was conducted during the first trimester of pregnancy, when foetal development is most vulnerable.
A systematic review of the safety of acupuncture during pregnancy reported in 2014 reviewed 105 studies. The objective of this review was to identify adverse events associated with acupuncture treatment during pregnancy. Total incidence of adverse events was 1.9%, the most common being needle pain and all were classified as mild to moderate. The conclusion was that acupuncture during pregnancy appears to be associated with few adverse events. The safety of acupuncture during pregnancy: a systematic review. Park, Jimin; Sohn, Youngjoo; White, Adrian R ; Lee, Hyangsook ; NLM. Acupuncture in medicine : journal of the British Medical Acupuncture Society 32.3 (Jun 2014): 257-66.
Acupuncture is safe when it is conducted by a qualified practitioner.
There is no statutory regulation of acupuncture in England though GPs, physiotherapists and nurses, are subject to statutory regulation and many are now trained in acupuncture.

Mild, short-lasting side effects do occur in some cases. These include:
• pain where the needles puncture the skin
• bleeding or bruising where the needles puncture the skin
• drowsiness
Because of the slight risk of bleeding, people with bleeding disorders such as haemophilia, or people taking medication to prevent blood clotting (anticoagulants), may not be able to have acupuncture.
Acupuncture is also not usually advised if you have a metal allergy or an infection in the area where needles may be inserted.
Acupuncture is not a substitute for prenatal medical care. It does however offer complementary care that may have many benefits with very few side effects.

Too Many Caesarian Sections.

Cesarean delivery is the most commonly performed surgical procedure in the United States. Cesarean delivery may be a safe alternative to vaginal delivery but its use in 1 of 3 women giving birth in the US seems too high.
American College of Obstetricians and Gynecologists (ACOG) 2017 Annual Meeting.
“About half the C-sections we do in the United States today are probably avoidable.” “According to our own guidelines, we shouldn’t be doing any C-sections on labor progress alone before 6 centimetres, if we just did that, it’s worth tens of thousands of C-sections per year.”

Rates in American hospitals for low-risk patients range from 2.4% to 36.5% (Health Aff [Millwood]. 2013;32:527-535)
In 2014, 1.3 million women in the United States delivered via cesarean, placing the rate at 32.2%, down just 0.7% from the peak in 2009.
In 2013-14, in the UK; 386,937 (60.9 per cent) of deliveries in NHS hospitals were spontaneous deliveries, while 166,081 (26.2 per cent) were caesarean deliveries.
In the 1950s, 3% of births in England were by CS. By the early 1980s this had risen to 10% and in the 1990s rates started to climb rapidly, from 12% in 1990 to 21% in 2001.
The cesarean rate has risen without improving maternal or neonatal outcomes.
One reason for increasing cesarean rates may be a rise in elective cesarean delivery, also known as cesarean delivery by maternal request (CDMR). estimated at 4% in the United States.
Physicians in one study reported that they were more likely to perform a cesarean if they had been sued recently or if they thought about being sued frequently. (Cheng YW, Snowden JM, Handler SJ, et al. Litigation in obstetrics: does defensive medicine contribute to increases in cesarean delivery? J Matern Fetal Neonatal Med. 2014;27:1668–1675.)
Delayed admission to an active delivery unit in the latent phase of labor may reduce cesarean deliveries. (Tilden EL, Lee VR, Allen AJ, et al. Cost-effectiveness analysis of latent versus active labor hospital admission for medically low-risk, term women. Birth. 2015;42:219–226.)
The effect of cesarean delivery on future pregnancies should be considered when the first cesarean is being performed. Infants born to mothers who have had prior cesareans are at increased risk of stillbirth, and in cases of trial of labor after Caesarian, uterine rupture carries a risk to the neonate. For pregnancies complicated by abnormal placentation, delivery before term may be required.
Solheim KN, Esakoff TF, Little SE, et al. The effect of current cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med. 2011;24:1341–1346.
Smith GC, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet. 2003;362:1779–1784.
Malpresentation
Fetal malpresentation, most commonly breech presentation at term, is seen in approximately 4% of pregnancies. Currently, the vast majority of such pregnancies are delivered via cesarean. When I first went to Canada I was amazed that a consultant obstetrician could not conduct a breech vaginal delivery, which had been common practice in England. Of course morbidity in untrained hands will be higher. The current primary approach to reducing cesareans in breech presentation is the use of external cephalic version (ECV). In general, ECV will be effective in approximately 70% of attempts and the majority of women with a successful ECV will go on to deliver vaginally. Finally, moxibustion (a Chinese medicine approach) has been shown to reduce breech presentation ( Cardini F, Weixin H. Moxibustion for correction of breech presentation: a randomized controlled trial. JAMA. 1998;280:1580–1584.)
Malposition
A major management issue for patients in the second stage of labor is fetal malposition. Persistent fetal malposition particularly occiput transverse or occiput posterior position occurs in approximately 5% of fetuses and is associated with an increased risk of cesarean delivery and both maternal and neonatal complications. In such cases, rotation of the fetal head is useful. Historically, this was accomplished with forceps, particularly Kielland forceps but fewer Obstetricians are being trained to perform forceps rotations. I always found Kiellands to be a useful instrument but certainly not one for untrained hands, when used correctly and with gentleness they can achieve a controlled, atraumatic delivery.
Kielland’s forceps help to minimise the following risks that can occur with manual rotation:
• the baby rotating back to a malposition following manual rotation
• cord prolapse following disimpaction of the head
• complete disimpaction of the head out of the pelvis – too high for a safe forceps delivery.
(USA) In 1990 slightly more than 9% of livebirths resulted from either forceps delivery (5.11%) or vacuum extraction (3.9%), by 2014 only 3.21% of livebirths resulted from operative vaginal delivery and forceps accounted for less than 20% of these births (0.57% of all live births).
Hamilton BE, Martin JA, Osterman MJ, Curtin SC, Matthews TJ. Births: Final Data for 2014. Natl Vital Stat Rep. 2015 Dec;64(12):1-64.
Twin gestations
Supportive evidence exists for intended vaginal delivery in a twin gestation if the presenting twin is cephalic. A randomized trial found no improvement in neonatal outcomes in planned cesarean for a twin gestation. (Barrett JF, Hannah ME, Hutton EK, et al; Twin Birth Study Collaborative Group. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med. 2013;369:1295–1305.)
If the second twin is breech it is obvious that the obstetrician needs to be trained in vaginal breech delivery.

Practices that have become standard over decades should be carefully questioned and replaced by standardized, evidence-based practices. This may safely decrease the cesarean rate. Obstetrics is an art as well as a science. Unfortunately much of the art has been lost and abandoned practices should possibly be revisited.

Pregnancy – Basic Facts

Term
Pregnancy has historically been dated from the last menstrual period (LMP) with a duration of 40 weeks to give an estimated date of delivery (EDD) as a specific date. In fact term is usually a range from 37 – 42 weeks and these days pregnancy dates are usually set by ultrasound measurement.
The American College of Obstetricians and Gynecologists, the American Institute of Ultrasound in Medicine, and the Society for Maternal-Fetal Medicine recommend that –
Ultrasound measurement of the embryo or fetus in the first trimester (up to and including 13 6/7 weeks of gestation) is the most accurate method to establish or confirm gestational age.
A new formula for estimating gestational age based on ultrasound examination was reported in – Obstet Gynecol. 2017;130:433-441

Preconception Care
Medical assessment prior to becoming pregnant. The Centers for Disease Control and Prevention (CDC) has defined preconception care as “a set of interventions that aim to identify and modify medical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management.”
Pre-conception care includes –
1. Optimizing the management of chronic maternal health problems.
2. Providing lifestyle advice to avoid behaviours hazardous to a pregnancy, such as smoking, drinking excessive alcohol, or taking drugs.
3. Providing advice to optimize the health of the mother and baby, such as guidance on taking folic acid supplements.
4. Identifying couples who are at increased risk of having a baby with a genetic or chromosomal malformation, and providing them with sufficient knowledge to make informed decisions.

Medical History
A number of factors have to be considered early in pregnancy, if not addressed at the pre-pregnancy stage.
Pre-existing medical conditions in the individual, such as diabetes, renal disease, hypertension, HIV, previous thrombosis and epilepsy, would have to be considered in managing the pregnancy. Congenital abnormalities and genetic problems have to be considered in both parents.
Obesity – a BMI of over 30 carries an increased risk of complications such as hypertension, diabetes, and caesarean delivery also attainment of a normal pre-conception BMI will also likely prevent obesity and related long-term health effects in the developing child.
Screening
Antenatal screening is offered for –
• Foetal anomalies by ultrasound
• Down’s syndrome
• Haemoglobinopathies
• Rubella status
• HIV
• Hepatitis B
• Tay-Sachs disease in high risk individuals

Body Changes
Blood volume increases during pregnancy, beginning at 6-8 weeks gestation, which accounts for part of the weight gain. The increase is mainly in the plasma rather than the cellular constituents of the blood leading to a fall in haemoglobin and the possible need for iron.
As the uterus grows pushing up the diaphragm there may be some breathlessness, light headedness and possible fainting. Palpitations and irregular heartbeats are also not uncommon in pregnancy.

Nutrition in Pregnancy
During early pregnancy, most women experience an increased appetite, with extra caloric needs of approximately 300 kcal/d. Some women have nonfood cravings, known as pica.
Should certain foods be avoided during pregnancy?
Pregnant women are at increased risk of bacterial food poisoning. For the safety of both mother and fetus, it is important to take steps to prevent foodborne illnesses, including the following
• Properly cook food to kill bacteria.
• Cook eggs until they have a firm yolk and are white. Eggnog and hollandaise sauce have raw or partially cooked eggs and are not considered safe.
• Eat liver in moderation. Liver can contain extremely high levels of vitamin A.
• Avoid products containing unpasteurized milk, including soft cheeses like brie, feta, and blue cheese. Also avoid unpasteurized juice.
• Carefully wash all fruits and vegetables to eliminate harmful bacteria.
• Longer-lived and larger fish, such as shark, swordfish, king mackerel, and tilefish, have increased mercury levels and the FDA advises that they should not be eaten by pregnant or nursing women.