Prenatal Visits and Checkups
Most women who are at low risk for pregnancy complications will see their health care provider every month during pregnancy. Women with special health problems or a high-risk pregnancy may have many more appointments. Don’t hesitate to call with questions or concerns in between visits.
On arrival at the office you will be asked to produce a urine sample. When a room becomes available, you will be escorted into it to wait for your provider. Remember that obstetricians have busy schedules and deliveries can be unpredictable, so you might want to bring a book or magazine in case you have to wait. You may be able to reschedule your appointment if there is a long delay. Check your provider's office policy for canceling appointments and rescheduling.
If you develop any of the following warning signs (UW Medicine, 2007), call your provider:
- any vaginal bleeding
- severe or continuous headache
- dimness or blurring of vision
- abdominal pain
- persistent vomiting
- chills or fever
- pain or burning during urination
- leaking of fluid from vagina
- swelling or pain in one lower extremity
At each visit, your provider will want to know how you are feeling and whether you have any particular concerns or issues. Tell your doctor if you have had any major changes in diet, lifestyle, or health since your last visit. Ask about any pain or discomfort you have had that concerns you.
You may want to compile a list of questions and comments ahead of time for your appointment. This way you can make sure you don’t forget anything you want to ask. Your doctor would rather answer all of your questions during a scheduled visit than to have you call in the middle of the night. In addition, your provider will most likely ask you about fetal movement, sleep patterns, diet and prenatal vitamin use, and symptoms of preterm labor and preeclampsia (hypertension, excessive protein in the urine, and swelling).
Medications and Supplements
Continue to take your multivitamins (for example, Prenate Advance) and iron pills (ferrous sulfate). Depending on your blood count, your doctor may have you take anywhere from one to three iron pills per day. If you are having heartburn, you can take calcium carbonate (Tums with calcium). This is effective treatment for heartburn and helps supply your body with calcium. However, you should always talk to your doctor before taking any new supplement or medication.
If you have questions about new medications or over-the-counter drugs (like pain pills or cough medicine), always discuss them with your doctor. If you have a new medical problem that requires medicine, your doctor can help you find something safe to take during pregnancy.
Your physical examination during each visit is usually brief. The nurse or assistant will check your weight and take your blood pressure while you are sitting down. After obtaining your recent health history and performing the physical examination, your provider will decide whether any more tests are needed.
Physical assessments during the second trimester usually include the following checks:
- fundal height (belly size) and fetal growth
- fetal heartbeat
- edema (swelling)
- weight gain
- blood pressure
- urine protein levels
Fundal Height: Is the Fetus Growing Appropriately?
Your provider will measure the height of your uterus (the fundal height). This measurement is taken from the top of your pubic symphysis (pelvic bone) to the top of your uterus. From 20 weeks until 35 weeks there is generally a relationship between the fundal height and the length of your pregnancy. For example, fundal height should be 20 centimeters (+ or - 2 cm) at 20 weeks, 30 centimeters (+ or - 2 cm) at 30 weeks, etc. Sometimes, however, this measurement is not accurate; fundal height may be unreliable in women who are obese, who have fibroids, who are carrying more than one fetus, or who have excess amniotic fluid.
Your provider will use the increase in your uterine size as a marker for fetal growth. There is normal variance among the actual measurements, and a 2 or 3 cm difference is not generally a cause for concern. If your fundal height does not grow or is growing slower or faster than expected, your provider will probably order an ultrasound to evaluate the fetus and the amniotic fluid.
Your provider will also listen for the fetus' heart beat with a Doppler ultrasound. Doppler technology uses sound waves to measure the heartbeat and is perfectly safe for you and the baby. A normal fetal heart rate is faster earlier in pregnancy, ranging from 120 to 160 beats per minute. During the examination, your provider will assess whether or not the heart rate is too fast or too slow. Occasionally, it will be difficult to distinguish your heartbeat from that of the fetus. If there is any question about whose heart beat it is, your provider can take your pulse and listen to the fetal heart rate at the same time. The two rates should be different.
Your provider will check your legs, ankles, and feet for the presence of edema (swelling). Swelling in your legs is quite common in pregnancy, and it generally becomes more severe in the third trimester. Abnormal swelling might indicate a problem like preeclampsia, gestational diabetes, or a blood clot.
Are You Gaining an Appropriate Amount of Weight?
Generally, doctors tabulate how much weight you have gained compared to your pre-pregnancy weight. They will also check how much weight you have gained since your last visit. The amount of weight you need to gain during the second trimester will depend on your pre-pregnancy weight, number of fetuses you are carrying, and how much weight you have already gained.
If you are gaining more weight than expected, you may need to limit your intake of fruit drinks and sweets. If this dietary change does not curb your weight gain, you may want to write down what and how much you are eating to help your provider evaluate your diet. Some women who gain an excessive amount of weight are not overeating but are simply gaining water weight, which is more easily lost after delivery.
If you are not gaining enough weight, you will need to supplement your diet. Your provider may recommend that you eat two or three healthy snacks a day in addition to what you've been eating. Again, writing down what you are eating will help your provider determine how best to ensure that you and your baby are well nourished. If the problem persists, you may want to consult a dietitian.
Is Your Blood Pressure Healthy?
By the time you realize you're pregnant, your blood pressure will have already decreased. Blood pressure decreases during pregnancy in response to pregnancy hormones and changes in your blood volume. Blood pressure usually reaches its lowest value at 24 to 26 weeks gestation. Your provider will watch to see whether your blood pressure has decreased in the expected way. Some women will have incredibly low blood pressures (for example, 80/40) in the second trimester. As long as you feel well, this is not a cause for concern (Zhang, et al., 2000).
Because of low blood pressure, you do need to be careful when you stand up abruptly from sitting or lying down. Your blood may be pooled in your lower extremities if your uterus has pressed on the blood vessels that drain your legs. When you stand up, you may feel faint because your body senses that not enough blood has reached the brain. Sit back down; when you are feeling better, stretch out your legs and slowly get up.
High blood pressure can be very dangerous during pregnancy (NHLBI). If your blood pressure is high or increasing, your doctor may evaluate you for other symptoms of gestational hypertension or preeclampsia. Many women have healthy babies despite high blood pressure during pregnancy, but other women may become very ill or give birth prematurely.
Urinalysis: Do You Have Warning Signs in Your Urine?
Each time you go to the office, your provider will check your urine for the presence of protein and sugars (APA, 2006). If you feel pain or burning during urination, your doctor may also check your urine for bacteria.
It is normal to have 0-1+ protein on a urine test. Sometimes, your protein will be higher if you have a urinary tract infection. The greatest concern with protein in your urine is that you may be developing a condition of pregnancy called preeclampsia, which is hypertension with edema and excessive protein in the urine.
A normal level of glucose in the urine is 0-0.8 mmol/l. If your levels are higher, your doctor may perform other tests for gestational diabetes. This condition causes high levels of sugar in the blood and can lead to problems with your and the fetus’ health during pregnancy.
If you have symptoms like painful urination, your doctor may also check your urine for bacteria. Urinary tract, bladder, and kidney infections can cause bacteria to appear in your urine. If the test reveals bacteria, your doctor may prescribe antibiotics that are safe to take during pregnancy.
Testing During the Second Trimester
During the second trimester, many women will have a variety of tests done. Most women will receive an ultrasound, blood work, urine tests, and a glucose tolerance test. In addition, some women may choose to get prenatal testing for problems with the fetus’ health. Women over the age of 35 may be advised to get invasive diagnostic tests, such as amniocentesis. Depending on the woman’s health and medical history, other tests may be recommended.
Ultrasound has become an essential tool for evaluation of the baby during pregnancy. Ultrasound bounces sound waves off your body tissues. This creates an image on a screen the same way a submarine uses sonar. More than half of all pregnant women in the United States get at least one ultrasound. Ultrasounds are safe for both you and the fetus. The need for an ultrasound varies depending on the gestational age of the pregnancy and whether there are any complications.
Many women have an ultrasound in the first trimester to confirm pregnancy. However, some women will not receive an ultrasound until the second trimester. This may take place in women without risk factors for complications. Also, if the first trimester pelvic exam was in agreement with menstrual dating, the initial ultrasound examination may be obtained in the second trimester. In these cases, a second trimester ultrasound can confirm or revise LMP (last menstrual period) dating. A second trimester ultrasound can date the stage of the pregnancy within 10 to 14 days. Between 13 and 27 weeks of pregnancy, an ultrasound will also allow an assessment of fetal anatomy, the placenta, and the amniotic fluid (APA, 2006).
In the second trimester, structures in the fetus's head can be seen with some detail. The palate, lips, eye sockets, stomach, four chambers of the heart, umbilical cord insertion site, number of blood vessels, amount of amniotic fluid, gender, and number of fetuses can also be evaluated. Evaluation prior to 16 weeks may prevent a good analysis of the sacral spine because of insufficient bone formation. In addition, the two great vessels coming from the heart (the aorta and pulmonary artery) are more easily seen after 18 weeks.
It is important to understand that there are limitations to diagnosis by fetal ultrasound. Some anatomical problems are easier to see than others, and some cannot be diagnosed prior to birth at all. For example, hydrocephalus or “water on the brain” can usually be found prenatally. Small defects in the heart, however, often go undetected before birth. The physician reviewing the ultrasound with you can let you know if an abnormality lends itself to prenatal diagnosis. This can be helpful if you know your fetus is at risk for a particular problem.
Various factors can affect the quality of the ultrasound image. A very thick maternal abdominal wall (for example, in obese women) may reduce resolution and contribute to diagnostic errors. Fetal position may also make it impossible to examine certain features. In order to get a better image, the ultrasound technician may roll you from side to side and tell you to drink plenty of fluids before the exam. Despite great effort, there are often still problems getting a good image. The physician who reviews the results with you will let you know if there were any problems evaluating anything. It is important to know that a normal ultrasound does not guarantee a normal and healthy baby. Many conditions and diseases are not associated with anatomic abnormalities or birth defects.
Your doctor may also order an ultrasound in the second trimester if you are going to be age 35 or greater by the time of your due date or if you had an abnormal triple screen.
Triple Screen Test
In the second trimester, all women under the age of 35 should be offered a triple screen test. This blood test may be called by other names, such as MSAFP, PACE, or multiple marker screening. The triple screen test can detect possible fetal abnormalities, such as spina bifida, Down syndrome, and trisomy 18 syndrome (APA, 2006).
Triple Screen Test for Women Over 35 Years Old
The use of the triple screen test for patients over 35 years of age is controversial. The current standard of care is to offer all women older than 35 amniocentesis or chorionic villus sampling for prenatal diagnosis. The risk of fetal conditions is higher in older women, and these tests are more precise than the triple screen test. Amniocentesis and chorionic villus sampling give a 100 percent detection rate for genetic abnormalities but carry a 0.5 percent risk of complication. Screening the blood through the triple screen test lowers the detection rate to 85 to 90 percent but is not associated with the same complications as invasive methods. Ten to 15 percent of Down syndrome cases are missed by the triple screen test. If you are older than 35, you should discuss your screening options with your doctor.
What is the Triple Screen Test?
The triple screen test checks the levels of maternal serum alpha-fetoprotein (MSAFP), unconjugated estradiol (UE3) and beta human chorionic gonadotrophin (beta-hCG) in the blood. Abnormal levels of these substances indicate increased risk for neural tube (which develops into the spinal cord and brain) defects, Down syndrome, and trisomy 18. The triple screen test cannot diagnose any fetal disorder; it is simply a screening tool to identify fetuses at increased risk for certain conditions.
- Alpha-fetoprotein is a fetal blood protein made by the placenta and present in amniotic fluid. Some of the fetal AFP can cross the placenta into the mother’s blood and be measured as MSAFP.
- Beta-hCG is a hormone produced by the placenta. Beta-hCG is the best single marker for the detection of Down syndrome.
- Unconjugated Estradiol (UE3) is a steroid hormone produced and modified by the placenta, fetal liver, and fetal adrenal gland.
When Should I Have the Triple Screen Test?
The test will be offered between 15 and 22 weeks of gestation, depending on the lab used. The ideal time to do the test is at 16 to 18 weeks, because the detection rate is better at this stage of pregnancy.
What Percent of Patients Have Abnormal Results?
Five to 10 percent of patients will have an abnormal maternal serum screen. Sometimes, abnormal results can be present even if the fetus is perfectly healthy. Most positive (abnormal) tests are associated with normal fetuses. A positive test simply means there is a higher risk for a complication and that further investigation should be considered.
What Conditions Are Associated with Abnormal Triple Screen Tests?
If an abnormal triple screen test is correct, there is a chance the fetus has Down syndrome, trisomy 18, or a number of other birth defects. Your doctor can tell you whether your results are normal for each marker. Each type of condition is associated with different test results.
- Down syndrome is associated with elevated beta-hCG, decreased MSAFP, and decreased UE3.
- Trisomy 18 is associated with decreased levels of all markers.
- Elevated MSAFP correlates with different fetal anomalies such as neural tube defects (anencephaly and spina bifida) and abdominal wall defects. It is also associated with fetal death, multiple gestations, and certain abnormalities of the placenta.
Both Down syndrome and trisomy 18 are chromosomal abnormalities. Down syndrome is characterized by an extra chromosome number 21, typical physical features, and mental retardation of varying severity. Trisomy 18 is marked by an extra chromosome number 18 and is usually fatal (Trisomy 18 Foundation, 2010). Advanced maternal age increases the risk for Down syndrome, trisomy 18, and trisomy 13.
What Happens If the Results Are Abnormal?
If your test results are abnormal, your doctor will try to figure out whether the test was correct or incorrect. A false abnormal triple screening may be caused by wrong gestational age, multiple gestation (such as twins), vaginal bleeding in the first trimester, or fetal demise. If results are abnormal, these causes must be excluded before the condition at risk is further tested.
An ultrasound is usually the first step after abnormal triple screen test results. Ultrasound can help rule out the possibility that incorrect gestational age, multiple gestation, or fetal demise caused the abnormal results. An ultrasound will also help your doctor look for physical signs of the following triple screen test conditions:
- Spina bifida. If the triple screen indicates an increased risk for open spina bifida, an ultrasound of the fetal spine and head can usually identify the condition. An ultrasound examination may not confirm or rule out the risk of fetal abnormality if the triple screen risk is high and the ultrasound quality is low. If spina bifida is suspected after the ultrasound or if there is a problem getting a good ultrasound image, amniocentesis may be done to confirm or rule out the diagnosis.
- Trisomy 18. If the triple screen indicates a risk for trisomy 18, the ultrasound will look for a small cranium, small or cleft cerebellum, clenched hands, small overall size, and rocker bottom feet. Not all abnormalities associated with trisomy 18 must be present, but finding any one of them (plus the positive triple screen test) would point to trisomy 18. The diagnosis can be confirmed or excluded by amniocentesis. In many cases, the absence of any typical trisomy 18 features by ultrasound is reassuring enough that the patient decides not to get amniocentesis.
- Down syndrome. The prenatal diagnosis of Down syndrome is trickier than that for spina bifida or trisomy 18. Down syndrome fetuses are less likely to show signs that an ultrasound can detect. A careful search for more subtle Down syndrome markers may also be done. Subtle physical markers include thickness of the skin at the back of the neck (the nuchal skin fold), short ears, small cerebellum, small frontal lobes, absence of the middle bone of the fifth finger, stunted long bones, echogenic or bright bowel, and splayed pelvic bones. The presence of any of these findings in addition to an abnormal triple screen may indicate the presence of Down syndrome (Mayo Clinic, 2011). The diagnosis of Down syndrome can be confirmed or ruled out by amniocentesis.
Chromosomal abnormalities often result in fetal anatomical abnormalities. Finding any major fetal abnormality by ultrasound, regardless of the triple screen results, warrants testing of the fetal chromosomes (fetal karyotype) if desired by the patient. The fetal karyotype can be determined from fetal cells obtained from the amniotic fluid. Alternatively, if the ultrasound is technically adequate and reveals no problems, then the patient may feel reassured enough to skip invasive amniocentesis testing.
Unlike the triple screen tests, amniocentesis can provide definitive diagnoses. Unfortunately, it carries a 0.5 percent risk of complications. During this procedure, your doctor will get a sample of amniotic fluid to test. The fluid is collected by inserting a small needle through your skin and into the amniotic sac. It will be used to check for a variety of chromosomal and genetic abnormalities that the fetus may have.
The decision to get amniocentesis is a personal choice. Because 0.5 percent of women experience medical complications, it is only used when the benefit of the information from the test is thought to outweigh the risk. Amniocentesis is an invasive procedure that carries a risk of losing the pregnancy (Mayo Clinic, 2010). It provides information that only you – not your physician – may use to make decisions or to alter the course of the pregnancy. You might decide to undergo amniocentesis based on how you would use the information from the test. For example, if knowing for sure that the fetus has Down syndrome would not alter the course of the pregnancy, amniocentesis may not benefit you. Similarly, if your doctor finds that an ultrasound already indicates a disorder, you may decide against amniocentesis. It is important to realize, however, that ultrasound results will not always be accurate. This is because they don’t analyze the fetal karyotype. Amniocentesis is required for patients wanting a definitive diagnosis.
One-Hour Glucose Tolerance Test (Glucola)
Another test obtained in the second trimester is a Glucola or one-hour oral glucose tolerance test.
The American College of Obstetrics and Gynecologists (ACOG) recommends that all women be screened for gestational diabetes (ACOG, 2011). Similar to the triple screen, the glucose test is a screening that is not diagnostic. The one-hour glucose tolerance test involves drinking a cup of a sugar solution (50 gm sugar) and having your blood drawn to check your glucose level (sugar level) after one hour. The sugar solutions come in different flavors. You do not need to do anything special to prepare for this test.
If your glucose test is abnormal (greater than 140 mg/dL), your provider will recommend a three-hour glucose tolerance test. A three-hour test can determine whether you have gestational diabetes. Some providers use a lower cut off on the screening test in order to ensure more women with gestational diabetes are diagnosed.
Gestational diabetes normally goes away after the baby is born. If you have gestational diabetes, your body is having trouble controlling the amount of sugar in your blood (MedlinePlus, 2011). You may need to make changes in your diet and exercise habits. Controlling blood sugar levels is important for a healthy delivery. Your doctor may also teach you to check your blood glucose levels at home.
Depending on your obstetrical history and your current health, your provider may perform additional tests. He or she may order a blood count, a platelet count, an RPR (a rapid plasma reagin test for syphilis), a screen for sexually transmitted infections (STIs), or a test for bacterial vaginosis. Some of these require a blood draw, and others can be done with the urine sample collected at a regular office visit. Your doctor may need to swab your cheek, vagina, or cervix to check for certain infections.
Blood and platelet tests can identify a weak immune system or problems with blood clotting. These problems can complicate pregnancy and childbirth. STIs and other bacterial infections can also cause problems for you and the fetus. If they are detected by a test during the second trimester, your doctor can help you get treatment before the baby is born.
Talking to your Doctor
If an abnormality in the fetus is diagnosed, you and your doctor should discuss it in detail. Your doctor may also tell you to speak with a genetic counselor. You will learn about the problem’s cause, prognosis, treatment, natural history, recurrence risk, and possible prevention. In order to learn the cause and recurrence risk (the chance of it happening again in a later pregnancy), a careful family history needs to be obtained.
Your doctor will tell you about your options for managing the pregnancy. If pregnancy termination is an option, your doctor should never tell you what decision to make. If termination is not an option due to your personal beliefs or advanced gestational age, the information your doctor shares with you may help you manage the pregnancy. This is particularly the case with neural tube defects, since the outcome is felt to improve with a cesarean delivery. Your doctor can also connect you with community resources to help you prepare for a baby with special needs.
If a maternal health problem is diagnosed, you will need to work closely with your doctor to fix or monitor the problem. Simple infections can usually be treated with antibiotics or proper rest and diet. More serious complications, such as hypertension or gestational diabetes, will require frequent visits to the doctor. In addition, you may need to make major changes to your diet or lifestyle. In some cases, doctors may order strict bed rest or emergency medication.
Regardless of any diagnosis, you should feel comfortable talking to your doctor about anything that concerns you. Use your checkups as an opportunity to ask questions and learn about any problems you or the fetus may have. If you do not feel comfortable talking to your doctor, consider finding a new provider.