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![FOGSI FOCUS: Adbhut Matrutva4
school education, smoking, drinking habits, poor social
activities of mother, and also her poor support system.
LBW may also happen because of death of close relative of
the mother in FGR, garbh sanskar and birth preparedness
and counseling helps (Figs. 1.4A and B).
Smoking or External Toxins
These are the modifiable risk factors. Twenty percent of
infants with LBW happen because of active or passive
smoking.12
Parental smoking is associated with increased
CVD risk, high BMI after puberty. Exposure to carbon
monoxide from wood fuel smoke results in reduction of
birth weight. Genetic or epigenetic factors which are res
ponsible for long-term effects of smoke exposure is difficult
todeterminebutmanyepigeneticfactorsplayanimportant
role as to have an effect on the developing pregnancy.
Miscarriage
Some of the reviews have shown that women with early
pregnancy miscarriage are more at risk of developing CVD
or ischemic heart disease (IHD) in later life.
Cardiovascular Profile-induced Health Risks
Ispreexistingmaternalhemodynamicsormetabolicdisease
isthecauseofgestationaldiabetesandhypertensivedisease
during pregnancy or placental pathology is the cause?
Or preexisting disease affects the placenta which in
turn causes these medical disorders in pregnancy and also
increases later health risks for both mother and offspring
exponentially.
Fetal Growth Restriction
It is a known fact that infant birth weight (BW) is related
to mother’s risk of IHD, coronary artery disease (CAD),
cerebrovascular disease or cardiac insufficiency. Also,
GDM, PE may be the shared increased risk factors for CVD.
We are concerned about SGA for many reasons and need
to asses on antenatal visits (Figs. 1.5A to H).
Adequate nutrition and micronutrient such as iron,
copper,zinc,iodine,selenium,andsomevitaminssuch
as A and D are necessary for fetal growth. Preventive
care and adequate nutritional supplements, poverty
reduction should be the utmost goals of maternal care.
Prepregnancy Obesity and Excessive Weight Gain in
Pregnancy
Obesity, before or during pregnancy, increases maternal
morbidity as well as mortality. As increased fats set a
metabolic syndrome and increased insulin resistance.13
As abdominal fat is a better predictor of mortality than
weight or BMI, so if body fat index is more informative in
terms of obstetric complications. Two questions need to
be addressed (Figs. 1.6A to H).
Breastfeeding
Mothers with more BMI tend to breastfeed less.14
BMI
greaterthan30kg/m2
isassociatedwithmorecardiovascular
complications and also truncal obesity is associated
with increased cancer risk because of hyperinsulinemia,
insulin resistance, or high levels of steroid hormones, and
cytokines which in turn may be linked to carcinogenesis.
Children to obese mothers are obese as early as 16–17 years
of age as compared to children of nonobese mothers (Fig.
1.7A).
Thrombosis Risk Profile
Most of the women attending preconception or antenatal
clinic are aware of their thrombotic diseases before
pregnancy.Pregnancyhasagreatimpactonthecoagulation
profile and it may modify the disease or make it severe or
worse during pregnancy. Thrombophilia, systemic lupus
erythematosus (SLE) and antiphospholipid antibody
syndrome (APS) are known risk factors for FGR, PE, and
also placental dysfunction, miscarriages. Anticoagulant
therapy in the form of aspirin and heparin may reduce
the adverse outcomes. Anticoagulant for all is not yet
A
B
Figs. 1.4A and B: Fetal growth restriction (FGR). (IUGR: intrauterine
growth restriction).
[Sources: Jyotsna Deshpande, Assistant Professor, Bharati Vidyapeeth
College of Nursing, Pune, PhD Nursing, Tilak Maharashtra Vidyapeeth,
Pune, Maharashtra, India; International Journal of Science and
Research (IJSR), ISSN (Online): 2319-7064, Index Copernicus Value
(2013): 6.14, Impact Factor (2013): 4.438].](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-28-2048.jpg)
![FOGSI FOCUS: Adbhut Matrutva18
Box 2.2: Expert group consultation on preconception care.
■■ Sex/gender and violence
■■ Interpersonal violence (both sexes, bullying, teasing, domestic
violence)
■■ Injury prevention
■■ Sexual abuse and harassment, violence
■■ Environmental health (e.g. indoor pollution—cooking practices,
evidence base at country level, lead/arsenic/endocrine
disruption).
Box 2.3: Basic package.
■■ Family planning (more than just contraception)
■■ Vaccine-preventable diseases
■■ Nutrition and micronutrients (including food and micronutrient
supplementation, food fortification, nutrition education)
■■ Tobacco cessation (including exposure to second-hand smoke)
■■ Reducing harmful environmental exposures (e.g. indoor air
pollution)
■■ Improving sexual health and behavior (screening, counseling,
treatment).
Box 2.4: Expanded package (basic package plus the following
issues).
■■ Mental health problems
■■ Intimate partner and sexual violence
■■ Genetic conditions
■■ Prevention of noncommunicable disease
■■ Environmental health
■■ Substance and drug use
■■ Injury prevention
■■ Nonpopulation-specific genetic diseases (e.g. Down syndrome).
Participation by male in his partner’s health and
improvement in their own health, irrespective of
immediate plans to become parent(s); and controlling
exposure to environmental risk factors in early life and
their long-term effect.
“Early prenatal care is too late”.
This message should be forwarded for social, health,
and economic benefits of the society. Awareness should be
created in targeted group for preconception care, not for
the high risk cases but for all.
Preconception risk assessment recommendations—
(A) For all:
Content Evidence of association
Sociodemographic data Good
Menstrual history Good
Past obstetric history G
Medical and surgical history G
Infection history G
Family and genetic history G
Nutrition G
Smoking/alcohol/drug G
Height/weight G
Hemoglobin and hematocrit G
Rh-factor G
Rubella titer G
Urine protein/sugar G
Gonococcal culture G
Syphilis test G
Hepatitis B G
HIV G
(B) For targeted population:
Content Evidence of association
Hemoglobinopathies G
Toxoplasma G
HSV G
Varicella G
CMV G
Tay-Sach’s disease G
Parental karyotype G
Chlamydia screening G
Obstetrics medicine: management of medical disorders in pregnancy
CONCLUSION
Preconception care brings attention to the missing
components, new interventions, and development of new
guidelines for addressing the needs of adolescents, young
women and their partners throughout reproductive life.
Thus, it offers a process of delivering direct or indirect
healthcare interventions with the potential to identify
and modify the biomedical, behavioral, and social risks
that determine reproductive health outcomes. We,
the healthcare providers, should learn that it aims at
improving the overall health status and continuum of care,
bytargetingriskbehaviorsfornoncommunicablediseases,
alcohol consumption, and substance abuse.2
Overall, preconception care has a positive impact on a
range of outcomes:
Reduces mortality and improves health indicators of
mothers.
Improved health outcome for the neonate/child,
which will lead to health benefits in later life as an
adolescent and adult.
Incidence of too-early and too-frequent pregnancies
and abortions are reduced effectively; and there is
improvement in the nutritional status of women.
REFERENCES
1. World Health Organization (2008). A framework for
implementing the Reproductive Health Strategy in the South-
East Asia Region. [online] Available from http://apps.searo.
who.int/PDS_DOCS/B3170.pdf [Accessed December 2018].
2. The Federation of Obstetric and Gynecological Societies of
India (2016). Good clinical practice recommendations on
preconception care. [online] Available from https://www.fogsi.
org/gcpr-preconception-care [Accessed December 2018].
3. http://www.searo.who.int/entity/child-adolescent/topics/
adolescent-health/sea-cah-16/en/Contd...
Contd...](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-42-2048.jpg)
![FOGSI FOCUS: Adbhut Matrutva28
an opportunity to promote the health and well-being of
the fetus and provide individuals with the best start in life
possible.
CONCLUSION
Thus, it has been proved, time and again, that positive
maternal emotions advance the health of the unborn child.
In the first formal study of fetal temperament in 1996,
it was recorded the heart rate and movements of 31 fetuses
six times before birth and compared them to readings
taken twice after birth (They have since extended their
study to include 100 more fetuses). Their findings—fetuses
that are very active in the womb tend to be more irritable
infants. Those with irregular sleep/wake patterns in the
womb sleep more poorly as young infants. And fetuses
with high heart rates become unpredictable, inactive
babies.
A fetus constantly receives messages from its mother
as it grows in the womb. This communication is not limited
to hearing her heartbeat and whatever music she might
play to her belly; it also gets chemical signals through the
placenta.
Therefore, the environment a fetus is growing up
in—the mother’s womb—is very important. Some effects
are obvious. Smoking and drinking, for example, can be
devastating. But others are subtler; studies have found that
people who were born during the Dutch famine of 1944,
most of whom had starving mothers, were likely to have
health problems like obesity and diabetes later.
A pregnant women’s psychological as well as physio
logical health have consequences for fetal neurobehavi
oral development, and consequently, child outcomes.
Studies have underscored the importance of considering
theeffectsofwomen’smentalhealthonchilddevelopment
during the prenatal, as well the postnatal, periods.
Stressful situations must be avoided to provide a
congenial womb environment for the baby. Parents-
to-be who want to further their unborn child’s mental
development should start by assuring that the antenatal
environment is well-nourished, low-stress, and drug-free.
The transition to motherhood begins antenatally
and is influenced by an array of factors, such as the life
circumstances of the parents, the social environment, and
the circumstances of conception. It is also influenced by
the level of support provided by the woman’s partner and
family, as well as the physical health of the mother and her
unborn baby. The mother’s experiences within her family
of origin, her past or current mental health issues and any
current or unresolved conflict, loss or trauma can also
affect, and sometimes disrupt, this transition.
Scientists are finding that our health throughout life
is greatly determined by the prenatal circumstances in
which we develop. The fetus is sensitive and the stimuli
coming from the mother has a deep, often life-long impact
on the development of the child.
While the baby is in the womb, his/her brain seemingly
develops in direct response to the mother’s experience
of the world. If a mother is plagued by anxiety or stress
during her pregnancy, the “message” communicated
to her baby (via stress hormones) is that they are in an
unsafe environment—regardless of whether or not such
information is factual. The baby’s brain will actually
mutate, or adapt, to prepare for the unsafe environment
into which it expects to arrive.
Chronic stress in pregnancy tends to sculpt a brain
suited to survive in dangerous environments—quick to
react, with reduced impulse control, and a dampened
capacity to remain calm and content. Chronic joy, by
contrast, allows for the optimal development of each
organ, the brain in particular—predisposing the baby
to greater health and serenity. Such traits constitute the
foundations of lifelong personality.
Hence, it has become indispensable to foster an
optimal womb environment for the life-long healthy
development of the child.
BIBLIOGRAPHY
1. Atkinson J, Braddick O. Sensory and perceptual capacities of
the neonate. In: Stratton P (Ed). Psychobiology of the Human
Newborn. London: John Wiley; 1982. pp. 191-220.
2. Birnholz J, Stephens JC, Faria M. Fetal movement patterns:
a possible means of defining neurologic developmental
milestones in utero. Am J Roentol. 1978;130:537-40.
3. Chamberlain D. Chapters 1 to 4. Windows to the womb.
Berkeley, CA: North Atlantic Books; 2013.
4. Chayen B, Tejani N, Verma UL, et al. Fetal heart rate
changes and uterine activity during coitus. Acta Obstetricia
Gynecologica Scandinavica. 1986;65:853-5.
5. deVries JIP, Visser GHA, Prechtl HFR. The emergence of fetal
behavior. ii. quantitative aspects. Early Hum Dev. 1985;12:99-
120.
6. Fox HE, Steinbrecher M, Pessel D, et al. Maternal ethanol
ingestion and the occurrence of human fetal breathing
movements. Am J Obstet Gynecol. 1985;132:354-8.
7. Kumar N, Kalsi HP. Effect of prenatal maternal stress on
foetal outcome and its long-term consequences: a review of
literature. EC Gynaecology. 2017;3(6):432-8.
8. Molly M. University of Washington News. (2013). While in
womb, babies begin learning language from their mothers.
[online] Available from https://www.washington.edu/
news/2013/01/02/while-in-womb-babies-begin-learning-
language-from-their-mothers/ [Accessed December 2018].
9. Science Daily. (2011). Association for Psychological Science.
Can fetus sense mother’s psychological state? Study suggests
yes. [online] Available from. www.sciencedaily.com/
releases/2011/11/111110142352.htm [Accessed December
2018].](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-52-2048.jpg)
![FOGSI FOCUS: Adbhut Matrutva32
healthsystems,societies,andeconomyoftheNation.Thus,
this is the high time to setup the momentum to tackle this
burning problem by utilizing knowledge of FOAD and thus
to decrease the burden of the disease by first improving
maternal nutrition and fetal development. There is an
urgent need to make environment ecofriendly at the same
time by implanting trees at large scale along with spiritual
empowerment of mankind. This is the only method by
which we can harmonize the nature and the mind by
transmitting positive vibrations to the environment.
CONCLUSION
Fetal programming is a well-established phenomenon
and maternal nutrition is central programming stimulus.
It is well-accepted that fetal nutrition can influence both
fetal growth and later risk of disease. There is indeed, a
nutritional basis for FOAD. This fetal programming would
lead to alternation in both fetal birth size and permanent
changes in structure and function of the organs,
subsequently leading to disease in adult life. However,
clear distinctions need to be drawn between maternal
nutrition and fetal size at birth at one hand and between
fetal nutrition and fetal growth on the other hand.
REFERENCES
1. Hales CN, Barker DJ, Clark PM, et al. Fetal and infant
growth and impaired glucose tolerance at age 64. Br Med J.
1991;303(6809):1019-22.
2. Barker DJ. The origins of the developmental origins theory.
J Intern Med. 2007;261(5):412-7.
3. Water land RA, Garza C. Potential mechanism of metabolic
imprinting that lead to chronic disease. Am J Clin Nutr.
1999;69:179-97.
4. Hales CN, Barker DJP. The thrifty phenotype hypothesis. Br
Med Bull. 2001;60:5-20.
5. Gluck man PD, Hanson MA, Spencer HG. Predictive
adaptive responses and human evolution. Trends Ecol Evol.
2005;20(10):527-33.
6. Ferland-McCollough D, Fernandez-Twinn DS, Cannel IG,
et al. Programming of adipose tissue miR-483–3p and GDF-
3 ex by maternal diet in type 2 diabetes. Cell Death Differ.
2012;19(6):1003-12.
7. WHO.(2018).Noncommunicablediseases.[online]Available
from http://www.who.int/mediacentre/factsheets/fs355/
en/ [Accessed December 2018].
8. Moore SE. Early life nutritional programming of health and
disease in the Gambia. J Dev Orig Health Dis. 2016;7(2):123-31.
9. Gillespie S, Haddad L. Attacking the Double Burden of
Malnutrition in Asia and the Pacific. Manila, Philippines:
Asian Development Bank; 2001.](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-56-2048.jpg)
![FOGSI FOCUS: Adbhut Matrutva34
Fig. 6.3: Prevalence of Down's syndrome.
Screening for aneuploidies has undergone evolution
to include serum markers which reflect fetal secretions
and placental secretions[Alpha fetoprotein (AFP) and
free serum beta-human chorionic gonadotropin (HCG)],
maternal factors (age, weight, smoking history, diabetes,
assisted reproduction, ethnicity, and previous history of
aneuploidy)andultrasoundmarkersofaneuploidy[nuchal
translucency (NT) thickness, ossification of nasal bone
(NB), presence of tricuspid regurgitation (TR), reversal of a
wave in the ductus venosus (DV) flow and facial angle]. In
thepastfewyearstheuseofcell-freefetalDNAfordetection
of aneuploidy has come into clinical practice.
First trimester screening also screens for adverse
pregnancy outcomes like development of early onset
growth restriction, placental dysfunction, pregnancy
induced hypertension, intrauterine growth restriction and
fetal demise. This includes maternal hemodynamic factors
like mean arterial pressure (MAP), uterine artery pulsatility
index (Ut PI) and placental secretions like placenta
associated plasma protein-A (PAPP-A), placental growth
factor (PIGF) and soluble fms-like tyrosine kinase (sFlt-1).
The window of opportunity offered at the time of
first trimester screening is also used to rule out major
structural defects. Screening of the cervical length can also
be done to stratify women at risk for preterm labor. So, the
first trimester screening forms the base of the pyramid of
care where maximum information regarding the risks and
future pregnancy care is obtained. This is described as
“inverting the pyramid of care”.2
(Figs. 6.4 and 6.5).
SCREENING FOR ANEUPLOIDY
Every year millions of women get pregnant:
Regardless of the risk category (low or high) all women
are at a risk of fetal anomaly Fig. 6.5: Inverting the pyramid of care.
Fig. 6.4: Pyramid of antenatal care.](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-58-2048.jpg)
![CHAPTER 7
Second Trimester Screening and Antenatal Care
Pratima Mittal, Sumitra Bachani
INTRODUCTION
Goal of antenatal care (ANC) is to ensure birth of a healthy
baby with minimal risk for the mother. Antenatal care aims
at accurate estimation of gestational age, monitoring of
fetal growth, and identification of pregnancies at increased
risk of maternal or fetal morbidity and mortality. It is ideal
to register the pregnancy as soon as a woman misses
a period, so that an accurate assessment is possible.
Evaluation involves history, physical examination,
and basic investigations (as explained in first trimester
screening). If the first ANC visit is in second trimester then
all the investigations advised in first trimester should be
done in second trimester and further management is done
as described later.
Goals for antenatal care in second trimester are:
To provide an ongoing screening program to confirm
that pregnancy continues to be low risk.
To provide ongoing primary preventive health care
and identify the high risk cases.
To prevent, detect, and treat complications at the
earliest, if any.
To educate the mother about the physiology of
pregnancy, labor, newborn care, and lactation.
To provide advice, reassurance, education, and
support for woman and family.
Main focus of second trimester ANC care is to screen for
any genetic or structural congenital anomalies in the fetus
and to identify high risk pregnancy.
SCREENING FOR FETAL ANEUPLOIDY
Fetal aneuploidies are less common than structural defects
however they have profound impact on the quality of life.
The most common congenital cause of mental retardation
is Down syndrome (DS).1,2
These fetuses do not have
any pathognomonic criteria on sonography, 50% may
have soft markers which are nonspecific. The definitive
way of diagnosing DS is by karyotyping the fetal cells
obtained by amniocentesis, chorionic villus biopsy or
fetal blood sampling. This is expensive, labor intensive,
and is associated with a risk of abortion. Screening for
aneuploidies can differentiate those women who are in
highriskcategoryandwillneedtoundergoinvasivetesting.
Protocolsforscreening:Presentlyscreeningforaneuploidies
has not been incorporated in a national program hence it
is most important to have a uniformity in the screening
protocols to prevent confusion amongst caregivers and
the clients.
Table 7.1 lists the details of the various screening tests
in second trimester.
The Dual test (11−13 weeks), the triple test,
and quadruple tests (16−22 weeks) are routinely
recommended. “Penta” screening [alfa-fetoprotein (AFP),
human chorionic gonadotropin (hCG), unconjugated
estriol (uE3), dimeric inhibin A (DIA), hyperglycosylated-
hCG (h-hCG)], adding a fifth element (hyperglycosylated
hCG) to the Quad screen, has been recently introduced
but there is limited data to compare Penta with Quad
screening’s accuracy.3
Table 7.2 lists the maternal serum marker pattern in
selected fetal syndromes.
Recommendations: Every pregnant woman should be
informed and counseled about the available screening
tests and the conditions for which they can be done.
A clearly defined and appropriate screening program can
be tailored as per the local situation. Each test should
be preceded and followed up by a pre-test and post-
test counseling. The woman and her partner should be
assisted to make an informed decision to participate in the
screening program.
SCREENING FOR STRUCTURAL ANOMALIES
Screening is advocated at 18−20 weeks of pregnancy. Box 7.1
lists components of assessment of structural anomalies.
ANC Visits in Second Trimester
WHO (2016 WHO ANC model for positive pregnancy
experience) has recommended minimum of eight contacts](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-65-2048.jpg)
![Second Trimester Screening and Antenatal Care 43
Evaluation of women with risk factors for fetal
growth restriction
Assessment of maternal perception of fetal activity
and documentation of fetal heart rate, if heard.
Review investigations:
Check routine antenatal investigations (Box 7.2)
Screening and testing for genetic abnormalities/
aneuploidies/neural tube defects (NTD)
Quadruple marker: 16−22 weeks
Level II USG/Anomaly scan: 18−20 weeks of ges
tation for fetal structural anomalies (see Box 7.1).
Also assess:
ŠŠ Fetal number, multiple gestations: Chorionicity,
amnionicity, comparison of fetal sizes,
estimation of amniotic fluid volume (increased,
decreased, or normal) in each gestational sac.
ŠŠ Qualitative or semi-quantitative estimate of
amniotic fluid.
ŠŠ Placental location, appearance, and relationship
to the internal cervical os.
ŠŠ Umbilical cord: Number of vessels in the cord,
and placental cord insertion site.
ŠŠ Measurements: Biparietal diameter, head
circumference, abdominal circumference, and
femoral diaphysis length.
ŠŠ Transvaginal assessment of cervical length as
short cervical length (<24 mm at 24 weeks) is
associated with spontaneous preterm birth.5
ŠŠ Maternal anatomy: Evaluation of the uterus,
adnexal structures, and cervix should be
performed when appropriate.
Second trimester screening algorithm is described in
Flowchart 7.1.
Selective screening:
Thyroid profile [T3, T4, thyroid-stimulating
hormone (TSH), antithyroid globulin]
Box 7.2: Routine antenatal investigations.
■■ Hemoglobin (Hb): If Hb <10.5, investigate for anemia including
thalassemia, if MCV<80
■■ Blood group, If Rh-negative recommend husband’s BG
■■ If wife Rh-negative and husband Rh-positive recommend
indirect Coombs test
■■ Oral glucose tolerance test at 24–26 weeks. If normal to
be repeated at 32 weeks in women at risk for diabetes in
pregnancy.
■■ Thyroid-stimulating hormone and antithyroid globulin as per
protocol
■■ Venereal disease research laboratory, HIV, and HBsAg
■■ Qualitative assessment of urine protein
■■ Urine culture and sensitivity (mid stream clean catch sample)
■■ Screening for cervical cancer as per protocol.
Box 7.3: Selective infection screen.
■■ Hepatitis C
■■ Tuberculosis
■■ Toxoplasmosis
■■ Bacterial vaginosis
■■ Trichomonas vaginalis
■■ Herpes simplex virus
■■ Cytomegalovirus
■■ Zika
■■ Chagas disease
■■ Documentation of rubella and varicella immunity.
Flowchart 7.1: Second trimester screening algorithm.
Hemoglobinopathies
Lead level
Infection screen (Box 7.3)
Screening for depression: Pregnant women should
be assessed at least once during pregnancy or the
postpartum period for depression and anxiety
symptoms using a validated screening tool.6
Screening for GBS by vaginorectal culture at 37−38
weeks is recommended by ACOG.7
Counseling:
Nutrition, dietary and food hygiene. Recommended
weight gain in pregnancy (Table 7.3).
Pregnant women of normal weight with a singleton
pregnancy need to increase daily caloric intake](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-67-2048.jpg)
![Second Trimester Screening and Antenatal Care 45
Table 7.5: Recommended vaccination in pregnancy.
Strongly recommended Recommended Not recommended
TT:2 doses or Tdap
TT
1st dose: Between 16–20 weeks, 2nd dose: 4–6 weeks after
the 1st dose.
Tdap
ŠŠ Can replace TT (wherever available)
ŠŠ Single dose replaces both doses of TT: Administered
28–36 weeks, if previously immunized but if not
immunized two doses of TT and one dose of Tdap
Influenza vaccine
(during flu season) Intramuscular
Can be given at any gestation but FOGSI
recommends after 1st trimester.
Immunity of this vaccination lasts for 1 year and baby
remains immune against flu for 6 months, if vaccine is
given to mother, 6 months before delivery
HPV MMR varicella
Vaccination for which indication is not altered by pregnancy : Rabies, Pneumococcal/Meningococcal/Hepatitis.
REFERENCES
1. Audibert F, De Bie I, Johnson JA, et al. No. 348-Joint SOGC-
CCMG Guideline: Update on prenatal screening for fetal
aneuploidy, fetal anomalies, and adverse pregnancy
outcomes. J Obstet Gynaecol Can. 2017;39(9):805-81.
2. Vasilica P. Down Syndrome-Genetics and Cardiogenetics.
Maedica(Buchar). 2017;12(3):208-13.
3. ACOG Practice Bulletin No. 162: Prenatal Diagnostic Testing
forGeneticDisorders. ObstetGynecol.2015;27(5):e108-e122.
4. World Health Organization (2016). WHO recommendations
on antenatal care for a positive pregnancy experience.
New Guidelines Nov 2016. [online] Available from https://
www.who.int/reproductivehealth/publications/maternal_
perinatal_health/anc-positive-pregnancy-experience/en/
[Accessed December 2018].
5. Society for Maternal-Fetal Medicine (SMFM). The role of
routine cervical length screening in selected high- and low-
risk women for preterm birth prevention. AJOG. 2016;215(3):
B2-B7.
6. Learman LA. Screening for depression in pregnancy and the
postpartum period. Clin Obstet Gynecol. 2018;61(3):525-32.
7. American College of Obstetricians and Gynecologists
Committee on Obstetric Practice. Prevention of early-onset
group B streptococcal disease in newborns. Committee
Opinion No. 485. Obstet Gynecol. 2011;117:1019-27.](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-69-2048.jpg)
![CHAPTER 8
Third Trimester Workup
Jayam Kannan, Prashitha Panneerselvam
INTRODUCTION
Screening in third trimester is done in both low-risk
pregnant mother and high-risk for diagnosing of late
pregnancy complications such as late onset intrauterine
growth restriction (IUGR), pre-eclampsia, gestational
diabetes, anemia, and infections.
SCREENING FOR HEMATOLOGICAL
CONDITIONS
Complete blood count is repeated again at 28 weeks which
allows enough time for treatment of anemia. Pregnant
women with anemia are at a 4-fold increase risk of anemia,
2.2-fold risk of low birth weight, and 1.8-fold risk of low
APGAR. WHO estimates 591,000 perinatal deaths and
1,150,000 maternal deaths globally, directly or indirectly
related to anemia.1
IndirectCoombstestinRh-negativemotherisrepeated
again at 28 weeks and if found positive, the mother should
bereferredtoappropriatecenterforfurtherinvestigations.2
SCREENING FOR INFECTIONS
Screening for asymptomatic bacteriuria is done at 12–16
weeks; if not done earlier, it can be done at 28 weeks.
Venereal disease research laboratory (VDRL)/human
immunodeficiency virus (HIV)/Hepatitis B are repeated
in third trimester. Third-trimester testing has the potential
to prevent pediatric HIV infection and universal testing
should be considered in high-prevalence areas.3
Testing pregnant women for group B Streptococcus is
done at 35–37 weeks and if found positive, they are treated
with antibiotics. It is a simple test and clinicians use a
sterile swab to collect sample from vagina and rectum.
SCREENING FOR MEDICAL CONDITIONS
Hypothyroidism is usually detected in first trimester
screening;ifthemotherdoesnothaveathyroid-stimulating
hormone (TSH) report it can be repeated in third trimester
normal cut-off TSH—less than 3 mU/L.
Hyperglycemia in Pregnancy
The recent concept is to screen for hyperglycemia in the
first trimester itself as the fetal beta cell recognizes and
responds to maternal glycemic level as early as 16th week
of gestation.4
If the first trimester screening is negative it is
performed again at 24–28th weeks and 32–34th weeks. The
diagnostic test for gestational diabetes mellitus (GDM)
advised by the Diabetes in Pregnancy Study Group of India
(DIPSI) is an estimation of plasma glucose after 2 hours
of 75 g glucose load irrespective of meal timings and the
threshold plasma glucose level of more than or equal to
140 mg/dL is taken as cut off for diagnosis of GDM. This has
also been included in the guidelines issued by the Ministry
of Health and Family Welfare, Government of India.5
FIGO declaration 2018 recommends universal screening
for all pregnant mothers at first visit and at 24–28 weeks.
It recommends WHO 2013 criteria for diagnosis of GDM
[fasting plasma glucose (between 92 mg/dL and 125 mg/
dL) and 1-hour plasma glucose (180 mg/dL) and 2-hour
plasma glucose (between 153 mg/dL and 199 mg/dL)
following a 75 g oral glucose load] and diabetes mellitus
[fasting plasma glucose (greater than 126 mg/dL) and
2-hour plasma glucose (higher than 200 mg/dL) following
a 75 g oral glucose load or random plasma glucose (200
mg/dL) in the presence of diabetes symptoms.
Monitoring Glycemic Control
If the target blood glucose level is achieved, blood sugars
are monitored at least once in 2 weeks from 28 weeks to
32 weeks, and once a week till delivery after 32 weeks. In
uncontrolled blood glucose level, frequency of monitoring
depends on the glucose levels. The patients are thought
self-monitoring of blood glucose. In women with pre-
existing diabetes, retinal assessment and renal assessment
is repeated at 28 weeks.
Gestational Hypertension and Pre-eclampsia
Blood pressure assessment and urine protein estimation
is done at each antenatal visit to screen for pre-eclampsia](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-70-2048.jpg)
![Third Trimester Workup 47
and all pregnant women should be made aware of the
imminent symptoms of eclampsia.6
Significant proteinuria
is considered if the dipstick reading is 1+ and protein/
creatinine ratio greater than equal to 0.3 or greater than
or equal to 300 mg per 24 hours urine collection. In the
absence of proteinuria, high blood pressure associated
with thrombocytopenia (<100,000/mL), elevated serum
creatinine more than 1.0 mg/dL or elevated blood liver
transaminases to twice normal are diagnostic of pre-
eclampsia.
In gestational hypertension and pre-eclampsia
women, ACOG task force recommends daily serial
assessment of symptoms and fetal movements, twice
weekly BP measurement and weekly platelet count and
liver enzymes. Ultrasonography is done to determine
fetal growth every 2 weeks and amniotic fluid volume is
assessed weekly.7
Fetal Growth Restriction
Symphysis fundal height is to be measured every visit from
24 weeks. Evidence does not support routine ultrasound
scanningandDopplerafter24weeksinlow-riskpregnancy
through it is important in diabetes or hypertension
complicating pregnancy.
Fetal growth restriction (FGR) is one of the most
common and complex problems in obstetrics and the
perinatal complication are preventable if diagnosed early.
There is increased risk of perinatal mortality and morbidity
for infants with FGR. Hence, screening, diagnosis, and
management is important for clinicians. Cochrane review
could not conclude the effectiveness of symphysis fundal
height (SFH) measurement in detecting FGR,8
SFH
measurement is routinely used in developing countries,
especially in low-risk cases. In a prospective cohort study
conducted in 4,000 pregnant women showed that routine
third trimester scan tripled the identification of small for
gestational age (SGA) infants and could detect growth
restricted infants9
while Cochrane review 2015 does
not show benefit in performing routine third trimester
ultrasound unless indicated (Box 8.1).
Identifying small for gestational age (estimated fetal
weight EFW <10th centile) and large for gestational age
(LGA) (EFW > 90th percentile) is important in patients
with medical disorders complicating pregnancy especially
in low resource settings so that the patients can be referred
to higher center for appropriate management. If the FGR
is identified, Doppler studies are done further to assess
the uteroplacental insufficiency and additional Doppler
studies like middle cerebral artery, ductus venous, and
aortic isthmus are done at specialized fetal medicine
centers, but there use in monitoring growth restricted
fetus needs more evidence.
The timeline for hypoxia with abnormal arterial
Doppler (CIA, MCA is approximate 2 weeks and abnormal
venosus Doppler is 2 days). The periodicity of antepartum
testing largely remains unclear, since there are no large
clinical trials, however, fetal well-being tests [nonstress
tests (NSTs), biophysical profile (BPP) and umbilical artery
Doppler] is repeated once or two times weekly and growth
estimation done every 2 weeks.
FETAL SURVEILLANCE
In low-risk pregnancy, regular growth and fetal heart
rate monitoring during antenatal visit and maternal
monitoring of kick count (10 movements in a period of
2 hours) every day is done. Other fetal surveillance tests
like NST, contraction stress test (CST), BPP, modified
BPP, and umbilical artery Doppler are done in high risk
pregnancy for fetal wellbeing and to plan the time and
mode of delivery.
Nonstress Test
Normal acceleration during fetal movements is good
indicator of fetal autonomic function. Reactive NST is
with normal beat to beat variability, with minimum two
acceleration of 15 beats from baseline lasting up to 15
seconds in a 20-minute trace. 15% of normal 28–32 weeks
fetus can show abnormal NST. Cause of nonreactive
NST includes fetal sleep cycle or fetal distress. If NST is
nonreactive it is extended to 40 minutes or vibro acoustic
stimulation of fetus is done. Contraction stress test is the
response of fetal heart rate to contraction of uterus.11
Biophysical Profile
Five components [NST, fetal breathing movements, fetal
movements, tone and amniotic fluid volume (single
vertical pocket >2 cm)], each is assigned a score of 2. A
score of 8–10 is normal, 6 is equivocal, and less than 4 is
abnormal. Modified BPP includes only NST and amniotic
fluid assessment only.
Umbilical artery Doppler velocimetry plays a
significant role in monitoring growth restricted fetus.
Box 8.1: Third trimester ultrasonography indications.10
■■ Fetal growth: Estimation and fetal well-being
■■ Antepartum hemorrhage, placental position
■■ Abdominal or pelvic pain evaluation
■■ Multiple gestation
■■ Suspected small for gestational age/large for gestational age
■■ Amniotic fluid abnormalities
■■ Preterm premature rupture of the membranes or preterm labor](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-71-2048.jpg)
![FOGSI FOCUS: Adbhut Matrutva48
Normal umbilical artery wave form shows high velocity
diastolic flow. In growth restricted fetus, there can be
decreased diastolic flow and severe growth restriction is
absent or reversed diastolic flow is seen.11
MENTAL HEALTH
The prevalence of antenatal depression is reported up
to 42.7%. Research has reported that 33% of postnatal
depression begins in pregnancy. Diagnosis of antenatal
depression is made difficult by the physiological signs that
overlap with symptoms of depression. The clinicians should
identify the risk factors like lack of social support, stress, fear
of pregnancy problems and childbirth, domestic violence
and if the pregnant women show any signs of depression,
prompt referral to psychiatry services will help the patient
to cope up with stress and prevent postpartum depression.12
REFERENCES
1. Management of Iron Deficiency Anemia in Pregnancy—
FOGSI General Clinical Practice Recommendation.
2. National Institute for Health and Care Excellence (2008).
Antenatal care for uncomplicated pregnancies. Clinical
Guidelines CG62. Available from http://www.nice.org.uk/
guidance/cg62 [Accessed December 2018].
3. Williams B, Costello M, McHugh E, et al. Repeat antenatal
HIV testing in the third trimester: A study of feasibility and
maternal uptake rates. HIV Med. 2014;15(6):362-6.
4. Seshiah V, Das AK, Balaji V, et al. Diabetes in Pregnancy
Study Group. Gestational Diabetes Mellitus—Guidelines. J
Assoc Physicians India. 2006;54:622-8.
5. Maternal Health Division, Ministry of Health & Family
Welfare. New Delhi: Government of India; 2014. National
guidelines for diagnosis and management of gestational
diabetes mellitus. Available from http://nhm.gov.in/
New_updates_2018/NHM_components/RMNCH_MH_
Guidelines/Gestational-Diabetes-Mellitus.pdf [Accessed
December 2018].
6. The Federation of Obstetric and Gynecological Societies of
India. Good Clinical Practice Recommendations—Routine
Antenatal Care for Healthy Pregnant Women. June 2015.
Available from https://www.fogsi.org/fogsi.icog-good-
clinical-practice-recommendatios/[Accessed December
2018].
7. Hypertensioninpregnancy.ReportoftheAmericanCollegeof
ObstetriciansandGynecologists’TaskForceonHypertension
in Pregnancy. Obstet Gynecol. 2013;122(5):1122-31.
8. Robert Peter J. Ho JJ, Valliapan J, et al. Symphysial fundal
height (SFH) measurement in pregnancy for detecting
abnormalfetalgrowth.CochraneDatabaseSystRev.2015;8:9.
9. Sovio U, White IR, Dacey A, et al. Screening for fetal growth
restriction with universal third trimester ultrasonography in
nulliparous women in the Pregnancy Outcome Prediction
(POP) study: a prospective cohort study. Lancet; 2015.
10. ACOG Practice Bulletin. Clinical management guidelines for
obstetricians-gynecologists. Number 175, December 2016:
Ultrasound in pregnancy. Obstet Gynecol. 2016;128(6).
11. ACOG Practice Bulletin. Clinical management guidelines
for obstetricians-gynecologists. Number 145, July 2014:
Antepartum Fetal Surveillance. Obstet Gynecol. 2014;124(1).
12. Zeng Y, Cui Y, Li J. Prevalence and predictors of antenatal
depressive symptoms among Chinese women in their
third trimester: a cross-sectional survey. BMC Psychiatry.
2015;15:66.](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-72-2048.jpg)
![Ultrasound in Pregnancy 67
The umbilical cord insertion should be imaged
to look for abdominal wall defects. The renal tract
is reviewed by imaging urine in the bladder with
surrounding umbilical arteries and assessing the
kidneys. The fetal kidneys should be imaged in two
planes, both coronal and axial.
Fetal musculoskeletal system: It is beneficial to image
thefetalspinethroughoutitslengthandthespineisbest
imagedinthreeplanes:(1)Coronal,(2)Sagittal,and(3)
Axial. There should be an intact skin line overlying the
back, especially over the sacral region. There should be
no spinal angulation or deformity. At the inferior end,
there should be sacrococcygeal tapering of the spine.
In axial section, the three ossification centers forms
an approximately equilateral triangle throughout the
length of the spine.
Each of the 12 long bones should be separately
visualized. Although both femurs could be measured,
usually only one is measured provided both have been
seen to be of similar lengths. The femur is measured
horizontally across the ossified diaphysis down the
middle of the shaft of the bone avoiding any triangular
echogenic extensions. Hands and feet should be
separately imaged taking particular care to ensure that
both left and right sides are separately seen.
Other structures: A qualitative or semiquantitative
estimation of amniotic fluid (like amniotic fluid index
or single deepest pocket) should be done to rule out
oligohydramnios or polyhydramnios. Umbilical cord
should be evaluated to look for number of vessels
in the cord, and placental cord insertion site. The
placenta should be visualized throughout to look for
abnormalities, placenta previa, or hemorrhages. The
presence of succenturiate lobe should be excluded.
The position of the placenta in relation to the internal
os should be ascertained. The maternal cervical canal
can also be measured.
The presence of any myoma or adnexal mass should
be documented. Presence of uterine anomalies should
also be documented.
Cervical length measurement by TVS is done for
prediction of preterm birth.
Color Doppler ultrasound is done to predict preeclam
psia and fetal growth restriction and also to diagnose
fetal jeopardy.
SAFETY
Diagnostic ultrasound in pregnancy is generally consi
dered safe.
CONCLUSION
Ultrasonography is now an established tool in the clinical
managementofpregnancy.Toensureappropriatematernal
and neonatal health, it is important that the quality of ANC
is optimized with addition of ultrasound.
BIBLIOGRAPHY
1. Abramowicz JS, Kossoff G, Marsal K, et al. Safety Statement,
2000 (reconfirmed 2003). International Society of Ultrasound
in Obstetrics and Gynecology (ISUOG). Ultrasound Obstet
Gynecol. 2003;21(1):100.
2. AIUM-ACR-ACOG-SMFM-SRU practice parameter for the
performance of standard diagnostic obstetric ultrasound
examinations. J Ultrasound Med. 2018;37(11):E13-24.
3. Belizán JM, Cafferata ML. (2011). Ultrasound for fetal assess
mentinearlypregnancy:RHLCommentary.[online]Available
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Department%20of%20Maternal%20%20Child%20Health/
who%20videos/apps.who.int/rhl/pregnancy_childbirth/
fetal_disorders/prenatal_diagnosis/jbcom/en/index.html.
[Last Accessed February, 2019].
4. Chudleigh T. The 18 + 0–20 + 6 Weeks Fetal Anomaly Scan
National Standards. Ultrasound. 2010;18(2):92-8.
5. Kongnyuy EJ, van den Broek N. The use of ultrasonography
in obstetrics in developing countries. Trop Doct. 2007;37(2):
70-2.
6. Salomon LJ, Alfirevic Z, Berghella V, et al. Practice guidelines
forperformanceoftheroutinemid-trimesterfetalultrasound
scan. Ultrasound Obstet Gynecol. 2011;37(1):116-26.
7. Stanton K, Mwanri L. Global maternal and child health
outcomes: the role of obstetric ultrasound in low resource
settings. J Prev Med. 2013;3(1):22-9.
8. Whitworth M, Bricker L, Neilson JP, et al. Ultrasound for fetal
assessment in early pregnancy. Cochrane Database Syst Rev.
2010;4:CD007058.](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-91-2048.jpg)
![Immunization during Pregnancy 69
avoid becoming pregnant until 3 months after receiving
the MMR vaccine.5
Incidence of congenital rubella syndrome following
inadvertent vaccination of pregnant mother has been
evaluated through rubella registers in the USA and
Europe.6-13
By administration of oral polio vaccine containing live
attenuated polio virus type 1, 2, and 3 to pregnant women
has shown possible development of viremia following
immunization and cases suggestive of vaccination-
associated anomalies have been reported.14,15
VACCINES, WHICH MAY BE GIVEN IN PRESENCE
OF SPECIFIC RISK FACTORS
Yellow fever vaccine is not recommended for pregnant
women and lactating mothers unless there is an
epidemic or the women is traveling to a high-risk area.16
Hepatitis A: If women have specific risk factors for
hepatitis A, they may receive vaccine. It is given in 2
doses, 6–12 months apart.17
Hepatitis B: Pregnant women who are at risk for this
diseaseandhavetestednegativefortheviruscanreceive
this vaccine. A series of 3 doses is required to have
immunity. Birth dose vaccination is a key intervention of
preventionofhepatitisBvirus(HBV)infectionininfants.
Universal HBV vaccination in newborn has dramatically
changed the epidemiology of chronic HBV infection.18
Hepatitis C: The World Health Organization (WHO)
estimates that 3–4 million people annually are infected
with hepatitis C virus (HCV) and approximately 130–
170 million people with chronic disease may go on to
develop cirrhosis or hepatocellular carcinoma. There is
no pre-exposure prophylaxis, vaccine or postexposure
prophylaxis for HCV and immunoglobulin is not
effective in preventing infection. Mothers and children
with chronic hepatitis C should be immunized against
hepatitis A and B.18
Hepatitis D: It is caused by hepatitis delta virus. A
coinfection with HBV or a super infection on chronic
HBVinfectioniswaysofgettinginfected.Immunization
against HBV prevents (HDV) infection.18
Hepatitis E: Waterborne epidemics of hepatitis in
developing countries are mostly caused by hepatitis
E virus (HEV) infection. Pregnant patients may have
fulminant hepatitis. Mortality from acute infection is
in range of 20% in the third trimester. The recombinant
hepatitisEvaccinewasapprovedinChinainDecember
2011 although there is no global recommendation.
Immunoglobulins are not effective. Women traveling
to HEV endemic countries should strictly follow food
and water precautions.18
Meningococcal A, meningococcal B, and pneumo
coccal vaccine may be given, if certain risk factors.
SIDE EFFECTS
Likeallmedicines,vaccinescanhavesideeffects.However,
the chance of a life-threatening reaction is small. The
CDC says the dangers of developing pertussis, tetanus, or
diphtheria far outweigh the risks of vaccination.
Side effects of Tdap may include:
Pain, redness, or swelling in the arm where the shot was
given, mild fever, headache, tiredness, stomach upset,
including nausea, vomiting, or diarrhea, muscle aches
and pains and swollen glands.
Someone may have a severe allergic reaction to
an ingredient in the Tdap or Td vaccine. This generally
happens in less than one in a million doses. Most of the
time,suchreactionsoccurwithinafewminutesofreceiving
the vaccine. The following can be signs of a severe allergic
reaction, called anaphylaxis:
Behavior changes
Breathing difficulty, including wheezing
Dizziness
Hoarse voice
High fever and pale skin
Rapid heart beat
Weakness.
One should seek immediate medical care, if any of
these signs after receiving the Tdap are noticed.
Flu vaccines have a good safety record. Hundreds of
millions of Americans have safely received flu vaccines
over the past 50 years, and there has been extensive
research supporting the safety of flu vaccines.
CONCLUSION
Vaccination during pregnancy is a cost-effective strategy
to improve pregnancy outcomes in India. All live vaccines
should be avoided during pregnancy. Common barriers
regarding vaccination during pregnancy are lack of
awareness regarding benefits and lack of concerns about
vaccine safety.
REFERENCES
1. Atkinson W, Hamborsky J. Diphtheria, Epidemiology and
Prevention of Vaccine-Preventable Diseases, 12th edition.
Maryland: Public Health Foundation; 2012. pp. 75-85.
2. Centers for Disease Control and Prevention. Pertussis
(Whooping Cough) Signs Symptoms. [online] Available
from: https://www.cdc.gov/pertussis/about/signs-symptoms.
html [Accessed December, 2018].
3. Committee on Obstetric Practice. ACOG Committee Opinion
No. 521: Update on immunization and pregnancy: tetanus,](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-93-2048.jpg)
![FOGSI FOCUS: Adbhut Matrutva70
diphtheria, and pertussis vaccination. Obstet Gynecol.
2012;119(3):690-1.
4. Arora M, Sharma A, Chauhan M. Influenza in Pregnancy:
Pal Bhasker (Ed)., Infections in Obstetrics Gynaecology.
FOGSI FOCUS, 2017.
5. FOGSI GCPR. (2014). Vaccination in women, September
26, 2014. [online] Available from: https://www.fogsi.org/
wp-content/uploads/2015/11/vaccination_women.pdf
[Accessed December, 2018].
6. Bar-Oz B, Levichek Z, Moretti ME, et al. Pregnancy outcome
following rubella vaccination: a prospective controlled
study. Am J Med Genet A. 2004;130A(1):52-4.
7. Da Silva e Sa GR, Camacho LA, Stavola MS, et al. Pregnancy
outcomes following rubella vaccination: a prospective study
in the state of Rio de Janeiro, Brazil, 2001-2002. J Infect Dis.
2011;204(Suppl 2):S722-8.
8. Badilla X, Morice A, Avila-Aguero ML, et al. Fetal risk
associated with rubella vaccination during pregnancy.
Pediatr Infect Dis J. 2007;26(9):830-5.
9. Minussi L, Mohrdieck R, Bercini M, et al. Prospective
evaluation of pregnant women vaccinated against rubella in
southern Brazil. Reprod Toxicol. 2008;25(1):120-3.
10. Pardon F, Vilariño M, Barbero P, et al. Rubella vaccination of
unknowingly pregnant women during 2006 mass campaign
in Argentina. J Infect Dis. 2011;204(Suppl 2):S745-7.
11. Soares RC, Siqueira MM, Toscano CM, et al. Follow-up study
of unknowingly pregnant women vaccinated against rubella
in Brazil, 2001-2002. J Infect Dis. 2011;204(Suppl 2):S729-36.
12. Hamkar R, Jalilvand S, Abdolbaghi MH, et al. Inadvertent
rubella vaccination of pregnant women: evaluation of
possible transplacental infection with rubella vaccine.
Vaccine. 2006;24(17):3558-63.
13. Sato HK, Sanajotta AT, Moraes JC, et al. Rubella vaccination
of unknowingly pregnant women: the Sao Paulo experience,
2001. J Infect Dis. 2011;204(Suppl 2):S737-44.
14. Horstmann DM, Opton EM, Klemperer R, et al. Viremia
in infants vaccinated with oral polio vaccine (Sabin). Am J
Hygiene. 1964;79:47-63.
15. Burton AE, Robinson ET, Harper WF, et al. Fetal damage after
accidental polio vaccination of an immune mother. J R Coll
Gen Pract. 1984;34(264):390-4.
16. World Health Organization. International travel and health.
Geneva: World Health Organization; 2012.
17. ACOG. (2018). ACOG committee opinion—Immunization,
Infectious Disease and Public Health preparedness Expert
Work Group. [online] Available from: https://www.acog.org/
Clinical-Guidance-and-Publications/Committee-Opinions/
Immunization-Infectious-Disease-and-Public-Health-
Preparedness-Expert-Work-Group/Maternal-Immunization
[Accessed December, 2018].
18. Gandhi AB, Kamale VV. Hepatitis in Pregnancy: Pal Bhaska
(Ed). Infections in Obstetrics Gynaecology. FOGSI FOCUS,
2017.](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-94-2048.jpg)
![The Road to Birth Naturally 73
We should use our time and expertise to look after high-
risk complicated pregnancies.
We obstetricians should open our minds, hearts,
and our birthing rooms to professional midwives and
accept them as professional colleagues. When we work
with mutual respect and trust, only then will women feel
respected and be assured of birthing naturally.
The Indian government in the recent Global Partners
Forum hosted in December 2018, announced a policy
Guidelines on Midwifery Services in India. This is a big step
forward on the road to helping mothers’ birth naturally.14
CONCLUSION
It is a woman’s fundamental right to choose the
circumstances under which she wishes to birth. It is her
basic human right to have a companion of her choice.
Professional midwives and obstetricians must begin a new
working relationship built on mutual respect and trust.
This calls for a serious change in attitude. It calls for us
obstetricians to admit with grace and humility the urgent
need to change childbirth practices in India. Only then,
will women be able to walk on the road to birth naturally.
Only then will women feel respected, cherished, and
believe their voices are indeed being heard.
As John Bowlby said “If a community values its
children, it must cherish its mothers”.15
REFERENCES
1. Bohren MA, Hofmeyr GJ, Sakala C, et al. Continuous support
for women during childbirth. Cochrane Database Syst Rev.
2017;(7):CD003766.
2. Dick-Read G. Childbirth Without Fear: The Principles and
Practice of Natural Childbirth. London: Heineman; 1933.
Republished by Printer Martin; 2004.
3. National Childbirth Trust, Royal College of Midwives, Royal
College of Obstetricians and Gynaecologists. Making Normal
BirthaReality:ConsensusStatementfromtheMaternityCare
Working Party; our shared views about the need to recognise,
facilitate and audit normal birth. London: NCT; 2007.
4. Supporting Healthy and Normal Physiologic Childbirth: A
Consensus Statement by ACNM, MANA, AND NACPM. J
Perinat Educ. 2013;22(1):14-8.
5. WHO recommendations: intrapartum care for a positive
childbirth experience. Geneva: World Health Organization;
2018.
6. Waldenstrom U, Hildingsson I, Ryding EL. Antenatal fear
of childbirth and its association with subsequent cesarean
section and experience of childbirth. BJOG. 2006;113:638-46.
7. Klaus M, Kennell J, Robertson S, et al. Effects of social support
during parturition on maternal and infant morbidity. Br Med
J. 1986;293:585-7.
8. Hodnett ED, Gates S, Hoffmeyer GJ, et al. Continuous
support for women during childbirth; a systematic review.
Am J Obstet Gynaecol. 2013;186(5):S160-72.
9. Mander R. Supportive Care and Midwifery. London:
Blackwell Science; 2002.
10. Renfrew MJ, Homer C, Soo D, et al. Midwifery: An Executive
Summary for the Lancet’s Series. The Lancet; 2014.
11. WHO. (2016). Standards for improving quality of maternal
and newborn care in health facilities. [online] Available from
https://www.who.int/maternal_child_adolescent/docu
ments/improving-maternal-newborn-care-quality/en/
[Accessed December 2018].
12. Sandall J, Soltani H, Gates S, et al. Midwife-led continuity
models versus other models of care for childbearing women.
Cochrane Database Syst Rev. 2016;(4):CD004667.
13. Brodie P, Leap N. From ideal to real: the interface between
birth territory and the maternity service organisation.
In: Fahy K, Froureur M, Hastie C (Eds). British Territory
and Midwifery Guardianship. Edinburgh: Butterworth
Heinemann/Elsevier; 2008.
14. Ministry of Health and Family Welfare, Government of India.
Guidelines on Midwifery Services In India; 2018.
15. Bowlby J, World Health Organization (1952). Maternal care
and mental health: a report prepared on behalf of the World
Health Organization as a contribution to the United Nations
programme for the welfare of homeless children/John
Bowlby, 2nd edition. [online] Available from http://www.
who.int/iris/handle/10665/40724 [Accessed December 2018].](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-97-2048.jpg)
![FOGSI FOCUS: Adbhut Matrutva78
cesarean deliveries in the second stage—(1) operative
vaginal delivery and (2) manual rotation of the fetal occi
put for malposition.
OPERATIVE VAGINAL DELIVERY
In a large, retrospective cohort study, the rate of intra
cranial hemorrhage associated with vacuum extraction
did not differ significantly from that associated with either
forceps delivery [odds ratio (OR), 1.2; 95% confidence
interval (CI), 0.7e2.2] or cesarean delivery (OR, 0.9; 95%
CI, 0.6e1.4).12
In a more recent study, forceps-assisted
vaginal deliveries were associated with a reduced risk
of the combined outcome of seizure, intraventricular
hemorrhage, or subdural hemorrhage as compared with
either vacuum-assisted vaginal delivery (OR, 0.60; 95%
CI, 0.40e0.90) or cesarean delivery (OR, 0.68; 95% CI,
0.48e0.97), with no significant difference between vacuum
delivery or cesarean delivery.13
Fewer than 3% of women in whom an operative
vaginal delivery has been attempted go on to deliver by
cesarean.14
Performing low or outlet procedures in fetuses
that are not believed to be macrosomic is likely to safely
reduce the risk of cesarean delivery in the second stage of
labor. However, the number of healthcare providers, who
are adequately trained to perform forceps and vacuum
deliveries, is decreasing. In one survey, most (55%)
resident physicians in training did not feel competent to
perform a forceps delivery upon completion of residency.15
Thus, training resident physicians in the performance
of operative vaginal deliveries and using simulation for
retraining and ongoing maintenance of practice would
likely contribute to a safe lowering of the cesarean delivery
rate.16
Hence, operative vaginal delivery in the second
stage of labor by experienced and well-trained physicians
should be considered a safe, acceptable alternative to
cesarean delivery. Training in, and ongoing maintenance
of, practical skills related to operative vaginal delivery
should be encouraged.
MANUAL ROTATION OF THE FETAL OCCIPUT
Occiput posterior and occiput transverse positions are
associated with an increase in cesarean delivery and
neonatal complications. Historically, forceps rotation of
the fetal occiput from occiput posterior or occiput trans
verse was common practice. Today this procedure,
although still considered a reasonable management
approach, has fallen out of favor. An alternative approach
is manual rotation of the fetal occiput, which has been
associated with a safe reduction in the risk of cesarean
delivery.17,18
To consider an intervention for a fetal
malposition, the proper assessment of fetal position must
be made. To safely prevent cesarean deliveries in the
setting of malposition, it is important to assess the fetal
position in the second stage of labor, particularly in the
setting of abnormal fetal descent.
NONOPERATIVE INTERVENTION IN
FETAL DISTRESS
Given the known variation in interpretation and manage
ment of fetal heart rate tracings, a standardized approach
is a logical potential goal for interventions to safely reduce
the cesarean delivery rate.
Category I—fetal heart tracings are normal and do
not require intervention unlike the category 3 CTG
tracings which are abnormal, demanding immediate
intervention.
Category II—most intrapartum fetal heart rate tracings
are category II, which is where the dilemma arises.
Most cesarean deliveries done for nonreassur
ing fetal heart rates belong to this category. These
are indeterminate, require evaluation, continued
surveillance, and initiation of appropriate corrective
measures.19
Scalp stimulation can be done when the cervix is
dilated to assure that the fetus is not acidotic. Conserva
tive measures—position change and amnioinfusion with
normal saline also have been demonstrated to resolve
variable fetal heart rate decelerations20,21
and reduce the
incidence of cesarean delivery.
FETAL MALPRESENTATION
Breech presentation at more than 37 weeks of gestation is
estimated to complicate 3.8% of pregnancies, and more
than 85% of pregnant women with a persistent breech
presentation are delivered by cesarean.22
In one recent
study, the rate of attempted external cephalic version
was 46% and decreased during the study period.23
Thus,
external cephalic version for fetal malpresentation
is likely underutilized, especially when considering that
most patients with a successful external cephalic version
will give birth vaginally.23
Fetal presentation should be
assessed and documented beginning at 36 0/7 weeks
of gestation to allow for external cephalic version to be
offered. Before a vaginal breech delivery is planned,
women should be informed that the risk of perinatal
or neonatal mortality or short-term serious neonatal
morbidity may be higher than if a cesarean delivery is
planned, and the patient’s informed consent should be
documented.](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-102-2048.jpg)
![FOGSI FOCUS: Adbhut Matrutva88
role in this exercise it would surely lead to compliance
without friction. Just like the Hindu mythological character
Abhimanyu learnt how to invade a “Chakravyuh” while he
was in his mother’s womb. This daily routine would surely
have a trickle-down effect on the baby providing positive
vibrations of spiritual energy, which would later helps
him survive the negativity of the external influences of the
world.
ROLE OF OBSTETRICIAN IN CREATING
POSTPARTUM DIVINE CONDITIONS
Afterthebirthofthechild,theobstetriciancanperiodically
monitormother’sactivitiesandsuggestcontinuationofthe
spiritual exercise taught during the prenatal stage. Keeping
a track of the evolutionary mother child relationship and
preventing any negative influence of the environment
shall be a prime duty of the obstetrician along with
helping the mother coping up with the postpregnancy
issues. Minor advices like keeping the child in a peaceful
place without and disturbance or noise, not leaving the
child alone for too long, passionate breastfeeding, etc. can
have a big impact of child’s perception of the bonding with
the mother. A strong bond will ensure easy transfer of the
inculcated spirituality of the mother to the baby.
A spiritual journey of the child and mother from the
prenatal to postpartum stage facilitated by the obstetrician
will make the mother physically and mentally fit and help
her cope up the stress period.
It will also sow the seeds of an empathetic, positive, and
compassionate attitude within the child along with all the
divine virtues ultimately leading to a new era of optimism,
full of life, a world with less anxiety, and more spiritualism,
a divine world.
REFERENCES
1. SSE. (2008). Society for Scientific Exploration. [online]
Availablefromhttp://www.scientificexploration.org/journal/
volume-22-number-4-2008 [Accessed December 2018].
2. Donna G. Message in the Water. Calgary, Alberta: Calgary
Herald; 2003. p. S8.
3. The Irish Times. (2011). The pseudoscience of creating
beautiful (or ugly) water. [online] Available from https://
www.irishtimes.com/news/science/the-pseudoscience-of-
creating-beautiful-or-ugly-water-1.574583[AccessedDecember
2018].
4. The holistic ingredient. (2015). 8 ways to raise your vibration
(your positive energy). (online) Available from https://
www.theholisticingredient.com/blogs/wholesome-
living/13587702-8-ways-to-raise-your-vibration-your-
positive-energy [Accessed December 2018].
5. Gupta SK. Soul-Mind-Body Medicine for Healthy Happy
Living: For Prevention of Angina and Heart Attacks. World
Congress on Clinical and Preventative Cardiology; 2006. pp.
22-4.
6. Hellín T. The physician-patient relationship: recent
developments and changes. Haemophilia. 2002;8(3):450-4.
7. Puchalski CM. The role of spirituality in health care. Proc
(Bayl Univ Med Cent). 2001;14(4):352-7.
8. WHO. (2016). WHO recommendations on antenatal care
for positive pregnancy experience. [online] Available from
https://www.who.int/reproductivehealth/publications/
maternal_perinatal_health/anc-positive-pregnancy-
experience/en/ [Accessed December 2018].](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-112-2048.jpg)
![CHAPTER 20
Gestational Diabetes Mellitus
Uma Pandey, Anupama Singh
INTRODUCTION
It is defined1
as carbohydrate intolerance of variable
severity with onset or first diagnosed during present
pregnancy [American College of Obstetricians and Gyne-
cologists 2013 (ACOG 2013)].2
This definition includes
womenwhoseglucosetolerancewillreturnbacktonormal
after pregnancy and also those who will develop type 2
diabetes. The latter group also includes those females
who had pre-existing type 2 diabetes. Gestational diabetes
mellitus (GDM) usually presents in the second or during
third trimester.
EPIDEMIOLOGY
The prevalence of GDM in India varies from 3.8–21% and
it is more in urban than rural areas.3-10
Risk Factors
Positive family history of diabetes (parents, sibling,
aunts, uncles, grandparents)
History of GDM or impaired glucose tolerance test11
Age 30 years
Ethnic group (East Asian, Pacific island ancestry)
Obesity
Historyofoverweightbaby(≥4kg)inpreviouspregnancy
Unexplained perinatal loss or malformed infants
Previous history of stillbirth with pancreatic hyper
plasia (revealed on autopsy)
Persistent glycosuria
Presence of polyhydramnios or recurrent vaginal
candidiasis in present pregnancy
Polycystic ovarian syndrome, cardiovascular disease,
hypertension, hyperlipidemia.
Screening12
Every pregnant female, fasting or random blood
glucose during the first antenatal visit (universal
screening).13-18
Compared to selective screening, uni
versal screening for GDM detects more cases and
improves maternal and neonatal prognosis.19-21
Hence,
universal screening for GDM is essential, as women
of Asian origin and especially ethnic Indians are at a
higher risk of developing GDM and subsequent type.
Type 2 diabetes.22-24
Fifth International Workshop-Conference on Gesta
tional Diabetes25
endorsed Selective Screening26,27
in
pregnant females based on risk assessment for detec
ting GDM using either:
Two step procedure (Flowchart 20.1):2,12,26
One step procedure:31-34
Diagnostic 100 g oral
glucose tolerance test (OGTT) performed on all
subjects.
If high risk; blood glucose test is done as early as
possible, using the procedures described previously. If
GDM is not diagnosed, blood glucose testing should be
repeated at 24–28 weeks’ gestation or at any symptoms or
signs suggesting hyperglycemia.
GDM Risk Assessment25
It should be ascertained at the first prenatal visit (Table 20.1).
DIAGNOSIS
There are various diagnostic criteria for diagnosis of GDM:
Criteria for diagnosis of GDM with 100 g oral glucose
Flowchart 20.1: Two step procedure for screening of
gestational diabetes.](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-120-2048.jpg)
![Gestational Diabetes Mellitus 97
[O’Sullivan and Mahan Modified by carpenter and
Coustan]35
and National Diabetes Data Group (NDDG)36
has been described in Table 20.2.
Criteria for diagnosis of impaired glucose tolerance
and diabetes with 75 g oral glucose (WHO)37
has been
described in Table 20.3.
International Association of Diabetes and Pregnancy
Study Groups (IADPSG) (75 g oral glucose) (mg/dL):
Diagnosis of GDM is made when one or more threshold
values are met or exceeded (Table 20.4).
DIABETES IN PREGNANCY SOCIETIES OF INDIA
(DIPSI)
One step diagnostic procedure for all pregnant females
(universal screening) in antenatal clinic with 75 g oral
glucose irrespective of her fasting status or timing of
previous meal. A venous plasma glucose level of greater
than 140 mg/dL, 2 hr later is diagnosed as GDM. This is
both a screening as well as diagnostic procedure; and is
approved by the Ministry of Health, Govt. of India and also
recommended by World Health Organization (WHO).
The recommendations of the American Diabetes
Association (ADA) and International Association of
Diabetes and Pregnancy Study Groups (IADPSG) in 2011
for diabetes in pregnancy was combined and algorithm40
was proposed which is specified in Flowchart 20.2.
MATERNAL AND FETAL EFFECTS48
Maternal Effects
During Pregnancy
Preeclampsia: One of the most severe complication of
GDM; occurs in 10% of patients with GDM. Factors asso
Table 20.1: GDM risk assessment.
Low-risk Average-risk High-risk
If all of the following are present:
ŠŠ Age 25 years
ŠŠ No history of diabetes in first degree relative
ŠŠ Weight normal at birth
ŠŠ Weight normal prior to pregnancy
ŠŠ No history of abnormal glucose metabolism
ŠŠ Ethnicity with low prevalence of GDM
ŠŠ No history of poor obstetrical outcome
ŠŠ Age 25 years
ŠŠ Diabetes in first degree relative
ŠŠ High weight at birth
ŠŠ Overweight since nonpregnant stage
ŠŠ Ethnicity with high prevalence of GDM
If 1 or more of these present:
ŠŠ Strong family history of type 2 DM
ŠŠ Previous history of GDM or impaired
glucose tolerance test or glucosuria
or macrosomic baby
ŠŠ Severe obesity
(DM: diabetes mellitus; GDM: gestational diabetes mellitus)
Flowchart 20.2: The recommendations of the ADA and IADPSG in
2011 for diabetes in pregnancy.
(HbA1c: glycosylated hemoglobin;41-47
FPG: fasting plasma glucose;
RPG: random plasma glucose; OGTT: oral glucose tolerance test; DM:
diabetes mellitus; GDM: gestational diabetes mellitus)
Table 20.3: Criteria for diagnosis of impaired glucose tolerance and
diabetes with 75 g oral glucose (WHO).37
Time
Normal
tolerance
Impaired glucose
tolerance Diabetes
Fasting 100 ≥100 and 126 ≥126
2 hr post-
glucose
140 ≥140 and 200 ≥200
Note: (1) Venous whole blood values are 15% less than the plasma
values;38,39
(2) mmol/L = mg% × 0.0555.
Table 20.2: Criteria for diagnosis of GDM with 100 g oral glucose
(O’Sullivan and Mahan modified by Carpenter and Coustan)35
and
National Diabetes Data Group (NDDG).36
Glucose Tolerance Test: Venous Plasma Glucose (mg/dL)
Time Carpenter and Coustan NDDG
Fasting 95 105
1 hr 180 190
2 hr 155 165
GDM diagnosed when any two values are met or elevated
(GDM: gestational diabetes mellitus)
Table 20.4: International association of diabetes and pregnancy study
groups (IADPSG) (75 g oral glucose) (mg/dL).
Time Values
Fasting 92
1 hr 180
2 hr 153](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-121-2048.jpg)
![Gestational Diabetes Mellitus 99
growth factor, leptin and adiponectin (Grissa, 2011;
Loukovaara,2004; Mazaki-Tovi, 2005).
Fetal Anomalies
Unlike in overt diabetes, rates of fetal anomalies do not
appear to be substantially increased (Sheffield, 2002)
Hydramnios
Amniotic fluid index (AFI) greater than 24 cm (fetal
hyperglycemia causes polyuria leading to hydramnios).
Fetal Death
Fasting hyperglycemia 105 mg/dL, increased risk of
fetal death during the final 4–8 weeks [ADA(2003)]
Other causes includes chronic hypoxia, placental villus
edema impairing nutrient transfer.
Chemical Imbalances
Fetal hypoglycemia (due to maternal hypoglycemia)
can cause sudden intrauterine fetal death.
Neonatal hypocalcemia (due to delayed postnatal
parathyroid hormone regulation) and hypomag
nesemia (due to longstanding diabetic nephropathy
in mother leading to loss of magnesium from maternal
kidney and hence less availability of Mg2+
for the fetus)
occur within 72 hr of birth.
Neonatal hyperbilirubinemia with risk increased due
to preterm delivery, and relative immaturity of hepatic
bilirubin conjugation and excretion.
Neonatal Hypoglycemia
Neonatal hyperinsulinemia and removal of the
exogenous glucose source (maternal) at the time of
delivery may provoke hypoglycemia within minutes of
birth.
Cornblath and associates (2000) established threshold
of 35 mg/dL in term neonates.
Respiratory Distress Syndrome
There is increased risk of respiratory distress syndrome
due to surfactant deficiency, which is due to increased
risk of preterm delivery in such mothers especially in
uncontrolled blood sugar levels in the mother, and also
due to late maturation of type 2 alveolar cells, and also
fetal hyperinsulinaemia antagonize the action of cortisol
causing blunted production of surfactant.
Long Term Sequela
Increased risk of obesity, type 2 diabetes, cardiovascular
disease and impaired cognitive and motor function.
MANAGEMENT53-62
Pharmacologicalmethodsareusuallyrecommendedifdiet
modification does not consistently maintain the fasting
plasma glucose levels 95 mg/dL or the 2 hr postprandial
plasma glucose 120 mg/dL (ACOG 2013).
The Fifth International Workshop Conference reco
mmended that fasting glucose levels be kept 95 mg/dL
(Metzger, 2007).
Diabetic Diet
The ADA recommends individualized nutritional coun
seling based on height and weight (Bantle, 2008). On
average, this includes a daily caloric intake of 30–35 kcal/
kg.
ACOG 2013 suggests that carbohydrate intake be
limited to 40% of total calories. The remaining calories
are apportioned to give 20% as protein and 40% as fat.
ADA 2003; obese women with body mass index
(BMI) 30 kg/m2
should have 30% calorie restriction
(approximately 25 kcal/kg/day).
Monitoring done by weekly assessment of ketonuria,
which have been linked with impaired psychomotor
development in offspring (Rizzo,1995; Scholre,2012).
Exercise
Physical activity during pregnancy reduces the risk of
gestational diabetes (Dempsy et al, 2004).
Resistance exercise decreases the need for insulin
therapy in overweight women with GDM (Brankston
et al, 2004).
ACOG 2013 recommends moderate exercise as part of
treatment in women with GDM.
Flowchart 20.4: Pedersen hypothesis.](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-123-2048.jpg)
![FOGSI FOCUS: Adbhut Matrutva102
20. Cosson E. Screening and insulin sensitivity in gestational
diabetes. Abstract volume of the 40th Annual Meeting of the
EASD, September 2004: A350.
21. Griffin ME, Coffey M, Johnson H, et al. Universal vs risk
factor-based screening for gestational diabetes mellitus:
detection rates, gestation at diagnosis and outcome. Diabet
Med. 2000;17(1):26-32.
22. Dornhorst A, Paterson CM, Nicholls JS, et al. High prevalence
of GDM in women from ethnic minority groups. Diabet Med.
1992;9(9):820-5.
23. Beischer NA, Oats JN, Henry OA, et al. Incidence and severity
of gestational diabetes mellitus according to country of birth
in women living in Australia. Diabetes. 1991;40(2):35-8.
24. Metzger BE, Coustan DR. Summary and recommendations of
the fourth international workshop-conference on gestational
diabetes mellitus. Diabetes Care. 1998;21(2): B161-7.
25. Metzger BE, Buchanan TA, Coustan DR, et al. Summary
and recommendations of the fifth international workshop-
conference on gestational diabetes mellitus. Diabetes Care.
2007;30(2):S251-60.
26. American Diabetes Association. Gestational Diabetes
Mellitus. Diabetes Care. 2002;25(1):S94-6.
27. NICE 2015. Diabetes in pregnancy: management from pre
conception to the postnatal period. [online]. Available from
https://www.nice.org.uk/guidance/ng3/resources/diabetes-
in-pregnancy-management-from-preconception-to-the-
postnatal-period-pdf-51038446021 [Accessed December 2018].
28. O’Sullivan JB, Mahan C. Criteria for OGT in pregnancy.
Diabetes. 1964;13:278-85.
29. World Health Organization. Definition, Diagnosis and
Classification of Diabetes Mellitus and its Complications
Report of a WHO Consultation, Part 1: Diagnosis and
Classification of Diabetes Mellitus. [online]. Available from
http://apps.who.int/iris/handle/10665/66040 [Accessed
December 2018].
30. American Diabetes Association. Standards of medical care in
diabetes-2013. Diabetes Care. 2013;36(1):S11.
31. Metzger BE, Gabbe SG, Persson B, et al. International
Association of Diabetes and Pregnancy Study Groups
Consensus Panel. International association of diabetes and
pregnancy study groups recommendations on the diagnosis
and classification of hyperglycemia in pregnancy. Diabetes
Care. 2010;33:676-82.
32. MetzgerBE,LoweLP,DyerAR,etal.HAPOStudyCooperative
Research Group. Hyperglycemia and adverse pregnancy
outcomes. N Engl J Med. 2008;358:1991-2002.
33. Vij P, Jha S, Gupta SK, et al. Comparison of DIPSI and
IADPSG criteria for diagnosis of GDM: A study in a north
Indian tertiary care center. Int J Diabetes Dev Ctries. 2015.
34. Anjalakshi C, Balaji V, Balaji MS, et al. A single test procedure
to diagnose gestational diabetes mellitus. Acta Diabetol.
2009;46:51-4.
35. Carpenter MW, Coustan DR. Criteria for screening tests for
gestational diabetes. Am J Obstet Gynecol. 1982;144:768-73.
36. National Diabetes Data Group. Classification and diagnosis
of diabetes mellitus and other categories of glucose
intolerance. Diabetes. 1979;28(12):1039-57.
37. World Health Organization. Diagnostic criteria and
classification of hyperglycaemia first detected in pregnancy.
Diabetes Res Clin Pract. 2014;103(3):341-63.
38. Balaji V, Madhuri BS, Paneerselvam A, et al. Comparison of
venous plasma glucose and capillary whole blood glucose in
the diagnosis of gestational diabetes mellitus: a community-
based study. Diabetes Technol Ther. 2012;14:131-4.
39. Bhavadharini B, Mahalakshmi MM, Maheswari K, et al.
Use of capillary blood glucose for screening for gestational
diabetes mellitus in resource-constrained settings. Acta
Diabetol. 2015;53(1):91-7.
40. MO-CDAPP-Hyperglycaemia Algorithm-7-18-11.pdf. Availa
ble at: www.cdph.ca.gov/progr.
41. Raiput R, Yadav Y, Raiput M, et al. Utility of HbA1c
for
diagnosis of gestational diabetes mellitus. Diabetes Res Clin
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42. Lowe P, Metzger BE, Dyer AR, et al. Hyperglycemia and
Adverse Pregnancy Outcome (HAPO) Study: Associations
of maternal A1C and glucose with pregnancy outcomes.
Diabetes Care. 2012;35(3):574-80.
43. Davies DM, Welborn TA. Glycosylated haemoglobin in
pregnancy. Aust NZJ Obstet Gynaecol. 1980;20(3):147-50.
44. Pollak A, Widness JA, Schwartz R. Minor hemoglobins:
an alternative approach for evaluating glucose control in
pregnancy. Biol Neonate. 1979;36(3-4):185-92.
45. Widness JA, Schwartz HC, Kahn CB, et al. Glycohemoglobin
in diabetic pregnancy: a sequential study. Am J Obstet
Gynecol. 1980;136(8):1024-9.
46. McFarland KF, Catalano EW, Keil JE, et al. Glycosylated
haemoglobin in diabetic and nondiabetic pregnancies.
South Med J. 1981;74(4):410-2.
47. Rafat D, Ahmad J. HbA1c
in pregnancy. Diabetes Metab Syndr.
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48. Alberti K, Zimmett P. Definition, diagnosis and classification
of diabetes mellitus and its complications. Part 1: diagnosis
and classification of diabetes mellitus provisional report of a
WHO consultation. Diabet Med .1998;15(7):539-53.
49. Vidaeff AC, Yeomans ER, Ramin SM. Pregnancy in renal
disease.
50. Merlob P, Hod M. Short-term Implications: the neonate.
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Martin Dunitz, Taylor Francis Group; 2003. pp.289-304.
51. Schwartz R, Gruppuso PA, Petzold K, et al. Hyperinsulinemia
and macrosomia in the fetus of the diabetic mother. Diabetes
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52. Chattfield J. ACOG issues guidelines on fetal macrosomia.
An FAM Physician. 2001;64(1):169-70.
53. Reiher H, Fuhramann K, Noack S, et al. Age-dependent
insulin secretion of the endocrine pancreas in vitro from
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1983;6(5):446-51.
54. Paul VK, Deorari AK, Singh M. Management of Low birth
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2002, pp. 60.
55. Langer O, Levy J, Brustman L, et al. Glycemic control in
gestational diabetes mellitus-how tight is tight enough:
small for gestational age versus large for gestational age? Am
J Obstet Gynecol. 1989;161(3):646-53.](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-126-2048.jpg)
![Medicolegal Aspect of Maternity Care 119
Patient or relatives dissatisfaction
Asking to take second opinion and one has refused
Asking to shift the patient to another hospital and one
has refused or delayed
Complications or an unexpected result:
Failure of procedure/operation
Trauma/injury
Hemorrhage
Infections
Complication of anesthesia
Tremendous expense against not expected result
Death of a young patient
Request for medical record and one has refuse
Failure of a patient to keep scheduled follow-up and
ended into complications.
So, if one is dealing with this situation, should be alert
to face litigation.
Prevention is always better than cure.
Here are some tips to follow to avoid litigation:
Proper antenatal care:
Antenatal care is systemic supervision of woman
during pregnancy
It provides necessary therapeutic interventions
and educating pregnant woman about planning
of safe delivery, to pick up high-risk factors in time
and planning accordingly, manage emergencies
during pregnancy, and due intensive management
accordingly
Antenatal visits:
ŠŠ Proper history with age, any symptom, detail
menstrual [last menstrual period (LMP)] and
detail obstetric history with past deliveries,
abortions, mode of delivery, complications, etc.
ŠŠ History of any systemic illness, surgery,
hospitalization, etc.
ŠŠ Proper counseling for antenatal visit monthly
up to 32 weeks, biweekly after 32 weeks up to
36 weeks, and weekly up to delivery
ŠŠ If any high-risk factor, then frequency of
antenatal visit will be more
ŠŠ Proper instructions during every visit
Proper physical examination:
ŠŠ Systemic examination
ŠŠ Abdominal examinations including fetal heart
auscultation when it becomes audible.
Pelvic examination:
ŠŠ Perspeculum and pervaginal examination as per
case
Investigations
Blood:
ŠŠ Grouping ABO Rh
ŠŠ Complete blood count (CBC): Hemoglobin at
initial visit and at least once in each trimester. If
patient is under treatment for anemia frequency
of test for hemoglobin will be more
ŠŠ If anemia, treat meticulously and if any high-risk
factor, then frequency of investigations will be
more
ŠŠ Venereal disease research laboratory (VDRL)/
hepatitis B surface antigen (HBsAg)/human
immunodeficiency virus (HIV)
ŠŠ Sugar: As per FOGSI guideline or Diabetes
in Pregnancy Study Group in India (DIPSI)
guideline, fasting blood sugar (FBS) at first visit
and glucose challenge test (blood sugar after 1
hour of 50 g glucose irrespective of fasting status)
between 24 weeks and 26 weeks
ŠŠ Thyroid profile
ŠŠ Test to rule out thalassemia trait
ŠŠ Specific investigations as per condition
Urine examination:
ŠŠ Routine and microscopy with albumin and sugar
Ultrasound examination:
ŠŠ In early pregnancy to confirm intrauterine/
ectopic pregnancy
ŠŠ During 11–13 weeks scan for NT and to rule out
congenital malformation
ŠŠ About at 22 weeks for four chamber view of
heart, three vessels view and out flow tract, and
to rule out other anomalies
ŠŠ During 32–34 weeks for fetal growth parameters,
liquor, and placental localization and to rule out
accreta, increta or percreta
Immunization:
ŠŠ Twodoseoftetanustoxoidinjection0.5mL/dose
deep intramuscular in upper arm at interval of
1 month after first trimester
ŠŠ Second dose at least 1 month before delivery
ŠŠ Prophylactic injection anti-D at 28 weeks in case
of Rh-negative patient.
Drugs:
ŠŠ Tablets iron folic acid (100 mg elemental iron
and 0.5 mg folic acid) daily till delivery and even
in postpartum period also for some period as
per case after first trimester
ŠŠ Tablet calcium 1,000 mg daily after first trimester
ŠŠ Otherdrugsaspercase,i.e.GDM,pre-eclampsia,
etc.
Diet and nutrition:
ŠŠ Counseling for nutrition and proper diet](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-143-2048.jpg)
![Preventing Cervical Cancer and STDs 123
including HPV vaccination. The current CDC recommen
dations for vaccination are as follows:6
All children aged 11 or 12 years should get two HPV
vaccine shots 6 to 12 months apart. If the two shots
are given less than 5 months apart, a third shot
will be needed. There could be future changes in
recommendations on dosing.
HPV vaccine is recommended for young women up to
age 26, and young men up to age 21.
Adolescents who get their first dose at age 15 or older
need three doses of vaccine given over 6 months. (0, 1,
6 or 0, 2, 6 as the vaccine schedule may be)
Persons who have completed a valid series with any
HPV vaccine do not need any additional doses.
To curb the menace today screening and treatment of
precancerous lesions is the only answer.
SCREENING FOR CERVICAL CANCER
Methods Available
Cervical cytology has been the oldest method of
screening and well-organized cytology programs
have been very successful to bring down the cervical
cancer rates in many countries, the glaring example
being British Columbia and Canada. It could be
conventional cytology, liquid base cytology (LBC), or
more advanced automated Pap smear testing methods
(AutoPap and AutoCyte Screen). Nonetheless it is
difficult to sustain effective cervical cytology programs
in developing countries like ours.
Visual inspection methods: Visual inspection of the
cervix with naked eye [after application of acetic acid
(VIA) or Lugol’s iodine (VILI)]. The test characteristics
have been evaluated in many field studies and
sensitivity ranges from 67% to 79% and specificity 49–
86%.7
HPV-based screening tests: With the discovery of
HPV as a necessary cause of cervical cancer by noble
laureate Harald zur Hausen, testing for the presence of
HPV as a marker for cervical cancer has emerged as an
important screening modality.
TherearevariousmethodsoftestingforHPV:CareHPV,
Cervista, Hybrid Capture 2, E6/E7 mRNA, etc. They rely on
molecular technologies to detect HPV DNA in cervical or
vaginal fluids. Detection rates of high-grade lesions by this
method are far better than visual methods and cytology.
They can however, complement each other which further
improves the pickup rates. Though very sensitive, the
specificity of these tests lacks specificity. Hybrid Capture 2
is the most commonly used method of HPV testing. With
the availability of simple, affordable, and accurate HPV
tests, it can be used as a primary screening approach in
low-resource settings for women who are at least 30 years
of age.8
Transient HPV infections are picked up as HPV
positive in women where no cytological changes have
occurred. Managing such women can be challenging.
FOGSI GCPR is an extremely useful guiding tool to decide
on screening modalities to be followed and also to manage
the screen positives according to the resource settings in
which we are working. There is, in fact, everything that can
be done in every situation.
But looking at the diverse demographic characteristics
of Indian population and the large unmet needs of
screening, visual methods of cervical screening have
emerged successful candidates in resource poor settings.
Of these, visual inspection after application of 3–5%
acetic acid and visual inspection with Lugol’s iodine are
the simplest and easily available and affordable. More
than that, these can be done by healthcare workers and
paramedics.Hence,alargepopulationcanbescreenedand
a single visit “screen and treat” will be the most effective
method of bringing down the rates of cervical cancer.
Awareness program about the preventable nature of
the disease and the preventive measures that are available
is again a crucial step that does not get due importance.
Then coming to secondary prevention, this includes
early detection which may be in symptomatic or
asymptomatic women. This is again a large segment which
is missed out because per speculum examination is falling
out of practice. Neither the patient nor the healthcare
professional appreciate the great importance of doing a
perspeculum examination, the great secrets that it reveals
which no Hi-Tech Investigation will. Please do not lose the
opportunity of doing a perspeculum examination for all
women attending any healthcare facility for any problem.
Screen Positive Women
This is a supplement to the screening program that
cannot be ignored. Hence developing a support system to
convince patients for treatment as close to their homes is a
trick that will do it. Hence screen and treat would be good
alternative and wisest option in India and accepting the
rates of overtreatment is the fine we pay for that.
FOGSI RECOMMENDATIONS
Human papillomavirus vaccines are licensed for use in
females aged 9–45 years; however, the preferred target
age group is 9–14 years (Level A).
Vaccination in sexually active females may be less
effective, but may provide some benefit as exposure to
all vaccine types previously is unlikely (Level B).](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-147-2048.jpg)
![Preventing Cervical Cancer and STDs 125
confidence and given thorough counseling about the
do’s and don’ts. Encouraging correct and consistent use
of condom by male and female should be encouraged
and screening asymptomatic persons at risk is the crux.
Monogamous relationships should be encouraged.
FOGSI “Adbhut Matrutva Programme” the flagship
programme of FOGSI President Dr Jaideep Malhotra has
been a great program and with its thrust on overall physical
and mental wellbeing of women of India, improvement of
nutritional status, improvement of maternal intelligence
to handle pregnancy and children safely will go a long way
to prevent cervical cancer and STDs in the coming future.
REFERENCES
1. Rathi A, Garg S, Meena GS. Human papilloma virus vaccine
in Indian settings: Need of the hour. J Vaccines Vaccin.
2016;7:346.
2. Kjaer SK, Nygård M, Dillner J, et al. A 12-year follow-up on
the long-term effectiveness of the quadrivalent human
papillomavirus vaccine in 4 Nordic countries. Clin Infect Dis.
2018;66(3):339-45.
3. Huh WK, Joura EA, Giuliano AR, et al. Final efficacy,
immunogenicity, and safety analyses of a nine-valent
human papillomavirus vaccine in women aged 16-26 years:
a randomised, double-blind trial. Lancet. 2017;390(10108):
2143-59.
4. Naud PS, Roteli-Martins CM, De Carvalho NS, et al.
Sustained efficacy, immunogenicity, and safety of the HPV-
16/18 AS04-adjuvanted vaccine: Final analysis of a long-
term follow-up study up to 9.4 years post-vaccination. Hum
Vaccin Immunother. 2014;10(8):2147-62.
5. Steinbrook R. The potential of human papillomavirus
vaccines. N Engl J Med. 2006;354(11):1109-12.
6. National Cancer Institute (2018). Human papillomavirus
(HPV) vaccines. [online] Available from https://www.cancer.
gov/about-cancer/causes-prevention/risk/infectious-
agents/hpv-vaccine-fact-sheet [Accessed December 2018].
7. Sankaranarayanan R, Gaffikin L, Jacob M, et al. A critical
assessment of screening methods for cervical neoplasia. Int J
Gynaecol Obstet. 2005;89:S4-12
8. Sankarnarayanan R, Nene BM, Shastri SS, et al. Concurrent
evaluation of visual, cytological, and HPV testing as
screening methods for the early detection of cervical cancer
in Mumbai, India. Bull World Health Organ. 2005;83:
186-94.
9. Barra F, Maggiore ULB, Bogani G, et al. New prophylactic
human papilloma virus (HPV) vaccines against cervical
cancer. J Obstet Gynaecol. 2018;27:1-10.
10. Gravitt PE, Belinson JL, Salmeron J, et al. Looking ahead:
a case for human papilloma virus testing of self-sampled
vaginal specimens as cervical cancer screening strategy. Int
J Cancer. 2011;129:517-27.
11. Dinshaw K, Mishra G, Shastri S, et al. Determinants of
complianceinaclusterrandomizedcontroltrialonscreening
of breast and cervical cancer in Mumbai, India. Compliance
to Screening. Oncology. 2007;73:145-53.](https://image.slidesharecdn.com/9-200817110932/75/Fogsi-focus-adbhut-matrutva-149-2048.jpg)
Uploaded byNARENDRA C MALHOTRA
Fogsi focus adbhut matrutva
This document discusses the launch of the "Adbhut Matrutva" project by the Federation of Obstetric and Gynaecological Societies of India (FOGSI) at the All India Congress of Obstetrics and Gynaecology on January 19th, 2018. The Adbhut Matrutva program aims to provide holistic antenatal care to reduce maternal and perinatal morbidity and mortality as well as prevent noncommunicable diseases. It addresses the fetal origins of adult diseases. The document notes that the Indian government prioritizes healthcare, especially for mothers and children, through programs targeting maternal mortality, infant mortality and malnutrition.
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Fogsi focus adbhut matrutva
- 1.
- 3. FOGSI FOCUS Adbhut Matrutva JAYPEEBROTHERS MEDICAL PUBLISHERS The Health Sciences Publisher New Delhi | London | Panama Foreword Jaideep Malhotra Federation of Obstetric and Gynaecological Societies of India (FOGSI) Co-Editors BK Shubhada Neel MD DGO DNB DFP(Mum.) Fellowship in Cancer Tata Memorial Hospital National Coordinator Adbhut Matrutva: A FOGSI Initiative Yoga and Meditation Expert Director and Consultant Neel Hospital and ICU New Panvel, Maharashtra, India Pushpa Pandey MD(Obs/Gyne) Senior Consultant Department of Gynecology Bombay Hospital Jabalpur, Madhya Pradesh, India Neharika Malhotra Bora MD(Obs-Gyn) FICMCH FMAS Infertility Consultant Rainbow IVF Hospital Assistant Professor Bharati Vidyapeeth Medical College Consultant, Malhotra Hospitals Jr Consultant and Fellow Reproductive Medicine at Patankar Hospital Pune, Maharashtra, India TM Editor-in-Chief Jaideep Malhotra MD FICMCH FICOG FICS FMAS FIAJAGO FRCOG FRCPI Professor, Dubrovnik International University, Croatia Imm. Past President, IMS President Elect, SAFOMS, 2019-2021 President Elect, ISPAT Editor-in-Chief, SAFOMS and SAFOG Journal Member, FIGO, Reproductive Endocrinology and Infertility Member, FIGO, RDEH Regional Director of South Asia Ian Donald School of Ultrasound Vice President, ISAR Managing Director, ART, Rainbow IVF Hospital Agra, Uttar Pradesh, India
- 4. Jaypee Brothers MedicalPublishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 E-mail: [email protected] Overseas Offices JP Medical Ltd Jaypee-Highlights Medical Publishers Inc 83 Victoria Street, London City of Knowledge, Bld. 235, 2nd Floor SW1H 0HW (UK) Clayton, Panama City, Panama Phone: +44 20 3170 8910 Phone: +1 507-301-0496 Fax: +44 (0)20 3008 6180 Fax: +1 507-301-0499 E-mail: [email protected] E-mail: [email protected] Jaypee Brothers Medical Publishers (P) Ltd Bhotahity, Kathmandu, Nepal Phone: +977-9741283608 E-mail: [email protected] Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2019, Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/ or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. The CD/DVD-ROM (if any) provided in the sealed envelope with this book is complimentary and free of cost. Not meant for sale. Inquiries for bulk sales may be solicited at: [email protected] FOGSI FOCUS: Adbhut Matrutva First Edition: 2019 ISBN 978-93-5270-839-0 Printed at
- 5. Dedicated to Divine mother-babyfor creating beautiful new world God's Message for all My sweet children look there the new golden world, just for you all Message for Gynecologists For you divine angels you are special Your positive thoughts and actions are so powerful that they radiate peace and happiness to the whole world.
- 7. Amitha Indersen MD Postdoctoral Fellowin Fetal Medicine Fellow in Advanced Obstetric and Gynecological Ultrasound Fetal Medicine Consultant Apollo Cradle Hospitals Hyderabad, Telangana, India Anupama Singh MD Junior Resident Department of Obstetrics and Gynecology Institute of Medical Sciences Banaras Hindu University Varanasi, Uttar Pradesh, India Asha Thakare MD(Obs/Gyne) Consultant Department of Obstetrics and Gynecology Akanksha Nursing Home Amravati, Maharashtra, India Awantika MBBS MD Consultant Department of Obstetrics and Gynecology Hope Maternity Centre Nirsa, Jharkhand, India Bhagyalaxmi Nayak MD PhD Oncology Committee, FOGSI Associate Professor Department of Gynecologic Oncology Regional Cancer Center Cuttack, Odisha, India Bharati Ghivalikar MD(Obs/Gyne) Consultant Department of Obstetrics and Gynecology Shree Prajakta Hospital Bhiwandi, Maharashtra, India BK EV Swaminathan B Tech(Mechanical Engineering) PHD Emotional and Spiritual Intelligence Visiting Faculty Department of Obstetrics and Gynecology Neel Hospital New Panvel, Maharashtra, India BK Shubhada Neel MD DGO DNB DFP(Mum.) Fellowship in Cancer Tata Memorial Hospital National Coordinator, Adbhut Matrutva: A FOGSI Initiative Yoga and Meditation Expert Director and Consultant Neel Hospital and ICU New Panvel, Maharashtra, India Dayanath Mishra MD DM DNB Director DM Hospitals Kolkata, West Bengal, India Evita Fernandez FRCOG Managing Director Fernandez Hospital Foundation Hyderabad, Telangana, India Gayatri Singh MD(Obs/Gyne) Consultant Department of Obstetrics and Gynecology Dhanbad Clinic Dhanbad, Jharkhand, India Jaideep Malhotra MD FICMCH FICOG FICS FMAS FIAJAGO FRCOG FRCPI Professor Dubrovnik International University, Croatia Imm. Past President, IMS President Elect, SAFOMS, 2019-2021 President Elect, ISPAT Editor-in-Chief, SAFOMS and SAFOG Journal Member, FIGO, Reproductive Endocrinology and Infertility Member, FIGO, RDEH Regional Director of South Asia Ian Donald School of Ultrasound Vice President, ISAR Managing Director, ART, Rainbow IVF Hospital Agra, Uttar Pradesh, India Jayam Kannan MD DGO Vice-President, FOGSI 2018 Department of Obstetrics and Gynecology Garbba Rakshambigai Fertility Centre Chennai, Tamil Nadu, India Keerti Parashar MS(Obs/Gyne) Consultant Department of Obstetrics and Gynecology Crescent Health Care Sasaram, Bihar, India Kumkum Mehrotra MBBS MRCOG Infertility and TVS Specialist Mehrotra Clinic Moradabad, Uttar Pradesh, India Lila Vyas MD Vice President, FOGSI Ex-Professor Department of Obstetrics and Gynecology Sawai Man Singh Medical College Jaipur, Rajasthan, India Contributors
- 8. FOGSI FOCUS: AdbhutMatrutvaviii Madhu Jain MD Professor Department of Obstetrics and Gynecology Institute of Medical Sciences Banaras Hindu University Varanasi, Uttar Pradesh, India Manju Gupta MBBS DGO Consultant Gynecologist Guru Nanak Hospital Director, Nirogam Medicare New Delhi, India Manpreet Sharma MBBS MS Consultant Department of Obstetrics and Gynecology Global Rainbow Healthcare Agra, Uttar Pradesh, India MC Patel MD(Obs/Gyne) Consultant Obstetrician, Gynecologist and Medicolegal Counselor Vice President, FOGSI 2018 Chairperson, Ethics and Medicolegal Committee FOGSI, 2011-2013 President, Ahmedabad Obstetrics and Gynaecological Society, 2010-2011 President, IMA Ahmedabad, Gujarat, India Narendra Malhotra MD, FICOG FICMCH FRCOG FICS FMAS AFIAP Professor Dubrovnik International University VP WAPM (World Association of Prenatal Medicine) President, ISPAT, 2017-2019 Managing Director Global Rainbow Healthcare Agra, Uttar Pradesh, India Neelam Gulati PG Diploma(Cosmetology) Senior Cosmetologist Global Rainbow Hospital Agra, Uttar Pradesh, India Neharika Malhotra Bora MD(Obs/Gyne) FICMCH FMAS Infertility Consultant Rainbow IVF Hospital (June 2015 to Present) Assistant Professor Bharati Vidyapeeth Medical College (June 2013 to June 2015) Consultant, Malhotra Hospitals (May 2011 to May 2012) Jr Consultant and Fellow Reproductive Medicine at Patankar Hospital (July 2012 to April 2013) Pune, Maharashtra, India Nidhi Gupta MS(Obs/Gyne) Consultant Department of Obstetrics and Gynecology Gangori Hospital Jaipur, Rajasthan, India Nisha Sahu MBBS DGO President Jabalpur Obstetric and Gynecological Society Superintendent Lady Elgin Hospital Jabalpur, Madhya Pradesh, India Nitika Sobti MBBS DGO Certified Birth Psychology Educator (APPPAH, USA) Director and Founder—Virtue Baby Principal Consultant Department of Obstetrics and Gynecology Max Hospital Gurugram, Haryana, India Prashitha Panneerselvam MS(Obs/Gyne) FRM Consultant Department of Obstetrics and Gynecology Garbba Rakshambigai Fertility Centre Chennai, Tamil Nadu, India Pratima Mittal MD FICOG FICMCH PGDHHM Professor and Consultant Department of Obstetrics and Gynecology VMMC and Safdarjung Hospital New Delhi, India Pushpa Pandey MD(Obs/Gyne) Senior Consultant Department of Gynecology Bombay Hospital Jabalpur, Madhya Pradesh, India Ragini Singh MD Past President Jamshedpur Obstetrics and Gynecological Society Vice President, AOGSBJ Vice President, IMA Women's Wing Senior Consultant Department of Obstetrics and Gynecology Shree Bajrana Diagnostic and Research Centre Jamshedpur, Jharkhand, India Rajat Ray MD FICOG Department of Obstetrics and Gynecology Ray Hospital and Test Tube Baby Centre Rourkela, Odisha, India Rashid Rizvi MD(Path.) Lab Director, Apollo Chief of Laboratory, DM Hospitals and RSV Hospital Former Lab Director Medinova Diagnostic Services Kolkata, West Bengal, India
- 9. Contributors ix Richa Baharani MD FICOG Diploma in Endoscopy Consultant Gynecologist Department of Obstetrics and Gynecology Jabalpur Hospital and Research Centre Jabalpur, Madhya Pradesh, India Sangita Rani MS(Obs/Gyne) Consultant Department of Obstetrics and Gynecology BP Neogi Hospital, DVC Maithon, Jharkhand, India Shakuntla Kumar DGO FIAOG FICOG Diploma in Endoscopy Kiel, Germany Senior Consultant Fortis Hospital, New Delhi Medical Director Nulife Hospital New Delhi, India Shashi Khare MS FICOG Retired Dean and Head NSCB Medical College Jabalpur, Madhya Pradesh, India Shilpa Joshi RD Consultant Department of Diet and Health Mumbai Diet and Health Centre Mumbai, Maharashtra, India Shuchi Jain MS Assistant Professor Department of Obstetrics and Gynecology Institute of Medical Sciences Banaras Hindu University Varanasi, Uttar Pradesh, India Somnath Bhattacharya MS(Obs/Gyne) Consultant Department of Obstetrics and Gynecology Vivekanand Hospital Durgapur, West Bengal, India Sonal Richharia DNB DGO MNAMS Secretary Jabalpur Society, Jabalpur (Obs/Gyne) Society Consultant and Gynecologist City Hospital Jabalpur, Madhya Pradesh, India Sonam Baharani MBBS Senior Resident Department of Obstetrics and Gynecology Sri Aurobindo Institute of Medical Sciences Indore, Madhya Pradesh, India Sumitra Bachani MD FICOG FICMCH Fellow, Maternal Fetal Medicine All India Institute of Medical Sciences, New Delhi Specialist and Assistant Professor Department of Obstetrics and Gynecology VMMC and Safdarjung Hospital New Delhi, India Sunita Lodaya DGO DFP PGDHA Fellowship in Infertility Clinical Director Khushi Test Tube Baby Centre Haveri, Karnataka, India Uma Pandey MD(Obs/Gyne) Associate Professor Department of Obstetrics and Gynecology Institute of Medical Sciences Banaras Hindu University Varanasi, Uttar Pradesh, India Veena Sinha MS(Obs/Gyne) Consultant Department of Obstetrics and Gynecology Shiva Nursing Home Jamshedpur, Jharkhand, India Vimee Bindra MBBS MS(Obs/Gyne) MHA Fellowship in Laparoscopic Gynecology, Mumbai Advanced Infertility Training, UK Consultant Gynecologist Laparoscopic Surgeon and Infertility Specialist Apollo Hospitals Hyderabad, Telangana, India
- 11. I am pleasedto learn that, the Federation of Obstetric and Gynaecological Societies of India (FOGSI) has launched a Unique Project “Adbhut Matrutva” in All India Congress of Obstetrics and Gynaecology (AICOG) on January 19th, 2018 in Bhubaneswar, Odisha, India. “Adbhut Matrutva” program is a unique initiative which focuses on providing holistic antenatal care, which will not only reduce maternal and perinatal morbidity and mortality, but will also prevent several intergenerational, noncommunicable diseases (NCDs) such as diabetes, arterial hypertension and cardiovascular disease. It addresses the fetal origin of adult diseases, thus preventing many NCDs. While providing quality health care to all is a top priority of the Government, special focus is on health care of the mother and child. The National Health Mission, through its targeted schemes, has made substantial progress in achieving Millennium Development Goats such as reduction in maternal mortality ratio and under-five mortality rate. Several innovative schemes such as the Janani Shishu Suraksha Karyakram, Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), LaQshya-Labor Room Quality Improvement Initiative, Mother Absolute Affection (MAA) Programme, Home Based Newborn and Young Child Care, Poshan Abhiyaan, Anemia Mukt Bharat, introduction of new vaccines, etc. have been launched by the Ministry to provide quality health care to pregnant women and children. Projects such as PMSMA and Adbhut Matrutva, I believe, play a vital role in highlighting the need for maintaining a physically, mentally and spiritually healthy self during all phases of pregnancy. The role of gynecologist during the crucial phases of motherhood cannot be underscored enough. It is heat-warming to know that more than 200 Adbhut Matrutva sessions were conducted across India for the enhancement of a quality care-giving to expectant mothers. I am also delighted to know that many programs were conducted on 9th of every month as part of ‘I Pledge for 9’—Pradhan Mantri Surkshit Matritva Abhiyan. I convey my best wishes to the President and organizers for the fruitful project. Anupriya Patel Minister of State Ministry of Health and Family Welfare Government of India Message
- 13. It is amatter of immense pleasure that the Federation of Obstetric and Gynaecological Societies of India (FOGSI) has launched a unique project “Adbhut Matrutva” under the dynamic leadership of President Jaideep Malhotra. The Government of India has a comprehensive reproductive, maternal, newborn, child and adolescent healthcare approach. Janani Shishu Suraksha Karyakram, LaQshya and Pradhan Mantri Surakshit Matritva Abhiyan are key programs implemented across the country for quality healthcare services to pregnant women and newborns. Although the Government is leaving no stone unturned to provide quality health care, but it would achieve momentum when various organizations join these efforts. In this context, the FOGSI is playing a significant role. I once again urge all FOGSI members to volunteer at nearby government hospitals on the 9th of every month under the Pradhan Mantri Surakshit Matritva Abhiyan. I also urge all mentors to join hands with the LaQshya–Labor Room Quality Improvement Initiative to ensure quality intrapartum and immediate partum care to pregnant women and newborns. I am sure that together we can create a better future for the mothers and children of our country. I extend my heartiest congratulations to FOGSI for their efforts in this direction and offer my best wishes for the success of their projects. Dinesh Baswal Deputy Commissioner In-Charge (Maternal Health) Minister of State Ministry of Health and Family Welfare Government of India Message
- 15. Om Shanti. Greeting ofPeace and Love for the New Year. It is a pleasure to witness the unwavering passion and commitment of the Federation of Obstetric and Gynaecological Societies of India (FOGSI) family. Each of you is an Angel who is touching so many lives in the most meaningful and diving way. The “Adbhut Matrutva” project has begun on an impactful note. By addressing very aspect of spiritual health, emotional health, mental health and physical health, the project has promised a happier and healthier new generation. I am confident that every expectant parent under the project’s ambit will experience a transformation in themselves, which will radiate as beautiful sanskars to their child. Your tireless efforts and pure intention will create miracles in families. Congratulation, Dr Jaideep Malhotra for your insightful leadership and guidance to roll out Adbhut Matrutva in 2018. This is just the beginning. You have sown the seeds of which the future generations will enjoy the fruit. As every member of the FOGSI family implements this project, each one will experience a new dimension in parent and child care. These experiences will take the project to the world. For 2019, along with all the wonderful projects you take to heal others, please take up the one main project “Self Care”. Please dedicate at least 30 minutes daily to nourish your mind with spiritual study and meditation. Your Self Caring…will become the Healing Energy for parents and children. BK Sister Shivani Awakening with Brahma Kumaris Message
- 17. Dear Friends, Women arethe pivot of any family and we obstetricians and gynecologists, our whole life revolves around the women of our country. We have 26 million pregnancies in our country with 20 million births and we today are the obesity, diabetes, and preterm delivery capital of the world. We have brought down our maternal mortality ratio to 130/1,00,000 but we are struggling to bring it down further and much needs to be done apart from institutional deliveries. When we look at the causes of maternal mortality, noncommunicable diseases (NCDs) are rising steadily on the top and so much so that more than 60% of the adult deaths are attributable to the NCDs. What can we do to reduce the burden of NCDs and also build up a healthy doctor- patient relationship, which would encourage bonding of the mother with the baby and have long-term impact on the outcomes maternal mortality ratio (MMR), neonatal mortality rate (NMR), vaginal deliveries, better neurocognitive development of children, make pregnancy a blissful experience and much more. Welcome to the World of Adbhut Matrutva. It is my proud privilege to bring to you this FOGSI Focus dedicated to Adbhut Matrutva and I sincerely hope that the contents are definitely going to benefit each and every one of you in your day-to-day practice and engage the patients much more with the baby and the doctor, because pregnancy is no disease, and giving birth should be the greatest achievement and not fear. “My dream is that every woman, everywhere, will know the joy of a truly safe, comfortable, and satisfying birthing for herself and her baby.”—Marie Mongan I would like to place on record, my sincere thanks to BK Sister Shivani, BK Dr Shubhda Neel and all BK Family, Mr Amit Bakshi, Mr Deepak Devgan, Mr Hrishikesh, Ms Padmaja, and the whole team from Eris Montana and I could not have made this concept as popular and reach as many people without your timely support and encouragement. I also have to put on record my gratitude to Dr Dayanand Mishra and Dr Rashid Rizvi for the beautiful Adbhut Matrutva App which I am sure will be very useful for all pregnant mothers and mothers to be. I cannot thank enough to my FOGSI family, especially all my Vice Presidents, Chairpersons, Dr Jaydeep Tank, Dr Madhuri Patel, Dr Suvarna, Dr Parikshit Tank, Dr Neharika Malhotra Bora, and Dr Narendra Malhotra for a full-hearted support for this endeavor and I sincerely hope that all Fogsians will definitely benefit from this concept of Garbh Sanskar and fetal origin of adult diseases. All the best and happy reading. Jaideep Malhotra Foreword
- 19. FOGSI Focus isa regular update on current developments in the field of Obstetrics and Gynecology by experts in their specialties. This issue is focused mainly on the project Adbhut Matrutva, especially designed for expectant mothers by the Federation of Obstetric and Gynaecological Societies of India (FOGSI). Previously, it was thought that outcome of pregnancy depends solely on quality of mother’s medical care, however, experts now recognize that each child is born with a different personality that depends on the physical, emotional, and spiritual state of mother during pregnancy. Various scientific studies prove that babies taste, listen, learn, feel, and memorize in the womb. Therefore, parenting of children starts even before their birth, right in the womb. Holistic health care, i.e. physical, emotional, social, and spiritual well-being during pregnancy leads to a healthy maternal and fetal outcome. This effort will spread values in the society and will lead to a healthy and a happy future generation. This issue covers revolutionary recent trends of antenatal care in the three trimesters of pregnancy separately; epigenetics, diet, exercise, stress management, and harmony in relationships. It also covers spiritual health and meditation scientifically. This book is also a gift for medical fraternity, as content included in some chapters can be applied to their own lives to be healthy and happy. It is multiauthored and views expressed are those of their own. We are grateful to all the esteemed contributors for sparing their valuable time to write these chapters. Above and beyond we thank the Almighty for giving the strength, sustenance, and guidance. Jaideep Malhotra BK Shubhada Neel Pushpa Pandey Neharika Malhotra Bora Neharika Malhotra BoraJaideep Malhotra BK Shubhada Neel Pushpa Pandey Preface
- 21. Special Acknowledgment toBrahma Kumaris We should always have an Attitude of Gratitude, because it is this value which would give us the blessings to scale the altitude of success. It is said that God cannot be everywhere and therefore God created Mother. Therefore, we invoke the presence of God, who has always been with us and all through guided in conceiving the idea to launch the unique project “Adbhut Matrutva Garbh Sanskar for Healthy-Happy Mother and Baby”. It is a great pleasure for us to acknowledge the contribution and support of all the individuals who have been a constant source of motivation and inspiration for us to launch the unique project “Adbhut Matrutva Garbh Sanskar for Healthy-Happy Mother and Baby”. We owe special thanks to Respected Rajyogini BK Dadi Janki Ji, Rajyogini BK Gulajar Dadi Ji, Rajyogini BK Ratan Mohini Didi Ji, Rajyogi BK Nirwer Bhai Ji, Rajyogini BK Santosh Didi Ji, Rajyogini BK Shivani Didi Ji, Dr Ashok Mehta, Dr Banarsilal Sah, Dr Satish Gupta, Dr Pratap Midha, BK Gireesh Bhai Ji, BK Swami Bhai Ji, and all the members of the Medical Wing (Brahma Kumaris) for the constant guidance and support for this project. We would hereby take the opportunity to express gratitude to everyone who has helped us for this project. We dedicate this project to all Mothers who are an embodiment of care and love. Last but not the least to this Beautiful Drama which has created such a beautiful role for us to play. With Godly Remembrance and Love Medical Wing (RERF) Brahma Kumaris BK Dadi Janki Ji Chief of Brahma Kumaris BK Shubhada Neel National Co-Ordinator (AM) Acknowledgments
- 23. 1. Nine MonthsWindows of Opportunity.......................................................................................1 Jaideep Malhotra, Vimee Bindra, Neharika Malhotra Bora, Narendra Malhotra, Ragini Singh 2. Preconception Care....................................................................................................................16 Lila Vyas, Nidhi Gupta 3. Science of Garbh Sanskar...........................................................................................................19 Pushpa Pandey, BK Shubhada Neel, Keerti Parashar, Shakuntla Kumar 4. Fetal Psychology.........................................................................................................................23 Nitika Sobti, BK Shubhada Neel 5. Epigenetics: Nature’s/Nurture’s Role in Fetal Origin of Adult Disease...................................29 Madhu Jain, Shuchi Jain, Nitika Sobti 6. First Trimester Screening...........................................................................................................33 Narendra Malhotra, Amitha Indersen, Jaideep Malhotra, Neharika Malhotra Bora 7. Second Trimester Screening and Antenatal Care.....................................................................41 Pratima Mittal, Sumitra Bachani 8. Third Trimester Workup..............................................................................................................46 Jayam Kannan, Prashitha Panneerselvam 9. Diet and Nutrition during Pregnancy.......................................................................................49 Shilpa Joshi 10. Feel Good Yoga for Body, Mind and Soul..................................................................................51 BK Shubhada Neel, Sonal Richharia, Pushpa Pandey, Sunita Lodaya 11. Role of Meditation during Pregnancy.......................................................................................60 BK Shubhada Neel, Pushpa Pandey, BK EV Swaminathan, Manju Gupta, Awantika 12. Ultrasound in Pregnancy...........................................................................................................64 Rajat Ray 13. Immunization during Pregnancy..............................................................................................68 Richa Baharani, Sonam Baharani, Pushpa Pandey 14. The Road to Birth Naturally.......................................................................................................71 Evita Fernandez 15. How to Reduce Cesarean Section Rate?....................................................................................74 Shakuntla Kumar, Somnath Bhattacharya, Keerti Parashar 16. Designer Baby.............................................................................................................................81 BK EV Swaminathan, BK Shubhada Neel, Gayatri Singh 17. Role of Obstetrician in Creating Divine World..........................................................................86 Keerti Parashar, Sangita Rani, BK EV Swaminathan, BK Shubhada Neel, Veena Sinha Contents
- 24. FOGSI FOCUS: AdbhutMatrutvaxxiv 18. Beauty in Pregnancy...................................................................................................................89 Neelam Gulati 19. Harmony in Relationships and Anger Management................................................................92 BK Shubhada Neel, Pushpa Pandey, Bharati Ghivalikar, Asha Thakare 20. Gestational Diabetes Mellitus...................................................................................................96 Uma Pandey, Anupama Singh 21. Breastfeeding............................................................................................................................104 Kumkum Mehrotra, Awantika 22. Postnatal Care...........................................................................................................................109 Manpreet Sharma, Neharika Malhotra Bora 23. Contraceptions to be Used After Child Birth..........................................................................111 Manpreet Sharma 24. Save Girl–Educate Girl–Empower Girl.....................................................................................114 Nisha Sahu, Shashi Khare, Pushpa Pandey, BK Shubhada Neel 25. Medicolegal Aspect of Maternity Care....................................................................................118 MC Patel 26. Preventing Cervical Cancer and STDs.....................................................................................121 Bhagyalaxmi Nayak, BK Shubhada Neel 27. Pradhan Mantri Surakshit Matritva Abhiyan.........................................................................126 Nisha Sahu, Pushpa Pandey 28. Adbhut Matrutva App............................................................................................................. 135 Dayanath Mishra, Rashid Rizvi
- 25. CHAPTER 1 Nine MonthsWindows of Opportunity “A healthy life depends on a healthy start to life” INTRODUCTION Over the last few years there has been exciting progress in our understanding of what creates a healthy start to life. We now know that many aspects of embryonic, fetal, and infant development are affected by somewhat subtle aspects of parental health and behavior. In this way, health—or conversely the risk of disease—is passed from one generation to the next, via processes operating independently of inherited genetics effects. This is important because it means that parents, supported by their families and healthcare professionals can take many positive steps to promote the health of their children, even before those children are born. Small changes in the developmental environment created by parental health and behavior before birth, and the circumstances of life over the first few years after birth, leave persistent echoes on the Child’s biology, operating both through what are called “epigenetic processes” and through learning. We are well aware that there are many other sources of information to which such parents-to-be will turn. In fact, there are too many sources, especially on the internet and through variety of media, as well as from peers, formal, and informal support groups or clubs. These are often accessed before or instead of, resorting to healthcare professional advice. Faced with the overload of conflicting information, it is not surprising that some parents do not make the best choices about life style. Women’s predisposition to many chronic diseases is unmasked during pregnancy because of physiologic changes. Many of the first trimester algorithms can help us identify the women at risk and if we use Barker and Reverse Barker Hypothesis,1 we cannot only identify chronic diseases in present generation but also past and future generations. These figures depict the facts of pregnancies all over the world and the major causes of deaths in new born (Figs. 1.1 and 1.2). Jaideep Malhotra, Vimee Bindra, Neharika Malhotra Bora, Narendra Malhotra, Ragini Singh The antenatal care (ANC) primarily focuses on present or current pregnancy but all of us know that pregnancy complications can have long-term implications and also past history can have impact on present pregnancy and development of the growing fetus as well. We all should be utilizing these 9 months window for detection, management of many medical disorders, and also, we can build a healthy generation and prevent chronic complications. Several researchers have shown that preeclampsia (PE), stress, gestational diabetes mellitus (GDM), high body mass index (BMI) increase chronic diseases and mortality rates in future generations.2,3 Now with the help of first trimester screening algorithms, it has become easier to predict PE, GDM, fetal growth restriction (FGR), spontaneous preterm birth (SPB) by utilizing markers of preexisting maternal risk profiles that not only detect pregnancy risks but also confers us the opportunity to lower the thresholds for future diseases.4,5 Is it all predetermined? From all research and observations, it has been proved that pregnancy does interact with the maternal phenotypes and may alter the risks for noncommunicable diseases (NCDs). There is Fig. 1.1: Pregnancy facts.
- 26. FOGSI FOCUS: AdbhutMatrutva2 an urgent need for a multidisciplinary care for pregnant women which will involve obstetricians, general practitioners, pediatricians, midwives, internists and who can look after not only the current pregnancy but can formulate strategies for population-based screening, prevention,andcase-specificsecondaryprevention.Italso needs the help of healthcare NCDs providers and policy makers if we want to avoid and limit the consequences of chronic in future generations. There are three times in a woman’s life when she is looked after most, one is during infancy and two other are during pregnancy and postpartum period. As we know chronic diseases take years to develop, the antenatal and postpartum period provide us a new early window of opportunity to identify risk factors for majority of women and we can aim to improve their long-term health and reduce the disease burden. Several researchers have shown that maternal complications such as PE, stress, GDM, excessive weight gain, increased chronic disease, and mortality in subsequent generations. This is related to perinatal programming, and a mismatch between prenatally acquired attributes and critical periods in development produces health effects that may be independent of a person’sgeneticcode(Barkerhypothesis,Dörnersconcept of functional teratology). Multiparity has an independent increased risk of cardiovascular disease (CVD) in later life.6 There is an association between number of children and CVD, which is lowest among those who have two children and increases with each additional child beyond two by 30– 47% for women.7 If there is a coexisting fertility conditions such as polycystic ovary (PCO), there is a 9% increase in CVD risk in women with only one child.8 Fig. 1.2: Major causes of death in newborns and children. WHO-2008. (Source: Causes of death: World Health Statistics 2010, WHO, Undernutrition: Black et al. Lancet, 2008).
- 27. Nine Months Windowsof Opportunity 3 GOALS OF ANTENATAL CARE Problems in Nine Months of Pregnancy Good detailed assessment during first and then subsequent antenatal visits by thorough clinical history, general, physical, and obstetric examination, appropriate investigations to identify high-risk cases. Early identification and treatment of pregnancy complications. To educate the mother regarding the physiology of pregnancy, labor, child care, breastfeeding and contraception through mother craft classes using demonstrations and diagrams. Allay her fears regarding labor and give psychosocial support. To teach women about the importance of antenatal and postnatal breathing, stretching and Kegel exercises, to tone up the muscles, preparing for labor and puerperium. To educate about lifestyle, nutritional supplements, food associated and other infections, risks of over the counter medicines, complimentary therapies, alcohol and smoking, travel, and sexual intercourse during pregnancy. Management of common symptoms of pregnancy, e.g. nausea and vomiting, constipation, heartburn, hemorrhoids, varicose veins, backache, etc. Measurement of weight, height, BMI, BP, breast examination (retracted nipples). This contact must be utilized to be empathetic and enquireaboutdomesticviolence,prediction,detection and initial management of any mental disorders. Screen for hematological conditions—anemia, red cell alloantibodies, hemoglobinopathies, fetal anomalies, Down’s syndrome, asymptomatic bacteriuria, DM, PE, placenta previa, fetal growth, and wellbeing. Management of specific clinical conditions, e.g. breech presentation, post-term and preterm labor (PTL). To discuss place, time, mode of delivery, and care of newborn (Figs. 1.3A to C). Prematurity and Low Birth Weight Women who ever had preterm birth are at risk of developing CVD and type 2 diabetes.4,9 The offspring following the preterm birth is at a higher risk of developing hypertension as it grows and also increased insulin resistance in infancy. Also, there exists the negative correlation between maternal diseases in later life and gestational age at delivery. Exact cause for this is not clear, but it may be because of peripartum exposure to cytokines, cardiovascular effect of pulmonary dysmaturity and also placental dysfunction. Stress Prolonged activation of the stress response may have adverse consequences. Maternal anxiety and stress can cause immediate changes in blood flow to uterus, changes in fetal heart rate pattern and also fetal movements (FM). Not only short-term changes they also induce long- term changes in growth, behavior, metabolism, and also cognition. Low birth weight (LBW) is associated with negative affections and a rival cynic personality in later life.10 Listening to soothing music and lullabies has been shown to reduce stress, anxiety, and depression in mother and similarly may be remembered by the fetus.11 Fetus may contribute to its own epigenesis as FM between 20 and 38 weeks stimulate maternal sympathetic arousal. The developing brain of fetus requires some stress, but it should not be an overwhelming stress. FGR due to stress may be associated with poor cognitive development, poor Figs. 1.3A to C: (A) Prediction of preterm deliveries; (B) Prematurity. (Source: Dalziel et al, 2007; Doyle, 2008; Irving et al, 2000; LK Rogers, M Velten Life Sciences. 2011;89:417-21.) A B C
- 28. FOGSI FOCUS: AdbhutMatrutva4 school education, smoking, drinking habits, poor social activities of mother, and also her poor support system. LBW may also happen because of death of close relative of the mother in FGR, garbh sanskar and birth preparedness and counseling helps (Figs. 1.4A and B). Smoking or External Toxins These are the modifiable risk factors. Twenty percent of infants with LBW happen because of active or passive smoking.12 Parental smoking is associated with increased CVD risk, high BMI after puberty. Exposure to carbon monoxide from wood fuel smoke results in reduction of birth weight. Genetic or epigenetic factors which are res ponsible for long-term effects of smoke exposure is difficult todeterminebutmanyepigeneticfactorsplayanimportant role as to have an effect on the developing pregnancy. Miscarriage Some of the reviews have shown that women with early pregnancy miscarriage are more at risk of developing CVD or ischemic heart disease (IHD) in later life. Cardiovascular Profile-induced Health Risks Ispreexistingmaternalhemodynamicsormetabolicdisease isthecauseofgestationaldiabetesandhypertensivedisease during pregnancy or placental pathology is the cause? Or preexisting disease affects the placenta which in turn causes these medical disorders in pregnancy and also increases later health risks for both mother and offspring exponentially. Fetal Growth Restriction It is a known fact that infant birth weight (BW) is related to mother’s risk of IHD, coronary artery disease (CAD), cerebrovascular disease or cardiac insufficiency. Also, GDM, PE may be the shared increased risk factors for CVD. We are concerned about SGA for many reasons and need to asses on antenatal visits (Figs. 1.5A to H). Adequate nutrition and micronutrient such as iron, copper,zinc,iodine,selenium,andsomevitaminssuch as A and D are necessary for fetal growth. Preventive care and adequate nutritional supplements, poverty reduction should be the utmost goals of maternal care. Prepregnancy Obesity and Excessive Weight Gain in Pregnancy Obesity, before or during pregnancy, increases maternal morbidity as well as mortality. As increased fats set a metabolic syndrome and increased insulin resistance.13 As abdominal fat is a better predictor of mortality than weight or BMI, so if body fat index is more informative in terms of obstetric complications. Two questions need to be addressed (Figs. 1.6A to H). Breastfeeding Mothers with more BMI tend to breastfeed less.14 BMI greaterthan30kg/m2 isassociatedwithmorecardiovascular complications and also truncal obesity is associated with increased cancer risk because of hyperinsulinemia, insulin resistance, or high levels of steroid hormones, and cytokines which in turn may be linked to carcinogenesis. Children to obese mothers are obese as early as 16–17 years of age as compared to children of nonobese mothers (Fig. 1.7A). Thrombosis Risk Profile Most of the women attending preconception or antenatal clinic are aware of their thrombotic diseases before pregnancy.Pregnancyhasagreatimpactonthecoagulation profile and it may modify the disease or make it severe or worse during pregnancy. Thrombophilia, systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APS) are known risk factors for FGR, PE, and also placental dysfunction, miscarriages. Anticoagulant therapy in the form of aspirin and heparin may reduce the adverse outcomes. Anticoagulant for all is not yet A B Figs. 1.4A and B: Fetal growth restriction (FGR). (IUGR: intrauterine growth restriction). [Sources: Jyotsna Deshpande, Assistant Professor, Bharati Vidyapeeth College of Nursing, Pune, PhD Nursing, Tilak Maharashtra Vidyapeeth, Pune, Maharashtra, India; International Journal of Science and Research (IJSR), ISSN (Online): 2319-7064, Index Copernicus Value (2013): 6.14, Impact Factor (2013): 4.438].
- 29. Nine Months Windowsof Opportunity 5 Figs. 1.5A and B: Small for gestation age (SGA). (FGR: fetal growth restriction; IUGR: intrauterine growth restriction). A B Figs. 1.5C and D: Monitoring cardiotocography (CTG). C D Figs. 1.5E to H: Fetal growth restriction (FGR) and cardiotocography (CTG). E F G H
- 30. FOGSI FOCUS: AdbhutMatrutva6 Figs. 1.6A and B A B Figs. 1.6C and D: Weight and reproduction. C D Figs. 1.6E and F: Impaired glucose tolerance. (HFD: high fat diet; IGT: impaired glucose tolerance). E F recommended until a randomized controlled trials (RCTs) shows the benefits15 patients with diagnosed SLE, APS, with prior thrombosis will have a better outcomes with anticoagulants and FGR and recurrent thrombosis can be averted.16 Women with these disorders are at lifelong risk of thrombosis and also women with arterial events should be managed aggressively. Hyperhomocysteinemia It increases the risk of PE three to four times in cases of raised first trimester homocysteine.17 Therapy should be considered for such cases. Low-dose aspirin helps in reducing the prothrombotic risk profile. Low folate intake increases hyperhomocysteinemia. High-dose folate is required to modify homocysteine levels (Fig. 1.7B). Gestational Diabetes Mellitus or Preexisting Diabetes Mellitus Preexisting diabetes may be type 1 or type 2 which exists before pregnancy. GDM is diagnosed first time in pregnancy characterized by glucose intolerance and is related to hyperinsulinemia, type 2 DM, dyslipidemia,
- 31. Nine Months Windowsof Opportunity 7 Fig. 1.7A: Benifits of breastfeeding. obesity, hypertension and CVD. Women with GDM may develop type 2 diabetes within 10 years in 30% of cases due to persistence glucose intolerance.18 Excessive weight gain during pregnancy is also directly related to increased incidence of GDM. First trimester prediction of GDM by risk profile by history or biochemical tests can be as sensitive as 80%19 (Figs. 1.8A and B). “Fetal origins of disease”—this hypothesis explained associations between impaired glucose tolerance (IGT), CVD with LBW.20 Likewise, early malnutrition may program metabolic syndrome due to poor develop- ment of pancreatic beta cell mass. Childhood obesity is more in children of mothers with GDM and fetal macrosomia. Cesarean delivery is associated with childhood obesity in later life and its independent of the fact that cesarean deliveries are more in obese women and the potential explanation may be the difference in infant intestinal microbiome.21 Birth preparedness needs to be discussed during the ANC including neonatal immunization(Fig. 1.9). Figs. 1.6G and H (Source: Yojnik CS, Deshmukh U, 2009). G H
- 32. FOGSI FOCUS: AdbhutMatrutva8 Fig. 1.7B: Hyperhomocysteinemia. (FGR: fetal growth restriction; IUFD: intrauterine fetal death; PTL: preterm labor). Figs. 1.8A and B: Universal screening by DIPSI. (DIPSI: Diabetes in Pregnancy Study Group of India; GDM: gestational diabetes mellitus; CV: cardiovascular). (Source: Figure A—Lancet. 2009;373(9677):1773). A B Fig. 1.9: Neonatal and birth immunization. (HTN: hypertension). Subfertility/Infertility/Assisted Reproductive Technology Pregnancy SubfertilitysuchasincasesofPCOsandprematureovarian insufficiency also increases the risk of CVD and metabolic syndrome. Many studies have shown children conceived through artificial reproduction have higher sugar levels as compared to offspring of natural conceptions. Hypertensive Disorders of Pregnancy, Preeclampsia Of the several risk factors for hypertensive disorders of pregnancy (HDP) most common are personal, cardio vascular, metabolic, and prothrombotic. Circulatory and metabolic syndromes are associated with early onset PE, FGR. First trimester prediction algorithms for PE can identifysurrogatemarkersofcardiovascularandmetabolic markers as independent contributors. Early pregnancy risk
- 33. Nine Months Windowsof Opportunity 9 profiles support the fact that there is a parallel rise of PE and long-term maternal complications. Risk factor assessment and prediction of preeclampsia needs attention in all patients (Figs. 1.10A to E). Placental functions and invasion are sensitive to cardiovascular changes in mother and in turn placenta can modulate fetal response to it. Mothers with HDP may have atherosclerotic diseases. Affected women with FGR, and placental syndromes should have their BP and weight checked 6 months postpartum and dietary lifestyle modifications should be stressed upon although acceptance for such behaviors is pretty low. Offspring of women with PE are at increased risk for hypertension, depression, stroke, and delays in cognition.22 Awarenessabouttheseassociationsmayhelpustoformulate strategies to prevent adult hypertensive disease and we can reduce the burden of disease and it all can start from the antenatal care. Pregnancy-associated plasma protein-A (PAAP-A) was the first serum biomarkers in first trimester which could correlatewithplacentalfunctionandfetalgrowth.Currently, first trimester algorithms for FGR and PE offer sensitivity of 60%andriskpredictionofupto90%.23 Ninety-onepercentof women may have cardiovascular and metabolic conditions if they are test positive at first trimester screen and these conditions may be treated. So, first trimester screen have screening as well as therapeutic benefits. Figs. 1.10A and B: Body mass index and hypertension. (BMI: body mass index; HTN: hypertension). A B Figs. 1.10C and D: Body mass index. (BMI: body mass index). (Source: Figure A—Circulation. 2013;127:681-90). C D
- 34. FOGSI FOCUS: AdbhutMatrutva10 Fig. 1.10E: Prediction of preeclampsia. (Source: Ekolokart et al. Prenat Diagn. 2011;31:66-74. Poon LC. Nicolaides KH. Obstet Gynecol Int. 2014. Audibert et al. Am J Obstet Gynecol. 2010). Metabolic Syndrome and its Effects on Pregnancy Metabolic syndrome and its components put women at risk of PE. Also women with PE have dyslipidemia and insulin resistance which may also continue postpartum and needs to be addressed. Breastfeeding Breastfeeding increases fat mobilization along with protection form hypertension (HTN) due to stress. Breastfeeding is also protective against type 2 diabetes, who had GDM along with reducing breast and ovarian cancer. Breastfeeding should be promoted and women to be counseled about its benefit for mother and baby and also its role in preventing obesity, CVD, DM, depression. NINE MONTHS ARE WINDOW OF OPPORTUNITY How many of us really think that pregnancy is a window of opportunity for neonatal and maternal health? All of us think so (Figs. 1.11 and 1.12). Pregnancy: A Window of Opportunity (Fig. 1.11) Pregnancy offers a window of opportunity to provide maternalcareservices,notonlytoreducethetraditionally known maternal and perinatal morbidity and mortality indicators, but also great potential for intergenerational prevention of several chronic diseases, such as diabetes, arterial hypertension, cardiovascular disease, and stroke.
- 35. Nine Months Windowsof Opportunity 11 Fig. 1.11: Windows of opportunity. (Source: Mustard, 2006). Fig. 1.12: Timeline. Early Antenatal Care is too Late (Fig. 1.12) To prevent some birth defects critical period of teratogenesis: D17 to D56 heart: Begins to beat at 22 ds after conception Neural tube: Closes by 28 ds after conception Palate: Fuses at 56 ds after conception To prevent implantation errors To restore allostasis: Maintain stability through change. An important objective of pregnancy care center (PCC) is to restore allostasis to women’s health before pregnancy. Effects of Preconceptional Lifestyle Negative factors include: Women’s smoking more than 15 cigarettes/day Men’s smoking more than 15 cigarettes/day Men’s alcohol more than 20 units/week Women’s coffee/tea intake more than 7 cups/day Women’s weight more than 70 kg Social deprivation score more than 60 Women’s age more than 35 years, and/or partners’ age more than 45 years at the time of discontinuing contraception. Is Pregnancy Body Mass Index Important? Prepregnancy BMI less than 19.8 kg/m2 indicates chronic malnutrition, and BMI of more than 26.1 kg/ m2 shows an imbalance between energy intake and expenditure. Several studies have shown that low BMI is associated with: Intrauterine growth restriction (IUGR) Preterm delivery Iron deficiency anemia. On the other hand, high BMI is related to: Infertility Gestational diabetes Hypertensionandpreeclampsiainducedbypregnancy Birth defects Infant macrosomia (weight ≥ 4500 g) Cesarean section, prolonged labor, and postpartum anemia. Scope of Preconceptional counseling and Antenatal Care Regular visits for prevention and early detection of high-risk pregnancy Accurate dating of gestation To formulate a plan for continuing obstetric care and delivery Effectively intervene for modifiable factors Reduce emergency interventions Prognostic evaluation. The First Visit History Physical examination Investigations Risk determination. Past Obstetric History Parity History of still birth Intrauterine fetal death (IUFD) Bad obstetric history (BOH) Preterm labor Macrosomic baby
- 36. FOGSI FOCUS: AdbhutMatrutva12 A B C Figs. 1.13A to C: Adbhut Matrutva—a FOGSI Eris Initiative. IUGR baby Severe pregnancy-induced hypertension (PIH). History Last menstrual period/estimated due date (LMP/ EDD) Age of the patient less than 18 years, more than 35 years Order of pregnancy primigravida or grand multipara Interval of less than 2 years since last pregnancy History of cardiac disease, diabetes, chronic hyper tension or any medical comorbidity. Life-threatening Situations History of postpartum hemorrhage (PPH) History of antepartum hemorrhage (APH) History of maternal recognition of pregnancy (MRP) History of eclampsia/hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) History of other complications associated with pregnancy which were life-threatening. DISCUSSION As we know a lot of NCDs in later life have their origin during pregnancy or fetal life. To reduce the disease burden, it is a unique opportunity for healthcare providers to detect the medical disorders during pregnancy which will help couples prevent NCDs and would reduce the healthcare costs as well. It is a nine-month window of opportunity for maternal-infant care, in turn care for the later life. Adverse pregnancy outcomes can have its origins during fertilization, gamete formation, embryonic development, fetal or placental development, and may translate into long-term health impacts.24 Many complications of pregnancy have been shown to be associated with maternal and infant health risks in later life. By identifying the key periods during pregnancy, and
- 37. Nine Months Windowsof Opportunity 13 identifying the medical disorders at the earliest, we have this unique window of opportunity for a better maternal and child health care. The selected time periods such as prenatal and early postnatal life gives us an opportunity in which environ mental factors can be modified and which may change epigenetics. As the pregnant women come in contact with the obstetrician or maternal-fetal medicine (MFM) specialists, it is our responsibility to create healthcare paths after C Figs. 1.14A to C: FOGSI recommended screening tests in pregnancy. A B C
- 38. FOGSI FOCUS: AdbhutMatrutva14 pregnancy. Introduction of balanced diet and lifestyle modification for reducing the risks of DM in later life. For high risk pregnancies, follow-up at 6 and 12 months for deciding the care pathways is important. Many European countries are utilizing the maternal passport for lifelong health records. Health apps for targeted health information about risks and intervention could also be useful. Focused antenatal care by proper history taking, making risk algorithms, and screening tests, we can advanceourselvesindetectionoffuturediseases.Increased health literacy, creates a balance between responsible and irresponsible resource management and hence reducing the burden of chronic diseases. The future obstetrician or MFM specialist should aim at giving less medication, less invasive testing, should be giving less medicine but this type of care would be more acceptable as it interests the patient’s future health. Women with a history of FGR, GDM, PE, PTL, miscarriage, high BMI, excessive weight gain, subfertility, PCO, thrombotic risk factors are more frequently associated with CVD, insulin resistance, dyslipidemia, thrombotic episodes in later life. These abnormalities have shown a significant correlation with future metabolic and cardiovascular abnormalities in various studies. So, we want to stress upon the fact that pregnancy is a nine- month window of opportunity for detection of future health. It is a complex interplay of genetics and epigenetics which has consequences for both mother and fetus. We as maternal fetal medicine specialists should be able to prevent these NCDs by proper patient consultation and utilizing multidisciplinary approach. Healthcare providers and also government should be involved in policy making for primary prevention which will help us to detect and reduce metabolic and cardiovascular diseases and reduce the disease burden. CONCLUSION FOGSI in 2018 has started an initiate called Adbhut Matrutva (Figs. 1.13 and 1.14). AlsoFOGSIhasnowrecommendedtestsandscreening in all trimesters as recommended and preferable (Figs. 1.14A to C). Knowing is not enough; we must apply, Willing is not enough; we must do —Goethe REFERENCES 1. Barker DJ, Osmond C, Golding J, et al. Growth in utero, blood pressure in childhood and adult life, mortality form cardiovascular disease. BMJ. 1989;298(6673):564-7. 2. Dörner G, Mohnike A. Further evidence for a predominantly maternal transmission of maturity-onset type diabetes. Endokrinologie. 1976;68:121-4. 3. Stupin JH, Arabin B. Overweight and obesity before, during and after pregnancy: part 1: pathophysiology, molecular biology and epigenetic consequences. Geburtshilfe Frauenheilkd. 2014;74(7):639-45. 4. Sattar N, Greer IA. Pregnancy complications and maternal cardiovascular risk: opportunities for prevention and screening? BMJ. 2002;325 (7356):157-60. 5. Rich-Edwards JW, McElrath TF, Karumanchi SA, et al. Breathing life into the lifecourse approach: pregnancy history and cardiovascular disease in women. Hypertension. 2010;56(3):331-4. 6. Ness RB, Harris T, Cobb J, et al. Number of pregnancies and the subsequent risk of cardiovascular disease. N Engl J Med. 1993;328(21):1528-33. 7. Lawlor DA, Ronalds G, Clark H, et al. Birth weight is inversely associated with incident coronary heart disease and stroke among individuals born in the 1950s:findings from the the Aberdeen Children of the 1950s prospective cohort study. Circulation. 2005;112(10):1414-8. 8. Cobin RH. Cardiovascular and metabolic risks associated with PCOS. Intern Emerg Med. 2013;8(Suppl 1):S61-4. 9. Bohrer J, Ehrenthal DB. Other adverse pregnancy outcomes and future chronic disease. SEmin Perinatol. 2015;39(4): 259-63. 10. Rikkönen K, Pesonen AK, Heinonen K, et al. Infant growth and hostility in adult life. Psychosom Med. 2008;70(3):306. 11. Chang MY, Chen CH, Huang KF. Effects of music therapy on psychological health of women during pregnancy. J Clin Nurs. 2008;17(19):2580-7. 12. CraneJM,KeoughM,MurphyP,etal.Effectsofenvironmental tobacco smoke on perinatal outcomes: a trospective cohort study. BJOG. 2011;118(7):865-71. 13. Despres JP. Is visceral obesity the cause of the metabolic syndrome? Ann Med. 2006;38(1):52-63. 14. Stuebe AM, Horton BJ, Chetwynd E, et al. Prevalence and risk factors for early, undesired weaning attributed to lactation dysfunction. J Womens Health(Larchmt). 2014;23(5):404-12. 15. Dodd JM, McLeod A, Windrim RC, et al. Antithrombotic therapy for improving maternal or infant health outcomes in women considered at risk of placental dysfunction. Cochrane Database Syst Rev. 2013;7:CD006780. 16. RuffattiA,SalvanE,DelRossT,etal.Treatmentstrategiesand pregnancy outcomes in antiphospholipid syndrome patients with thrombosis and triple antiphospholipid positivity. A European multicentre retrospective study. Thromb Haemost. 2014;112(4):727-35. 17. Cotter AM, Molloy AM, Scott JM, et al. Elevated plasma homocysteine in early pregnancy: a risk factor for the development of nonsevere preeclampsia. Am J Obstet Gynaecol. 2003;189(2):391-4. 18. Freinkel N, Metzger BE. Gestational diabetes: problems in classification and implications for long range prognosis. Adv Exp Med Biol. 1985;189:47-63.
- 39. Nine Months Windowsof Opportunity 15 19. Gabbay-Benziv R, Doyle LE, Blitzer M, et al. First trimester prediction of maternal glycemic status. J Perinat Med. 2015;43(3):283-9. 20. Barker DJ. The fetal and infant origins of adult disease. BMJ. 1990;301(6761):1111. 21. Darmasseelane K, Hyde MJ, Santhakumaran S, et al. Mode of delivery and offspring body mass index, overweight and obesity in adult life: a systematic review and meta-analysis. PloS One. 2014;9(2):e87896. 22. Hakim J, Senterman MK, Hakim AM. Preeclampsia is a biomarker for vascular disease in both mother and child: the needforamedicalalertsystem.IntJPediatr.2013;2013:953150. 23. Krantz DA, Hallahan TW, Carmichael JB, et al. First trimester screening for early onset preeclampsia is a cost effective approach in prenatal care. Pregnancy Hypertens. 2015;5(1):92. 24. Pozharny Y, Lambertini L, Clunie G, et al. Epigenetics in women’s health care. Mt Sinai J Med. 2010;77(2):225-35.
- 40. CHAPTER 2 Preconception Care LilaVyas, Nidhi Gupta “Preconception care is defined as the provision of biomedical, behavioral, and social health interventions to women and couples before conception.” BACKGROUND AND HISTORY Healthy reproductive life is the ambition of all the couples of the childbearing age. In India, where literacy rate is low and child marriage rate is high, women suffer a lot from unintended pregnancies, maternal death and disability, gender-based violence, and their partners’ sexual behavior. An effective continuum of care is needed for further reduction in the neonatal and child mortality; maternal mortality and morbidity. At present, the care spectrum is available from early pregnancy to the birth of the baby, childhood and early adolescence, and then there is gap from adolescence to the pregnancy. Preconception care fills this gap and maintains the continuum of health surveillance, so that a woman enters in the pregnancy in her best health. On preconception care WHO meeting was held in Geneva in 2012 for the global consensus and in South-East Asia Region was organized, an expert group meeting of its members in August 2013. UNICEF, UNFPA, experts from institution of excellence, academic institutes in the region and collaborators of WHO, all took part in the meeting as expert members. This was a logical step in the global concept of preconception care to the regional level and developing a consensus on positioning preconception care as part to improve reproductive health in pregnancy, neonatal outcome, and child and adolescent health collectively. However, the approach depends on socio demographic and epidemiological situation.1 Components of Preconception Care Evidence had been collected from various countries and discussed in Geneva 2012 meeting. Conclusion was drawn regarding major risk factors, affecting maternal and child
- 41. Preconception Care 17 healthcare which had been included as components of preconception care. NUTRITIONAL ISSUES Folic Acid Deficiency of folic acid causes malformation in fetus so food fortification to supply folic acid in required quantity in preconception period. Iron, calcium, iodine, and other micronutrients should also be supplied to females of childbearing age. Nutritional status should be adequately maintained in the preconception care; advice regarding nutrition depends on her present condition and medical co-morbi dities; for details of different components please refer to FOGSI GCPR 2016.2 There are currently crucial gaps in the continuum of care in health programs where the critical age group (5–14 years) does not come under child health, maternal health or adolescent health programs. Also, women before and between pregnancies do not benefit from the ongoing maternal and child health program. CONTINUUM OF CARE Packages of Preconception Care In the meeting, all the participants agreed for packages of preconception care, e.g. “healthy transitions for adolescents” targeting older children and adolescents and “prepregnancy program” consisting mainly of maternal and reproductive health package for partners/couples (Boxes 2.1 to 2.4). The package should include region-specific genetic diseases (e.g. sickle cell anemia and thalassemia). It is suggested that it may be useful to propose a basic or minimum package to use, in the health and development continuum, addition of preconception care and healthy transitions would ensure health throughout the life-course from adolescence to adulthood.3 Additional Benefits Socialandeconomicbenefitsforfamiliesandcommuni ties. Box 2.1: Healthy transitions for adolescents package. ■■ Personal hygiene ■■ Mental health including screening for depression ■■ Vaccine-preventable diseases ■■ Prevention of noncommunicable diseases ■■ Tobacco, drugs, and alcohol exposure (effect on fertility, the fetus and the neonate) ■■ Substance and medication abuse ■■ Healthy diet and physical activity ■■ Screening for eye problems and other diseases, diabetes, body mass index ■■ Nutritional conditions (deworming, emerging deficiencies, e.g. vitamin D deficiency) ■■ Iron and folic acid supplementation ■■ Too-early, unwanted and repeated adolescent pregnancies ■■ Contraception information services (including emergency contraception) ■■ Genetic conditions (sickle cell anemia and thalassemia) ■■ Information on infertility ■■ STI/HIV ■■ Reproductive knowledge and managing menstruation and masturbation.
- 42. FOGSI FOCUS: AdbhutMatrutva18 Box 2.2: Expert group consultation on preconception care. ■■ Sex/gender and violence ■■ Interpersonal violence (both sexes, bullying, teasing, domestic violence) ■■ Injury prevention ■■ Sexual abuse and harassment, violence ■■ Environmental health (e.g. indoor pollution—cooking practices, evidence base at country level, lead/arsenic/endocrine disruption). Box 2.3: Basic package. ■■ Family planning (more than just contraception) ■■ Vaccine-preventable diseases ■■ Nutrition and micronutrients (including food and micronutrient supplementation, food fortification, nutrition education) ■■ Tobacco cessation (including exposure to second-hand smoke) ■■ Reducing harmful environmental exposures (e.g. indoor air pollution) ■■ Improving sexual health and behavior (screening, counseling, treatment). Box 2.4: Expanded package (basic package plus the following issues). ■■ Mental health problems ■■ Intimate partner and sexual violence ■■ Genetic conditions ■■ Prevention of noncommunicable disease ■■ Environmental health ■■ Substance and drug use ■■ Injury prevention ■■ Nonpopulation-specific genetic diseases (e.g. Down syndrome). Participation by male in his partner’s health and improvement in their own health, irrespective of immediate plans to become parent(s); and controlling exposure to environmental risk factors in early life and their long-term effect. “Early prenatal care is too late”. This message should be forwarded for social, health, and economic benefits of the society. Awareness should be created in targeted group for preconception care, not for the high risk cases but for all. Preconception risk assessment recommendations— (A) For all: Content Evidence of association Sociodemographic data Good Menstrual history Good Past obstetric history G Medical and surgical history G Infection history G Family and genetic history G Nutrition G Smoking/alcohol/drug G Height/weight G Hemoglobin and hematocrit G Rh-factor G Rubella titer G Urine protein/sugar G Gonococcal culture G Syphilis test G Hepatitis B G HIV G (B) For targeted population: Content Evidence of association Hemoglobinopathies G Toxoplasma G HSV G Varicella G CMV G Tay-Sach’s disease G Parental karyotype G Chlamydia screening G Obstetrics medicine: management of medical disorders in pregnancy CONCLUSION Preconception care brings attention to the missing components, new interventions, and development of new guidelines for addressing the needs of adolescents, young women and their partners throughout reproductive life. Thus, it offers a process of delivering direct or indirect healthcare interventions with the potential to identify and modify the biomedical, behavioral, and social risks that determine reproductive health outcomes. We, the healthcare providers, should learn that it aims at improving the overall health status and continuum of care, bytargetingriskbehaviorsfornoncommunicablediseases, alcohol consumption, and substance abuse.2 Overall, preconception care has a positive impact on a range of outcomes: Reduces mortality and improves health indicators of mothers. Improved health outcome for the neonate/child, which will lead to health benefits in later life as an adolescent and adult. Incidence of too-early and too-frequent pregnancies and abortions are reduced effectively; and there is improvement in the nutritional status of women. REFERENCES 1. World Health Organization (2008). A framework for implementing the Reproductive Health Strategy in the South- East Asia Region. [online] Available from http://apps.searo. who.int/PDS_DOCS/B3170.pdf [Accessed December 2018]. 2. The Federation of Obstetric and Gynecological Societies of India (2016). Good clinical practice recommendations on preconception care. [online] Available from https://www.fogsi. org/gcpr-preconception-care [Accessed December 2018]. 3. http://www.searo.who.int/entity/child-adolescent/topics/ adolescent-health/sea-cah-16/en/Contd... Contd...
- 43. CHAPTER 3 Science ofGarbh Sanskar Pushpa Pandey, BK Shubhada Neel, Keerti Parashar, Shakuntla Kumar Thetwopowerfulgiftswecangivetoourchildren,“Sanskar” and “Wings”! INTRODUCTION Garbh Sanskar is a scientific method to educate the fetus in womb. Garbh denotes the fetus in the womb; Sanskar is to educate the mind. Every parent wants to see their child healthy, happy, intelligent, and virtuous. To make everyone’s dreams to make future generation happy and healthy come true, this project is the need of hour. As we know, infant mortality rate (IMR) and maternal mortality rate (MMR) have decreased due to the efforts of various organizations working for “healthy mother and healthy baby”. One of today’s challenges in the society is to deal with the younger generation that lacks moral and emotional values which is clearly depicted by the spiraling social crimes and terrorism. This raises the question, how and when can we instill sanskars and increase emotional quotient (EQ) and spiritual quotient (SQ) in the future generation? The foundation should be strong to build a house. To bring about a change in the society, we have to instill sanskars in the fetus itself. Garbh Sanskar is an effort to purify and refine the accumulated negative evil tendencies and enlighten the pure inner core of the subconscious mind by teaching good things to unborn child right in mother’s womb. Some of the great examples of “Garbh Sanskar” can be found in many mythological stories in Indian history. The story of Abhimanyu quoted in the Mahabharata is very well known. Abhimanyu, son of Arjuna, learned how to enter the chakravyuha when he was in his mother’s womb. He remembered his father’s story when he became a warrior in the Kurukshetra war. Another great story depicting importance of Garbh Sanskar is the story of Prahlad. He was born to a family of demons. His mother listened to devotional prayers and stories about lord Vishnu, while he was in her womb. As a result, he became a devotee of lord Vishnu. Another one is the well-known story of Hanuman. His mother, Anjana, was a devotee of lord Shiva. When she was pregnant, she ate a blessed dessert that was meant to produce divine children. Thus, Hanuman was born with divine powers. A few great examples from the modern world are also worth mentioning. When Zakir Hussain (tabla vadak) was in mother’s womb, his father, Ustad Allah Rakha, used to beat lightly with his fingers on his mother’s abdomen. Freedom fighter Savarkar’s mother used to read the courageous tales from Ramayana and Maharana Pratap to her son when he was in womb. SCIENCE ALSO CONFIRMS LIFE IN UTERO— THE BABY CAN HEAR, SMELL, TASTE, AND SEE BEFORE BIRTH Fetus begins to swallow amniotic fluid at 12 weeks of gestation and can learn tastes experienced only prenatally. Fetus favors its mother’s meal and picks up the food taste culture in the womb.1 Touchsensationstartsfrom16thweekafterconception, at 23rd week, it fully develops.2 From the 7th month, the fetus can hear the sounds from mother’s womb and from the surroundings of the mother and also responds to them. Fifer has found that fetal heart rate slows when the mother is speaking, suggesting that fetus not only hears and recognizes the sound, but calmed by it. Fetus reacts to loud voice and prefers mother’s voice. He has a memory of experiences before birth.3 Newborn prefers a story read to it repeatedly when in the womb. PRINCIPLES OF GARBH SANSKAR It is scientifically proven that fetus has the same life as an adult and can use its senses to see, taste, hear, or feel from much earlier period than previously agreed upon. As per the new model of health (soul, mind, body and medicine), “human being” is derived from two words, “humus” and “being”; or “body” and “psyche” or “consciousness”. Health
- 44. FOGSI FOCUS: AdbhutMatrutva20 is a dynamic process of harmony in the flow of spiritual, mental, and physical energy.4 Due to advancements in technology,antenatalcareisnotonlyroutinepalpation,but it includes diagnostic modality of imaging, biochemical, biophysical marker, vaccination, and screening for medical and obstetric disorders. However, in routine antenatal care, evennownoattentionisbeinggiventomentalandspiritual energies (being) of developing fetus. Garbh Sanskar gives equal importance to holistic development of growing fetus. Personality (sanskar) of a human being is nonphysical. It remains in subconscious mind which makes 90% of consciousness (Fig. 3.1). Holistic personality development also needs three types of energies: (1) soul (being) has spiritual energy which is primary and works as software, (2) brain works as hardware, and (3) the body is like a robot. Flow of spiritual energy is the root of good health and personality. How are our personalities shaped? Every thought word and action we create becomes our sanskar (i.e. personality). Sanskar (health or behavior) of any person is influenced by: Owns original sanskars, i.e. innate qualities of soul (spiritual energy). Sanskar (spiritual energy) carried forward from the past birth. Sanskars received from the mother and father (parent’s role, Garbh Sanskar). A pregnant mother has two lives within, hers and the fetus’. It has been proven that personality of the future generation is greatly influenced by pregnant mother’s feelings and state of mind. Likewise, most of the behavioral traits also originate in the womb. Infants, toddlers, and adolescents largely suffer from many emotional and behavioral problems, the seeds of which are sown on the unborn baby due to negative hormonal secretions that are activated by mother’s thoughts in response to stress. By keeping harmony in spiritual, mental, and physical energy, she can nourish both making both (herself and fetus) physically and mentally healthy. Foundation of intelligence quotient (IQ), EQ, and SQ is mainly laid down inside the womb. The best time to develop good qualities in the baby is from the day of conception to 2–5 years of life because the subconscious mind is active. All negative or positive sanskars remain in the subconscious mind. After 5 years, conscious mind starts to work. It is very difficult to change once the personality of fetus is laid down within the womb. Personality is colored by family, company, and environment. Garbh Sanskar means that expectant mothers should take care of their physical, mental, and spiritual energy. By taking care of her own sanskars, she can draw the portrait of her child’s elevated fortune. GOOD TIPS FOR GARBH SANSKAR Keeping a High Self-esteem This is the best way of emotionally nourishing an unborn child during pregnancy. Happiness is truly a choice, it not only depends on the surroundings but also depends upon one’s self-esteem. Antenatal mother should take care of her self-esteem by keeping her thoughts pure, positive, and purposeful. She should respect herself, read positive books, and preferably write down positive versions many times daily to keep her self-esteem high, for example: I am a powerful being. I am loveful being. I am peaceful being, I am the child of ocean of peace. Such types of thoughts create a positive feeling that reaches the unborn child through neuropeptides. It should be remembered that expectant mother cannot hide her feelings from the unborn child.2 A pregnant woman’s thoughts have a physical connection to her unborn child. “Everything the pregnant mother feels and thinks is communicated through neurohormones to her unborn child, just as surely as are alcohol and nicotine”, says Dr Thomas Verny. It is also suggested that positive thinking can shape the body, heal internally, and even nurture a healthier child during pregnancy. It is advised to keep pictures of great leaders in the room and watch good programs on TV. Reading fiction novels and watching horror or sad movies in social media or TV are inadvisable. In the new study, carried out at Nagasaki University in Japan, 10 pregnant volunteers were asked to watch an upbeat 5-minute clip from the Julie Andrews musical, “The Sound of Music”. Another 14 watched a tear-jerking 5-minute clip from the 1979 Franco Zeffirelli film “The Champ”, in which a boy cries at the death of his father. Fig. 3.1: Model of consciousness (90% subconscious mind 10% conscious mind).
- 45. Science of GarbhSanskar 21 The clips were “sandwiched” between two extracts of neutral programs so that the researchers could measure any changes in the movement of the babies. The mothers-to-be listened to the movies using earphones to guarantee their unborn babies were not being influenced by the movie’s soundtrack. Dr Kazuyuki Shinohara, who led the study, used ultrasound scans to count the number of arm, leg, and body movements of the babies while their mothers were watching the clips. Researchers found that the fetuses moved their arms significantly more during the happy clip from “The Sound of Music”. But in the other group, the unborn babies moved significantly less than normal while their mothers watched the weepie. What we see daily creates thoughts in our mind, which shape sanskars of the expectant mothers of the unborn child. Watching good scenes and pictures also helps expectant mother in creative visualization, at a subconscious level, of how her child should be. Listen Calm Music Garbh Sanskar can be an effective by means of sound in the form of mantras, shlokas because the rhythmic sounds are captured by a child’s subconscious mind very effectively. The vibrations of sound waves can influence both mother and her fetus; therefore, the music designed for Garbh Sanskar is useful for the health and personality development of fetus. If the mother listens to relaxing music, in last trimester of pregnancy, the baby responds positively to the resonant sound and after birth when it is exposed to the same music, it calmed down. A study researched the ability of the fetus to learn a TV theme tune. On hearing the theme tune, it became alert, stopped moving, and the heart rate decreased (orienting). In this study, the first group consisted of pregnant mothers who frequently watched “Neighbors”, an Australian television soap opera.4 After delivery, these mothers were asked to watch the TV show again along with their babies. It was observed that the newborn babies (2–4 days of age) became alert, stopped moving, and their heart rate decreased (orienting) upon hearing the theme song. These same individuals showed no such reaction to other unfamiliar tunes. The newborns of the second group of pregnant mothers, who did not watch the same TV program during pregnancy, showed no reaction to the tune. Communicate with Unborn Baby Communicate with the child with unconditional love. Good communication builds strong bonds. Dr Komal Jain, gynecologist from Jabalpur, says “When I was pregnant I used to say to my unborn child, “you are the most beautiful child in the world”, when my baby grew up and start talking first sentence, she spoke “mommy you are the most beautiful mother in the world”. Reading out loud good stories and healthy discussions between parents improves baby’s memory. Baby learns around 5,000 words from mother other than from siblings’, father, and family members. So, 4–5 hours quality sound exposure is necessary. Negative words have negative effects on unborn fetus. The mythological story of Saint Ashtavakra depicts the traumatic effect of loud noises and abuses on the fetus. Ashtavakra is a sage mentioned in Hindu scriptures. His parents wished for an intelligent and a spiritual child. Kahod, his father, was a scholar yet arrogant. He would recite scriptures to his wife, Sujata, during her pregnancy. Consequently, the baby learned everything when inside the womb and grew up to be very intelligent. It is believed that Ashtavakra, when still in womb, interrupted his father eight times to indicate that his knowledge is pedantic and notspiritual.Kahodrebukedandcursedhisownbabyeight times that caused the eight curves in his body. Ashtavakra epitomizes a baby with cerebral palsy (CP) and high IQ. CP is a general term for a group of permanent, nonprogressive movement disorders that cause physical disability. It is caused by damage to the motor control centers of the developing brain that can occur during pregnancy, during childbirth, or after birth due to some reason which is still debatable. As prenatal events are thought to be responsible for approximately 75% of all causes of CP, although it is usually impossible to determine the nature and exact timing of event.5 Spiritual Lifestyle and Regular Meditation Practice It is an important aspect of spirituality and helps to adapt positive thinking, manage stress, and improve mental, social, and spiritual health. Spiritual lifestyle is a disciplined healthy lifestyle. Waking up and sleeping should be according to circadianrhythms.Whenactivitiesareinrhythmwithone’s biological clock, they reduce energy expense and stress, and prove beneficial for the health of mind, intellect, and body.4 Practice meditation for 20 minutes in the morning and evening before going to bed when the subconscious mind is active. Recitation of some shlokas with feeling is also useful. The mothers are advised to consume good nutritious food mixed with vibration of God’s love. Avoid spicy food and addictive substances. Practice Asanas under the guidance of a yoga expert and sleep adequately.
- 46. FOGSI FOCUS: AdbhutMatrutva22 It is also recommended to read good books and listen to positive verses and relaxing alpha music everyday throughout the pregnancy. Practice of celibacy is advised, as the feeling of sexual arousal is transmitted to the unborn fetus. By practicing celibacy, many cases of rape and teenage pregnancy can be prevented in future generation. “Dear mother, You are the most important person in my life. I am blessed to have a divine mother like you. Please take care ofyourphysical,mental,social,andspiritualhealth.Please hug me, protect me, praise me, read to me, sing to me, love me, and make me safe so that I will grow up to be a happy person with great personality. I like the good vibrations when you practice meditation. This will decide my future health and personality. The two little words “Thank You” can be never enough to appreciate every little thing you will ever do for me. Regards Unborn little baby (fetus)”. CONCLUSION Garbh Sanskar is scientific method of building physical and mental character of a child during pregnancy. Positive mental energy (thoughts, emotions, attitude, and memory—a positive TEAM) release positive neuro transmitters which help to develop good qualities like happiness, cheerfulness, relaxation, instructiveness, intelligence, attentiveness, creativity, self-esteem, and increases logical skill and inner silence. The baby listens and feels mother’s feelings even when it is developing in womb. Expectant mother can shape up her baby by listening to good music, visualizing, and massaging gently while meditating. The advantages of Garbh Sanskar are not only to educate the child but to develop a bond between the mother and child. In fact, this has a great impact on the health of the mother as well. Positive thinking and attitude promotes physical well-being of the mother. REFERENCES 1. Khera N. Antenatal care beyond medicine: Garbh sanskar. In: Gupta S (Ed). FOGSI Focus: Preconception and Antenatal Care. New York: FOGSI Publication; 2016. pp. 14-6. 2. Wirth F. Prenatal pregnancy. In: Wirth F (Ed). Self-esteem: The Key to Successful Pregnancy, 1st edition. USA: CRC Press; 2001. 3. Hepper PG. Fetal memory: does it exist? What does it do? Acta Paediatr Suppl. 1996;416:16-20. 4. Gupta SK, Sawhney RC, Rai L, et al. Regression of coronary atherosclerosis through healthy lifestyle in coronary artery disease patients—Mount Abu Open Heart Trial. Indian Heart J. 2011;63:461-9. 5. Reddihough DS, Collins KJ. The epidemiology and causes of cerebral palsy. Aust J Physiother. 2003;49:7-12.
- 47. CHAPTER 4 Fetal Psychology NitikaSobti, BK Shubhada Neel INTRODUCTION Supporting massive experiences and holistic approach in the field of medical support given to parents-to-be, right from the “Planning for a Baby” stage to the ultimate arrival of the “Bundle of Joy”, the article details about how the parents-to-be, especially the mother should be aware, informed, constantly nourish her own mind, body and spirit, exercise, eat healthy and bond with this most wondrous Creation of God, which only she has the privilege to bring to this Earth. Birthing is a momentous occasion that will always be treasured by couples for the rest of their life. Although everyone wishes to have a perfect start for the new life joiningthembutapprehensionsandworriesofeverydaylife surround them always. They have to stay parallel with their own set of responsibilities, corporate as well as domestic duties, busy and hectic schedules, and daily targets. Stress, anxiety, and depression are hence, perceived as natural by them. The reality is that these problems during pregnancy may have some severe consequences for the health of her unborn baby, if a would-be mother does not learn to manage it. Lifelong well-being of the baby begins in the womb. Dr. David Chamberlin, a well-known psychologist who has done research in psychology, prenatal development, and bonding elaborates, “The womb is a classroom every child attends”. Birth imprints have a long-term effect on the baby that last for a lifetime. Indian mythology is littered with stories that illustrate the power of Garbh Sanskar. Curt A Sandman, Elysia P Davis, and Laura M Glynn of the University of California-Irvine in a study discovered how the mother’s psychological state affects a developing fetus. The study was conducted on pregnant women and they were examined for depression before and after they gave birth. They also performed tests on their babies to understand the trajectory of their development. A compelling observation was made—a significant factor that mattered to the babies was the consistency of the environment before and after birth. Those babies had a healthier development whose mothers were healthy both before and after birth. Similarly and surprisingly, babies did best if they had mothers who were depressed before birth and stayed depressed afterward. However, it was change in the environment that impaired the development of the baby. A mother who was depressed before birth and became healthy afterward or was healthy before and became depressed after giving birth, had a negative effect on the psychological state of the baby. Scientists revealed that the strength of this finding shook them. Pacific Lutheran University in a new study found that babies begin listening to their mother’s talk during the last 10 weeks of pregnancy. They, at birth, have the ability to demonstrate what they have heard inside the womb. Moreover, under Birth Psychology, science has now proven that programming of lifetime health is dependent not only on our genes but also by the environment a mother offers to her baby within the womb. Therefore, all would-be parents can honor the sacred journey of bringing forth life and help protect their baby’s lifetime health and emotional well-being and support healthy psychological patterning from the moment they plan to conceive. NINE MONTHS: NO MORE GRACE PERIOD! Contrary to the widespread notions, several childcare experts and pediatrics strongly believe that the emotional development of a child begins even before it comes into this world. Anne Murphy Paul’s recent cover story for Time Magazine elaborates how “A pregnant women’s mental state can shape her offspring’s psyche”. It was concluded that the 9 months of gestation considerably affected the physical, mental, intellectual, and emotional functioning of the unborn baby. Motherhood is not confined to the physical growth and development of the baby. Thus, those crucial 9 months should not be considered as a “grace-period” for the mother.
- 48. FOGSI FOCUS: AdbhutMatrutva24 During this phase, every moment, every day of the pregnancy should be filled with love, tolerance, peace, and patience. The mother should have faith in herself as it is this self-trust that will enable her to blossom into the mother and person she is meant to be. There is uncertainty—especially for those women who have conceived for the first time. This uncertainty of the unknown may create fear and anxiety. This is where members of the family, friends, and colleagues, and healthcare providers should play a role in creating a positive environment for the mother and the child. Generally, when we consider the factors that affect our health,wethinkofexerciseandnutrition,i.e.thoseelements that have a direct impact on our “physical well-being”. However, equally significant is the role played by the mind and emotions as they mould our values and beliefs. Our values shape our character and how we respond to stress, relationships, and our support networks. The nature of our response reveals how aware we are about ourselves—and a pregnancy must be created in awareness. How can we create this mindfulness? By making enquiries about our beliefs, experiencing true feelings, investigating mental patterns, releasing old systems, and continuing to evolve to become a better human being. Basic underlining that forms the complete edge of the topic is that emotional development stands as a main pillar for the baby’s overall health. During pregnancy, as the baby grows inside the womb, it can recognize the voices and sounds outside the mother’s body. These external stimuli along with the mother’s mood—whether she is happy or stressed or upset shape the baby’s emotional well-being. When you step into motherhood, you shoulder the responsibilities of two lives. Thus, care must be taken about lifestyle choices, even before conception begins. This is vital, not just for your own baby but for future generations as well. A mother needs to begin before birth. SCIENCE BEHIND GARBH SANSKAR Babies, undoubtedly, pick up cues even before they are born. The knowledge that we have garnered over the years about life before birth has driven us to retune the clock on parenthood. This information about the womb has made us believe that the womb is not a secret place anymore. Ancient scriptures, including the Vedas, are testimony to the fact that the creation of a child’s personality begins in the womb. There are ample theories of Garbh Sanskar suggesting that your baby has the ability to sense and respond to external stimuli, such as music as well as the internal influences of your thoughts and feelings. Once the baby is conceived, his/her mental and behavioral development starts. This growth is largely affected by the emotional state of the mother, precisely why the elderly have always taught about staying positive and relaxed during pregnancy. The need of the hour is to honor the synthesis of a holistic and natural trend in pregnancy and childbirth
- 49. Fetal Psychology 25 witha whole-hearted acceptance of all that is modern in medicine. During pregnancy, whatever emotional perceptions a woman experiences, same are transmitted to the fetus/garbha. Selecting and transmitting positive influences by means of yoga, reading, thinking, praying including healthy eating and cheerful behavior is really significant for overall personality of the baby. Recent scientific studies on the subject, and evidences from past researches, all indicate that a baby’s brain develops while in the womb. How Maternal Stress Affects Growing Fetus? Pregnancy is a long, evidently complex and a dynamic experience. The psychological state of a mother is perpetually changing. This induces a number of reactions in the body, including changes in blood flow to the uterus as well as alterations to the intrauterine sensory environment experienced by the fetus. We are aware that pregnant women share an intricate physiological relation with their fetus. Therefore, it is obvious that the maternal psychological environment plays a role in shaping the neurodevelopment of the fetus and ultimately that of the child. The fetus, however, requires the transduction of a maternal physiological signal since there are no direct neural connections between the pregnant woman and the fetus. Studies on maternal psychological stress and emotions has emerged over the past decades, focused both on pregnancy outcomes, such as timing of delivery and infant size at birth, as well as more persistent effects on child development, behavior, and temperament. Studies that show links between prenatal maternal distress and measured child outcomes reveal a complex pattern of results that can be instrument, age or gender- specific. The effect of stress experienced by a mother is similar to the harmful consequences of a potent teratogenic agent. Surprisingly,asperastudy,properfetalmotorandcognitive development does require stress in small amounts. It is interesting to note that prenatal stress can affect the fetus in different ways. It can result into absolutely contrasting fetal outcomes—either a more progressive physical development or a more anxious child. How does emotional stress or insult incite an adaptive response inside the body? This process involves the hypothalamic-pituitary-adrenal axis, with various immune (Interleukins 1, 6, and tumor necrosis factor- alpha), hormonal (prostaglandins), and neurohormonal (corticotropin-releasing hormone, hence cortisol and catecholamines) mediators. The result is a proinflammatory state, occurring as a response to excessive maternal stress. This was found to be similar to that resulting from exposure to numerous non- emotional situations. In both the cases, heavy production of free radicals or reactive oxygen species (ROS) such as trauma, infections, ionizing radiation, heat injury, obesity, smoking, and environmental pollution. The excessive production of ROS must be balanced by the defensive antioxidant activity of the body. Failure of this counterbalancing act leads to oxidative stress, causing oxidation of essential macromolecules and DNA. This can cause change in vital cell functions along with systemic inflammatory leading to perpetual repercussions. In addition, the placenta produces heavy metals like iron. Hence, mostly from the second trimester, pregnancy becomes a stressful condition. In case of additional insult, emotional or non- emotional, the release of stress mediators increases, which can cause extensive visceral injuries, alterations in sub- decidual angiogenesis, increased maternal-fetal transfer of stress substances, and decrease in intrauterine blood flow. A direct consequence of these developments is the increase in myometrial irritability and fetal inflammatory climate, responsible for higher rates of pregnancy losses, preterm deliveries, intrauterine growth restriction, low birth weight babies, and neonatal intravascular hemo rrhage. It has been found that the elevated prenatal maternal cortisol is one of the strongest predictor of these neonatal outcomes. The biochemical profile of newborn babies of depressed mothers is generally alike to their mother’s prenatal biochemical profile with high cortisol levels and reduced dopamine and serotonin levels. Effects of Prenatal Stress on Fetus The theory of harmful consequences of maternal stress and anxiety on the developing fetus finds mention in old tradition and fables. According to scientific evidence, antenatal stress and depression can have the following harmful effects on the developing fetus: Preterm birth Low birth weight Reduced cognitive ability Increased fearfulness Increased incidence of respiratory and skin illnesses in early life. The effect of stress is so deep-seated that it puts depressed women at a higher risk of delivering prema turely. The neonates, thus, born require intensive care for
- 50. FOGSI FOCUS: AdbhutMatrutva26 postnatal complications as compared to normal pregnant women. There is also an increased risk of having low birth weight (< 2500 g), small for gestational age babies (<10th percentile), higher rates of placental abnormalities, pre- eclampsia, and spontaneous miscarriage. In another study, it was found that fetal heart rate, fetal activity; sleep patterns and movements, which are all indicators of fetal neurobehavioral development, were drastically affected by maternal stress, depression, and anxiety. Paradoxically, a meta-analytic review found that there was a weak link between psychosocial stress during pregnancy and neonatal weight and risk for low birth. The meta-analysis of 50 studies reported similar findings of no relationship between anxiety symptoms during pregnancy and poor perinatal outcomes. The analysis thus follows that along with extreme prenatal stress, the environment and circumstances prevailing around pregnant women such as everyday hassles, pregnancy-specific anxiety or relationship strains, etc. all carry adverse effects on developing fetus. PRENATAL DEVELOPMENT Prenatal development is the process in which a human embryo or fetus grows and develops during pregnancy, from fertilization until birth. The process of prenatal development occurs in three main stages: 1. Germinal period (single-cell zygote → morula → blastocyst): Conception to attachment (8–10 days later). 2. Embryonic period (embryo): Attachment to end of 8th week (when all major organs have taken primitive shape). 3. Fetal period (fetus): 9th week (with first hardening of the bones) until birth. The early body systems and structures established in the embryonic stage continue to develop in this period. This stage of prenatal development lasts the longest and is marked by amazing change and growth as summarized below: 10th week: Intestines in place; breathing and jaw- opening movements 12th week: Sexual characteristics; well-defined neck; sucking and swallowing movements 16th week: Head erect and lower limbs well-developed 5th month: As many nerve cells as it will ever have 7th month: Eyes open and lungs capable of breathing 8th month: Many folds of the brain present 9th month: Brain more convoluted Fetus doubles in weight in final weeks before birth. Age of First Fetal Behavior Despiteanumberoftechniquestoassessfetalwell-being(e.g. analysisofgenetic/chromosomalconstitution,structure,and autonomic function), none directly assess the functioning of the brain. Since the behavior of the fetus directly represents the functioning of its nervous system, observation of the fetus’s behavior provides an excellent means of assessing neural function and dysfunction (Table 4.1). MATERNAL EMOTIONAL IMPLICATIONS AND PRENATAL CARE We now understand that fetuses are fully sentient and aware beings. In this new climate of appreciation for the surprising dimensions of fetal behavior, sensitivity, and intelligence, our endeavor should be to bring a host of new information and light about the transformative journey that a baby undergoes in the womb. Table 4.1: Fetal behavior. Behavior Gestational age (weeks) Just discernible movement 7 Startle 8 Hiccup 9 Fetal breathing movements 10 Hand-face contact 10 Yawn 11 Sucking and swallowing 12 Rooting 14 Eye movements 16
- 51. Fetal Psychology 27 Studyof fetal psychology wonderfully unravels the significance of prenatal period and behavior for our development. Moreover, with greater understanding of fetalbehavior;healthofthefetuscanbeimprovedtoagreat level. Early views of the fetus portrayed its environment as one of sensory deprivation. Research has revised this view and demonstrated that the fetus has considerable sensory abilities. It is argued that maternal anxiety influences the functioning of the maternal hypothalamic- pituitary-adrenal axis, which in turn influences fetal brain development, resulting in the subsequent poorer psychological and behavioral performance. The maternal womb is an optimal, stimulating, interactive environment for human development. For the overall health of the baby, it is important to pay equal attention to the physical as well as the emotional development. A baby can sense when the mother is upset or reeling under stress. The intimate connection shared by the baby and the mother enables the baby to feel whatever the mother is feeling. Therefore, it is important for the mother to remain calm and avoid stress as much as possible during pregnancy. After the baby is born, he/she is surrounded by a number of conditions and situations. These experiences further expand the babies’ emotional development. This exposure enables the baby to understand their needs— hunger, comfort or need to be changed, which helps the baby to remain emotionally satisfied. Research suggests that the behavior of the fetus is important for its development both before and after birth. Adapting to the womb—the fetal environment is very different from that experienced after birth. The experiences attained during the prenatal period are significant for the development of the brain and for normal growth as well. It is well-established that the nervous system develops in response to the experiences it receives and from activity generated within the system. The more informed we become about the fetus behavior and the factors that affect its development, the more chances we have to enhance the health of the fetus. Woman today, empowered by the atmosphere of enquiry are asking for answers. Moreover, with their partners they chose to be as much in-charge as they can and affirmatively participate in all activities pertaining to their lives and their bodies. Today’s mother does a lot of research by reading books and surfing variegated baby sites. She is often confused about the right way to look after her unborn baby because of the confusing thoughts she has when she compares what she has read and the well-meaning advice she has been given by the elderly members in family. Conception should be a conscious and planned decision. To conceive is a significant event in a woman’s life. Everything the mother eats and the emotions she experiences influence the child and long before he/ she comes into this world, the baby is prepared for several situations. Exemplifying a positive example of moral challenge to the modern world, this article forms a middle path between imbibing traditional as well as modern ideas in a practical manner. Science and technology has unlocked secrets and discoveries of a baby’s nine-month journey that could change perspectives and inspire us to formulate a new viewpoint about both unborn and newborn fetuses. However, the old view that unborn babies have always been inactive and nothing short of insignificant growing clump of human cells has been replaced with the view that sensory and psychological development of an unborn fetus is rapid and full of constant activity and reaction. TRAINING THE FETUS Can babies learn while still in the womb of their mother? It has been long believed more as folklore that they can and do. It is with this belief that mothers-to-be and family members sing lullabies and soft songs to the baby even before birth. Pregnancy and birth can be a time of joy, elation, fun, and heartfelt love. Every woman innately knows how to nurture and birth her baby. The phase of pregnancy and birth becomes a very clinical time, where we do not trust our intuition and bodies to gently guide and lead us through this beautiful journey. Although a concentric series of barriers buffer the fetus from the outside world; but still surrounded with amniotic fluid, embryonic membranes, uterus, and the maternal abdomen; the fetus lives in a stimulating matrix of sound, vibration, and motion. Conclusively,societytodayisundergreatpressurewith people resorting to violence and terrorism to demonstrate their anguish. More and more people are blaming parents and the family of the offender. The article trains, offers solutions, providing quick fix techniques and conditions the mother to thus, remain relaxed, happy, spiritually inclined and strong enough for conceiving a healthy and happy baby, who grows to be a world citizen. This preparation thus sets the foundation for a very hopeful new generation of individuals who are the future of this great human race. The first 38 weeks of our development has been shrouded in mystery, but now the embryonic science of fetal psychology is revealing the importance of this period for the rest of our lives. As well as advancing our knowledge of the ontogenetic processes before birth, the greater understanding of prenatal development presents
- 52. FOGSI FOCUS: AdbhutMatrutva28 an opportunity to promote the health and well-being of the fetus and provide individuals with the best start in life possible. CONCLUSION Thus, it has been proved, time and again, that positive maternal emotions advance the health of the unborn child. In the first formal study of fetal temperament in 1996, it was recorded the heart rate and movements of 31 fetuses six times before birth and compared them to readings taken twice after birth (They have since extended their study to include 100 more fetuses). Their findings—fetuses that are very active in the womb tend to be more irritable infants. Those with irregular sleep/wake patterns in the womb sleep more poorly as young infants. And fetuses with high heart rates become unpredictable, inactive babies. A fetus constantly receives messages from its mother as it grows in the womb. This communication is not limited to hearing her heartbeat and whatever music she might play to her belly; it also gets chemical signals through the placenta. Therefore, the environment a fetus is growing up in—the mother’s womb—is very important. Some effects are obvious. Smoking and drinking, for example, can be devastating. But others are subtler; studies have found that people who were born during the Dutch famine of 1944, most of whom had starving mothers, were likely to have health problems like obesity and diabetes later. A pregnant women’s psychological as well as physio logical health have consequences for fetal neurobehavi oral development, and consequently, child outcomes. Studies have underscored the importance of considering theeffectsofwomen’smentalhealthonchilddevelopment during the prenatal, as well the postnatal, periods. Stressful situations must be avoided to provide a congenial womb environment for the baby. Parents- to-be who want to further their unborn child’s mental development should start by assuring that the antenatal environment is well-nourished, low-stress, and drug-free. The transition to motherhood begins antenatally and is influenced by an array of factors, such as the life circumstances of the parents, the social environment, and the circumstances of conception. It is also influenced by the level of support provided by the woman’s partner and family, as well as the physical health of the mother and her unborn baby. The mother’s experiences within her family of origin, her past or current mental health issues and any current or unresolved conflict, loss or trauma can also affect, and sometimes disrupt, this transition. Scientists are finding that our health throughout life is greatly determined by the prenatal circumstances in which we develop. The fetus is sensitive and the stimuli coming from the mother has a deep, often life-long impact on the development of the child. While the baby is in the womb, his/her brain seemingly develops in direct response to the mother’s experience of the world. If a mother is plagued by anxiety or stress during her pregnancy, the “message” communicated to her baby (via stress hormones) is that they are in an unsafe environment—regardless of whether or not such information is factual. The baby’s brain will actually mutate, or adapt, to prepare for the unsafe environment into which it expects to arrive. Chronic stress in pregnancy tends to sculpt a brain suited to survive in dangerous environments—quick to react, with reduced impulse control, and a dampened capacity to remain calm and content. Chronic joy, by contrast, allows for the optimal development of each organ, the brain in particular—predisposing the baby to greater health and serenity. Such traits constitute the foundations of lifelong personality. Hence, it has become indispensable to foster an optimal womb environment for the life-long healthy development of the child. BIBLIOGRAPHY 1. Atkinson J, Braddick O. Sensory and perceptual capacities of the neonate. In: Stratton P (Ed). Psychobiology of the Human Newborn. London: John Wiley; 1982. pp. 191-220. 2. Birnholz J, Stephens JC, Faria M. Fetal movement patterns: a possible means of defining neurologic developmental milestones in utero. Am J Roentol. 1978;130:537-40. 3. Chamberlain D. Chapters 1 to 4. Windows to the womb. Berkeley, CA: North Atlantic Books; 2013. 4. Chayen B, Tejani N, Verma UL, et al. Fetal heart rate changes and uterine activity during coitus. Acta Obstetricia Gynecologica Scandinavica. 1986;65:853-5. 5. deVries JIP, Visser GHA, Prechtl HFR. The emergence of fetal behavior. ii. quantitative aspects. Early Hum Dev. 1985;12:99- 120. 6. Fox HE, Steinbrecher M, Pessel D, et al. Maternal ethanol ingestion and the occurrence of human fetal breathing movements. Am J Obstet Gynecol. 1985;132:354-8. 7. Kumar N, Kalsi HP. Effect of prenatal maternal stress on foetal outcome and its long-term consequences: a review of literature. EC Gynaecology. 2017;3(6):432-8. 8. Molly M. University of Washington News. (2013). While in womb, babies begin learning language from their mothers. [online] Available from https://www.washington.edu/ news/2013/01/02/while-in-womb-babies-begin-learning- language-from-their-mothers/ [Accessed December 2018]. 9. Science Daily. (2011). Association for Psychological Science. Can fetus sense mother’s psychological state? Study suggests yes. [online] Available from. www.sciencedaily.com/ releases/2011/11/111110142352.htm [Accessed December 2018].
- 53. CHAPTER 5 Epigenetics: Nature’s/Nurture’sRole in Fetal Origin of Adult Disease Madhu Jain, Shuchi Jain, Nitika Sobti INTRODUCTION Fetaloriginofadultdisease(FOAD),aconceptfirstproposed by Barker1,2 postulates that exposure to hostile environment tothedevelopingfetusduringcriticalperiodofdevelopment may have significant consequences on an individual’s short- and long-term health.2 The recent nomenclature of FOAD is developmental origin of health and disease (DOHD). It was noted that low-birth weight babies are associated with hostofdiseasesrangingfromcoronaryarterydisease(CAD), type II diabetes mellitus, cancer, and osteoporosis to various psychiatric illnesses etc. (Box 5.1). CHRONIC DISEASES ASSOCIATED WITH THE FETAL ORIGIN OF ADULT DISEASES HYPOTHESIS This is a new idea on biological phenomenon. It is not only an individual gene, but also epigenetic factors like improper uterine environment (caused by insults such as poor nutrition, infection, chemicals, metabolites or hormonal perturbations) that had proven to have a bearing on adulthood diseases. The implications of this Barker hypothesis notably for social and public health policy are that a lot of interventions can be planned and done to make the uterine environment favorable to a disease-free fetus, infant, and hence a healthy adult.3 FOAD is based on the concept of the “developmental plasticity”: a single genotype influenced by specific intrauterine events, has the capability to produce different phenotypes. There exist definite or specific developmental periods when the organism is sensitive or plastic to its environmental diversity to provide the best fit between phenotype and the environment. Thus, the fetus in order to preserve neurodevelopment and survivalwillundergoremodelingorprogrammingofvarious organs in terms of structure and function (Fig. 5.1). FETAL ORIGIN OF ADULT DISEASES— BIOLOGICAL BASIS AND UNDERLYING MECHANISMS Thrifty Phenotype Hypothesis On this hypothesis if the developing fetus is exposed to any hostileuterineenvironmentsuchaspoornutrition,infection, chemicals, metabolites, etc. it responds by developing adaptations predictive adaptive responses (PARs). This PAR not only predetermines immediate viability, but also its survival in later life if a similar environment is encountered in later life. Short-term adaptation may be in terms of downregulation of endocrinal and/or metabolic function (likeinsulinresistanceorimpairedglucosetolerance),and/or specificorganfunctiontoslowdownitsgrowthratetomatch the nutrient supply in the deprived uterine environment. Long-term irreversible change in the development structure and function of some tissues and vital organs may occur as a result of alterations in gene expression, cell differentiation, and proliferation. However, if the individual then grows up in an extrauterine environment of high-energy food or with nutritional abundance environment, the reverse of that experienced in utero, would be highly susceptible to noncommunicable disease (NCD) due to “mismatch and poorer fit” environment (Fig. 5.2). Box 5.1: Chronic diseases attributed to“developmental fetal origin”. ■■ Diabetes mellitus ■■ Obesity ■■ Dyslipidemia ■■ Hypertension ■■ Coronary artery disease ■■ Stroke ■■ Kidney failure—glomerulosclerosis ■■ Liver failure—cholestasis and steatosis ■■ Lung abnormalities—bronchopulmonary dysplasia and reactive airway disease ■■ Immune dysfunction ■■ Reduced bone mass ■■ Alzheimer’s disease ■■ Depression, anxiety, bipolar disorder, and schizophrenia ■■ Cancer
- 54. FOGSI FOCUS: AdbhutMatrutva30 Fig. 5.1: Fetal programming. Fig. 5.2: Influence of nature and nurture in development of FOAD. Thus, this thrifty phenotype hypothesis adds to the understanding on diabetes epidemic in our country and proved the role of environments on the origin of FOAD.4 Excessive Exposure to Glucocorticoids Maternal undernutrition will cause excessive fetal exposure to glucocorticoids (GCs) by creating a stress response. This GCS provide a common mechanism as shown in Flowchart 5.1 through which other insults exert their effect. Repeated or chronic stress through the increased secretion of adrenocorticotropic hormone (ACTH) could ultimately result in decreased secretion of insulin-like growth factor binding protein-I and alteration in hepatic gluconeogenesis. This hypothalamus pituitary adrenal axis programming would persist later on in life and would lead to aberrant behavior and thoughts in children. These children also show alteration in hippocampus functional activity due to reduction in pyramid neurons and decreased synaptogenesis at the neural and decreased synaptogenesis at the neural level. Dysregulation of Hypothalamic Pituitary— Adrenal Axis A number of environmental factors during early part of intrauterine life will alter the activity of hypothalamic pituitaryadrenalaxisandthusdevelopmentandregulation of various organs and homeostatic system. Irreversible Changes in Organ Structure Early life insult will result permanent dysfunction and disease through irreversible changes in organ structure. For example, under nutrition and hypoxia in utero would Flowchart 5.1: Hypothesis of fetal origin of adult diseases.
- 55. Epigenetics: Nature’s/Nurture’s Rolein Fetal Origin of Adult Disease 31 result in decrease in number of nephrons’ numbers/ function and subsequently increase risk of hypertension and renal diseases in older age. Alteration in Gene Expression through Epigenetics Prenatal insults such as under nutrition can cause epigenetic modulations by altering deoxyribonucleic acid (DNA) methylation, histone marks, and noncoding ribonucleic acids (RNAs) regulate gene expression which is independent of the changes in the DNA sequence. For example, in utero exposure to famine during the Dutch Hunger winter of 1944–1945 showed that due to reduce methylation at regulatory regions for the insulin growth factor II can lead to adult disease (a hormone critical for growth and development).5 Similarly, undernutrition in utero alters the methylation rates of the 11BHSD2 and hormonal receptor sites (GC receptors) that can disturb hormone homeostasis and can lead to FOAD. Changes in noncoding RNA and histone modification at genes of transcription factors can affect organ development and cellular metabolism and differentiations of cells and increase susceptibility to type 2 diabetes mellitus (T2DM). Other proposed mechanisms are genetic, cellular aging, and intergenerational effects. Small for gestational age (SGA) babies are having alteration in activity of promoters of glucose transporter 4, PDX-1, GCs receptor, and peroxisomal proliferator-activated receptor alpha gene due to epigenetic modifications. This could be responsible for obesity and insulin resistance later on. MANIFESTATION OF FETAL ORIGIN OF ADULT DISEASE Prenataldevelopmentofchildgrowthwhenorganogenesis and rapid growth are occurring is critical for the immediate future health of the infant. If undernutrition occurs in early life of the infant, it shows not only retarded growth but also inducts lifelong changes in hormonal concentrations, abnormal organ development, and diseases such as T2DM and cardiovascular disease, kidney disease, obesity, hypertension, osteoporosis, and metabolic syndrome in later life. In contrast, if undernutrition occurs during midpregnancy, it may alter placental development along with fetal wasting that can result in indistinct metabolic phenotypes in adulthood. Exposure to various other environmental factors including maternal stress, infections, hypertension, obesity, teratogen, alcohol, drugs, undernutrition, smoke, and over nutrition within the critical windows of growth and development is associated with increased risk of FOAD. Malnourishment during pregnancy or infancy is associated with diminished power to cope with high calorie diets in later life. This concept can be utilized as a mean by which phenotypic modifications can be induced within a single generation in order to best accommodate prevailing or anticipated environmental circumstances. THE EFFECT OF FETAL ORIGIN OF ADULT DISEASE ON NONCOMMUNICABLE DISEASE Noncommunicablediseasesaretheleadingcausesofdeath globally accounting for about (70%) deaths annually.6 The risk factor responsible for NCD is poor diet, lack of exercise, tobacco, smoke, and consumption of alcohol. However, in developing countries many other factors are said to be responsible because presentation of NCD occurs at earlier stage and disease progresses at a faster rate. A proportion of NCD could be probably explained by FOAD7 due to adverse experiences during critical periods of growth. Thus, FOAD science would be greatly helpful in future to prevent NCD by using approaches that addresses the influence of environmental factors on growth and development. CONTROVERSIES FOR FETAL ORIGIN OF ADULT DISEASE HYPOTHESIS A recent rise in NCD in developing countries suggests a susceptibility to environmental changes which could be either a genetic basis (thrifty genotype) or fetal programming (thrifty phenotype). However, these would make different predictions for the future. Thrifty genotype theory would stress the need to improve lifestyle factors and to become less obese. On the other hand, the thrifty phenotype would concentrate on the need of better nutrition of girls and mothers and subsequently fetal nutrition and thus to prevent FOAD. RELEVANCE OF FETAL ORIGIN OF ADULT DISEASE IN INDIA AND DEVELOPING COUNTRIES InIndia,themeanfull-termbirthweightis2.6–2.7kg,almost 1 kg lower than in Western Europe.8 A high proportion of infants and children in India are still undernourished but with economic progress, the obesity is an emerging problem. It is calculated that by the year 2020,9 20% of women and 16% of men in India will be overweight. Together with other often related NCD, these represent a significant burden of ill health and economical strain not only on individuals but also on families and overall on
- 56. FOGSI FOCUS: AdbhutMatrutva32 healthsystems,societies,andeconomyoftheNation.Thus, this is the high time to setup the momentum to tackle this burning problem by utilizing knowledge of FOAD and thus to decrease the burden of the disease by first improving maternal nutrition and fetal development. There is an urgent need to make environment ecofriendly at the same time by implanting trees at large scale along with spiritual empowerment of mankind. This is the only method by which we can harmonize the nature and the mind by transmitting positive vibrations to the environment. CONCLUSION Fetal programming is a well-established phenomenon and maternal nutrition is central programming stimulus. It is well-accepted that fetal nutrition can influence both fetal growth and later risk of disease. There is indeed, a nutritional basis for FOAD. This fetal programming would lead to alternation in both fetal birth size and permanent changes in structure and function of the organs, subsequently leading to disease in adult life. However, clear distinctions need to be drawn between maternal nutrition and fetal size at birth at one hand and between fetal nutrition and fetal growth on the other hand. REFERENCES 1. Hales CN, Barker DJ, Clark PM, et al. Fetal and infant growth and impaired glucose tolerance at age 64. Br Med J. 1991;303(6809):1019-22. 2. Barker DJ. The origins of the developmental origins theory. J Intern Med. 2007;261(5):412-7. 3. Water land RA, Garza C. Potential mechanism of metabolic imprinting that lead to chronic disease. Am J Clin Nutr. 1999;69:179-97. 4. Hales CN, Barker DJP. The thrifty phenotype hypothesis. Br Med Bull. 2001;60:5-20. 5. Gluck man PD, Hanson MA, Spencer HG. Predictive adaptive responses and human evolution. Trends Ecol Evol. 2005;20(10):527-33. 6. Ferland-McCollough D, Fernandez-Twinn DS, Cannel IG, et al. Programming of adipose tissue miR-483–3p and GDF- 3 ex by maternal diet in type 2 diabetes. Cell Death Differ. 2012;19(6):1003-12. 7. WHO.(2018).Noncommunicablediseases.[online]Available from http://www.who.int/mediacentre/factsheets/fs355/ en/ [Accessed December 2018]. 8. Moore SE. Early life nutritional programming of health and disease in the Gambia. J Dev Orig Health Dis. 2016;7(2):123-31. 9. Gillespie S, Haddad L. Attacking the Double Burden of Malnutrition in Asia and the Pacific. Manila, Philippines: Asian Development Bank; 2001.
- 57. CHAPTER 6 First TrimesterScreening Narendra Malhotra, Amitha Indersen, Jaideep Malhotra, Neharika Malhotra Bora INTRODUCTION John Langdon Haydon Down first described the genetic condition classified as Down syndrome in 1862. The condition was identified to be due to Trisomy 21 by Jerome Lejeune in 1958. (Fig. 6.1) First trimester screening has focused on the detection of this syndrome primarily, for the past few decades but is no longer limited to only this. The identification of the association of advancing maternal age and the incidence of aneuploidies was the starting point for the evolution of screening for aneuploidies. Serum markers were identified and added to the screening protocol to improve the detection rate for lower false positive rates. First trimester screening has now become the standard of care due to its proven benefits.1 First trimester screening now screens for thecommonaneuploidiesinchromosome13,18,21,Xand Y, risk of early onset growth restriction and pre-eclampsia (PE), preterm labor and major structural anomalies. So, it is a comprehensive yet extensive screening exercise with maternal and fetal implications. Even though the care for mentally handicapped has improved, the debate will always go on, can we avoid such individuals from being born and is it right to do so. Usually, nature does not allow babies with major chromosomal aberrations be born and early pregnancy miscarriages occur. Even in aneuploidies the incidence of aneuploid fetuses in early pregnancy are higher than those that reach term as many of them miscarry. Incidence and Prevalence The estimated incidence of Down syndrome is between 1 in 1,000 to 1 in 1,100 live births worldwide. Each year approximately 3,000 to 5,000 children are born with this chromosome disorder.1 With advances in the understanding and medical facilities available, the life span of people with Down syndrome has increased and many of them have near normal life span. Down syndrome can have a spectrum of presentation. They can present with varying degrees of mental retardation, with or without structural abnormalities like cardiac defects, gastrointestinal obstruction, etc. hormonal abnormalities, immunological abnormalities, and growth issues. The association between maternal age and the increased risk of aneuploidy is known and as the maternal age increases the incidence of Down syndrome increases. But the majority of Down syndrome babies are born to younger mothers simply because majority of pregnancies occur in younger mothers. (Figs. 6.2 and 6.3) Fig. 6.1: Down syndrome. Fig. 6.2: Prevalence of Down syndrome by mother’s age.
- 58. FOGSI FOCUS: AdbhutMatrutva34 Fig. 6.3: Prevalence of Down's syndrome. Screening for aneuploidies has undergone evolution to include serum markers which reflect fetal secretions and placental secretions[Alpha fetoprotein (AFP) and free serum beta-human chorionic gonadotropin (HCG)], maternal factors (age, weight, smoking history, diabetes, assisted reproduction, ethnicity, and previous history of aneuploidy)andultrasoundmarkersofaneuploidy[nuchal translucency (NT) thickness, ossification of nasal bone (NB), presence of tricuspid regurgitation (TR), reversal of a wave in the ductus venosus (DV) flow and facial angle]. In thepastfewyearstheuseofcell-freefetalDNAfordetection of aneuploidy has come into clinical practice. First trimester screening also screens for adverse pregnancy outcomes like development of early onset growth restriction, placental dysfunction, pregnancy induced hypertension, intrauterine growth restriction and fetal demise. This includes maternal hemodynamic factors like mean arterial pressure (MAP), uterine artery pulsatility index (Ut PI) and placental secretions like placenta associated plasma protein-A (PAPP-A), placental growth factor (PIGF) and soluble fms-like tyrosine kinase (sFlt-1). The window of opportunity offered at the time of first trimester screening is also used to rule out major structural defects. Screening of the cervical length can also be done to stratify women at risk for preterm labor. So, the first trimester screening forms the base of the pyramid of care where maximum information regarding the risks and future pregnancy care is obtained. This is described as “inverting the pyramid of care”.2 (Figs. 6.4 and 6.5). SCREENING FOR ANEUPLOIDY Every year millions of women get pregnant: Regardless of the risk category (low or high) all women are at a risk of fetal anomaly Fig. 6.5: Inverting the pyramid of care. Fig. 6.4: Pyramid of antenatal care.
- 59. First Trimester Screening35 Some are at a greater risk Prevalence of anomalies is about 6.5% though only about 2% are potentially life-threatening. PRENATAL DIAGNOSIS Many fetal anomalies can be diagnosed today. But only a few are common enough for screening to be worthwhile. Anomaly can be chromosomal or only structural So we need to do a genetic scan (11–14 weeks) and an anomaly scan (18–24 weeks). As in any other screening modality, pre-test and post- test counseling is essential, with explanation of the method of screening, what the risk assessment implies, how it is interpreted and what the confirmatory tests are, to allow the patient to make an informed choice. The detection rates, predictive rates, the sensitivity, and specificity rates for the tests quoted is heavily dependent on the tests being performed in adherence to the protocols with quality control and regular audit. The operators performing the ultrasoundmarkersareideallyrequiredtoundergotraining in the protocols, have certification and periodic audits. Similarly, the laboratories performing the serum screening are required to have regular standardization, audits and use validated software for the assessment of risk. Thebasicparameterfortheaneuploidyscreeningisthe maternalage-basedrisk.Asthematernalageincreases,the aging oocyte has a higher probability of undergoing errors in disjunction and causing aneuploidy in the offspring. To the age-based risk, the other risk assessment parameters are applied. The continuous variables like NT and the serum analytes are always converted to multiples of median(MoM)forthesamplepopulation.ThisuseofMoM makes the evaluation relevant to the test population and makes it gestational age independent. Each parameter has a positive and negative likelihood ratio that alters the risk accordingly. The parameters vary with gestational age, are continuous variables, and percentile charts are available for most of them. Hence, the gestational age of the fetus should be assigned accurately. The combined test which includes the serum markers and the ultrasound markers for a software-based calculation of risk assessment is the most popular. First trimester screening for aneuploidies based on maternal age, maternal levels of free β human chorionic gonadotropin and pregnancy-associated plasma protein-A (PAPP-A), and measurement of fetal NT has a false positive rate of 5%, detection rate of DR 78.7% (95% confidence interval, 66.3–88.1).3-9 There are various testing protocols in use. Ideally the highest feasible detection rate for the lowest achievable false positive rate is aimed at keeping feasibility and cost constraints in consideration (Table 6.1). Contingent: 1 in 50–1500 borderline risks (at term, equivalent to 1 in 38-1200 at mid-trimester), stepwise: borderline or lower risks, anomaly: major malformation, large NF, short femur, echogenic intracardiac focus, Table6.1:ModelpredictedDownsyndromedetectionratefora3%false-positiverateandpositivepredictivevalueforvariousscreeningprotocols.10 Protocol (completed weeks*) DR OAPR 1: n 1a PAPP-A+ freeβ (10), NT (12) 82% 29 1b PAPP-A+hCG (10) 80% 29 1c PAPP-A+freeβ (12), NT (12) 80% 29 1d PAPP-A+hCG (12), NT (12) 79% 30 2a AFP+freeβ+uE3+InhA (15-19) 64% 36 2b AFP+hCG+uE3+ InhA (15-19) 60% 39 3a PAPP-A+freeβ (10), NT (12), contingent AFP+ freeβ+ uE3+InhA (15-19) 90% 26 3b PAPP-A+hCG (10), NT (12), contingent AFP+hCG+uE3+InhA (15-21) 88% 27 3c PAPP-A+freeβ (10), NT (12), stepwise AFP+freeβ+uE3+InhA (15-21) 92% 25 3d PAPP-A+hCG (10), NT (12), stepwise AFP+hCG+uE3+InhA (15-21) 91% 26 4a PAPP-A (10), NT (12), AFP+freeβ+uE3+InhA (15-19) 91% 26 4b PAPP-A (10), NT (12), AFP+hCG+uE3+InhA (15-19) 89% 26 4c PAPP-A+freeβ (10), NT (12), AFP+freeβ+uE3+InhA (15-19) 93% 25 4d PAPP-A+hCG (10), NT (12), AFP+hCG+uE3+InhA (15-19) 91% 26 4e PAPP-A+freeβ (10), AFP+freeβ+uE3+InhA (15-19) 80% 29 4f PAPP-A+hCG (10), AFP+hCG+uE3+InhA (15-19) 75% 33 Contd...
- 60. FOGSI FOCUS: AdbhutMatrutva36 5a PAPP-A+freeβ (10), NT+NB (12) 91% 26 5b PAPP-A+freeβ (10), NT (12), contingent NB 89% 26 5c PAPPA+freeβ (10), NT (12), contingent TR 88% 27 5d PAPPA+freeβ (10), NT (12), contingent DV 88% 27 6a AFP+freeβ+uE3+InhA+NF+NBL+PT (15-19) 90% 26 6b AFP+hCG+uE3+InhA+NF+NBL+PT (15-19) 89% 27 7a PAPP-A+freeβ (10), NT (12), ANOMALY (18+) 88% 27 7b PAPP-A+hCG (10), NT (12), ANOMALY (18+) 86% 27 8a ANOMALY (18+) 56% 41 8b AFP+freeβ+uE3+InhA (15-19), ANOMALY (18+) 80% 29 8c AFP+freeβ+uE3+InhA (15-19), contingent ANOMALY (18+) 77% 30 9a PAPP-A+freeβ (10), NT (12), AFP+freeβ+uE3+InhA (15-19), ANOMALY (18+) 96% 25 9b PAPP-A+hCG (10), NT (12), AFP+hCG+uE3+InhA (15-19), ANOMALY (18+) 95% 25 The rates specified are for the purposes of comparison of protocols and do not necessarily indicate optimal cut-offs. (AFP: alpha fetoprotein; DV: ductus venosus; hCG: human chorionic gonadotropin; Inh A: inhibin A; NB: nasal bone absence; NBL: nasal bone length; NF: nuchal skinfold; NT: nuchal translucency; PAPP-A: pregnancy-associated plasma protein-A; PT: prenasal thickness; TR: tricuspid regurgitation; uE3: unconjugated estriol). Contd... pyelectasis, echogenic bowel and ventriculomegaly, completed weeks, e.g. 10 = 10 weeks 0 days to 10 weeks 6 days (see recommendations for optimal times to provide tests). Predicted performance is based on published statistical parameters for NT and biochemical markers (Cuckle and Benn, 2010), NB (Cicero et al., 2004), TCR and DV (Sonek and Nicolaides, 2010), NF, NBL and PT (Miguelez, et al. 2010). The serum markers perform better as screening parameters earlier in gestation (10–11weeks) but the ultrasound markers perform better in later gestation of 12– 14 weeks. The greatest advantage of doing the ultrasound later in the screening period is that the anatomical survey of the fetus can be done to rule out major anomalies. So often the compromise is by having the serum parameters assessed earlier and this is combined with the ultrasound parameters later. The other alternative is by having the patient come for screening around 12 weeks and both the serum test as well as the ultrasound is done to give a combined test report. Once the risk assessment reports are available the post-test counseling is to be done to help the patient understand the risk calculated and in case of a screen positive report, to inform them of further testing options and the implications. Ideally, the entire screening process, as well as the confirmatory tests is to be available to the patient in the same place and to be completed in one visit. In a screen positive case, the option of invasive fetal testing like amniocentesis or chorionic villus sampling (CVS) to test the chromosomes of the fetal cells directly or the option of cell-free fetal DNA testing is to be offered with their pros and cons. This concept is called “one stop clinic for assessment of risk (OSCAR)”.11 PRE-ECLAMPSIA SCREENING Screening for women who are at risk for development of PE and its related complications is done along with the aneuploidy screening using maternal MAP measurement, mean uterine artery resistance/pulsatility index, placental factors—PAPP-A and PIGF. Other placental markers like placental protein-13(PP-13), vascular endothelial growth factor (VEGF) and sFlt-1 showed association too. For a false positive rate of 5%, first-trimester uterine artery Doppler studies will detect 50–65% of women who will develop severe PE (i.e. needing delivery before 35 weeks).12 Combined screening using maternal factors, Uterine artery-PI, MAP and PIGF predicted 90% of early PE, 75% of preterm PE and 41% of term PE requiring delivery less than 37 weeks, at a screen-positive rate of 10%.13 The calculation of the risk assessment is done using the appropriate software. The early assessment of risk allows for the institution of prophylactic aspirin by the end of the first trimester. The benefit of prophylactic aspirin 150 mg at bed time, started before 16 weeks, has been demonstrated in the Aspirin for evidence-based pre- eclampsia prevention (ASPRE) trial. In all participants with adherence of 90%, the adjusted odds ratio of development of early PE in the aspirin group was 0.24 (95% confidence interval, 0.09e0.65); in the subgroup with chronic hypertension it was 2.06 (95% confidence interval,
- 61. First Trimester Screening37 0.40e10.71); and in those without chronic hypertension it was 0.05 (95% confidence interval, 0.01e0.41).14 The recent screening program for pre-eclampsia (SPREE) trial (screening for PE) compared the performance of use of maternal history and demographic details for screening as in the NICE guidelines versus multimarker combined screening as discussed earlier. The screen-positive rate by the NICE method was 10.3% and the DR for all PE was 30.4% and for preterm PE it was 40.8%. Women found to be screen positive in this protocol were started on aspirin but had only 23% compliance. In screening for preterm PE by a combination of maternal factors, MAP and PIGF, the DR was 69.0%, which was superior to that of the NICE method by 28.2% (95% CI, 19.4–37.0%) and with the addition of uterine artery-PI the DR was 82.4%, which was higher than that of the NICE method by 41.6% (95% CI, 33.2–49.9%).15 PENTA MARKER SCREENING Now first trimester penta-marker screening is also available. It includes human chorionic gonadotropin (HCG), PAPPA, PIGF, AFP and Inhibin-A. This has the advantage of effective screening for aneuploidies as well as PE as a one-step comprehensive test in the first trimester itself. NONINVASIVE PRENATAL TEST (NIPT) OR CELL FREE DNA ANALYSIS Following the screening for aneuploidies using the ultrasound markers and the serum markers, the screen positive cases are to be confirmed. This is conventionally done by invasive fetal testing—amniocentesis or CVS for fetal karyotyping. The invasive tests amniocentesis has a pooled risk of miscarriage of 0.11% (95% CI, –0.04 to 0.26%) and CVS 0.22% (95% CI, –0.71 to 1.16%).16 Noninvasive prenatal test (NIPT) which tests the cell-free fetal DNA in the maternal circulation circumvents this risk as it is only a blood test for the mother. The cell-free fetal DNA from the placenta enters the maternal circulation and can be tested from 10 weeks of gestation onwards. Following delivery, it is cleared from the maternal circulation in a few hours. When combined first trimester screening is done, a contingent screening protocol can be offered. Women with risk of more than or equalto1in100areofferedaninvasivetestandwomenwith an intermediate risk from 1 in 100 to 1 in 1000, NIPT can be offered.Inthismethodwhereultrasoundexaminationwith the combined test was followed by NIPT in intermediate risk cases, it reduced the number of false positives and the rate of invasive tests17 on one hand as well as picked up the major structural anomalies in the ultrasound. The option of only NIPT in the first trimester is not preferred for this reason. NIPT had the same sensitivity for Trisomy 21, Trisomy 18, and Trisomy 13, but significantly increased specificity, when compared with offering an invasive test to all women with a risk of more than or equal to 1 in 300.17 NIPT using cell-free fetal DNA has very high sensitivity and specificity for Down syndrome (detection rate 99.9%), with slightly lower sensitivity for Edwards and Patau syndrome. However, it is not 100% accurate and should not be used as a final diagnosis for positive cases.18 SUGGESTED AND RECOMMENDED ALGORITHMS 1. First trimester FOGSI screening protocol (Figs. 6.6 and 6.7). 2. First trimester genetic screen protocol (Figs. 6.8 to 6.10). 3. Extended first trimester screening (genetic + pregnancy-induced hypertension (PIH) + preterm) (Figs. 6.11 to 6.13). Fig. 6.7: First trimester FOGSI screening protocol. Fig. 6.6: The 11 to 13 weeks scan.
- 62. FOGSI FOCUS: AdbhutMatrutva38 4. What to do after screening (Fig. 6.14). 5. Diagnostic tests in first trimester (Figs. 6.15 and 6.16) 6. Diagnostic genetic tests (Figs. 6.17 and 6.18). 7. FOGSI recommended first trimester antenatal check list (Fig. 6.19) Fig. 6.10: First trimester genetic screen protocol (contingent screening). Fig. 6.8: Full integrated screening. Fig. 6.9: Integrated step wise. Fig. 6.11: Screening in first trimester. Fig. 6.12: Be happy protocol. Fig. 6.13: Extended first trimester screening.
- 63. First Trimester Screening39 Fig. 6.14: After screening activities. Fig. 6.15: Chorionic villus sampling (CVS). (NIPT: noninvasive prenatal testing). Fig. 6.16: Amniocentesis. (NIPT: noninvasive prenatal testing) Fig. 6.17: Diagnostic genetic tests. Fig. 6.18: Diagnostic genetic tests. (CMA: chaperone-mediated autophagy; FISH: fluorescence in situ hybridization; NGS: next- generation sequencing; PCR: polymerase chain reaction) Fig. 6.19: Antenatal check list as recommended by FOGSI.
- 64. FOGSI FOCUS: AdbhutMatrutva40 REFERENCES 1. Malone FD, Berkowitz RL, Canick JA, et al. First-trimester screening for aneuploidy: research or standard of care? Am J Obstet Gynecol. 2000;182(3):490-6. 2. Sonek JD, Kagan KO, Nicolaides KH. Inverted pyramid of care. Clin Lab Med. 2016;36(2):305-17. 3. Wapner R, Thom E, Simpson JL, et al; First trimester maternal serum biochemistry and fetal nuchal translucency screening (BUN) study group. First-trimester screening for trisomies 21 and 18. N Engl J Med. 2003;349(15):1405-13. 4. Wright D, Kagan K, Molina F, et al. A mixture model of nuchal translucency thickness in screening for chromosomal defects.Ultrasound Obstet Gynecol. 2008;31(4):376-83. 5. Snijders R, Noble P, Sebire N, et al. UK multicentre project on assessment of risk of trisomy 21 by maternal age and fetal nuchal-translucency thickness at 10–14 weeks of gestation. Fetal medicine foundation first trimester screening group. Lancet. 1998;352(9125):343-6. 6. Atzei A, Gajewska K, Huggon I, et al. Relationship between nuchal translucency thickness and prevalence of major cardiac defects in fetuses with normal karyotype. Ultrasound Obstet Gynecol. 2005;26(2):154-7. 7. Souka A, von Kaisenberg C, Hyett J, et al. Increased nuchal translucency with normal karyotype. Am J Obstet Gynecol. 2005;192(4):1005-21. 8. Cicero S, Avgidou K, Rembouskos G, et al. Nasal bone in first-trimester screening for trisomy 21. Am J Obstet Gynecol. 2006;195(1):109-14. 9. Falcon O, Faiola S, Huggon I, Allan L, et al. Fetal tricuspid regurgitation at the 11 + 0 to 13 + 6-week scan: association with chromosomal defects and reproducibility of the method. Ultrasound Obstet Gynecol. 2006;27(6):609-12. 10. Benn P, Borell A, Chiu R, et al. Position statement from the Aneuploidy Screening Committee on behalf of the Board of the International Society for Prenatal Diagnosis. Prenat Diagn. 2013;33(7):622-9. 11. Spencer K, Spencer CE, Power M, et al. One stop clinic for assessment of risk for fetal anomalies: a report of the first year of prospective screening for chromosomal anomalies in the first trimester. BJOG. 2000;107(10):1271-5. 12. First trimester screening for preeclampsia Aris T Papageorghiou; Stuart Campbell, Current Opinion in Obstetrics and Gynaecology. 18(6):594-600. 13. Tan MY, Syngelaki A, Poon LC, et al. Screening for pre- eclampsiabymaternalfactorsandbiomarkersat11-13 weeks’ gestation. Ultrasound Obstet Gynecol. 2018;52(2):186-195. 14. Poon LC, Wright D, Rolnik DL, et al. Aspirin for evidence- based preeclampsia prevention trial: effect of aspirin in prevention of preterm preeclampsia in subgroups of women accordingtotheircharacteristicsandmedicalandobstetrical history. Am J Obstet Gynecol. 2017;217(5):585.e1-585.e5. 15. Tan MY, Wright D, Syngelaki A, et al. Comparison of diagnostic accuracy of early screening for pre-eclampsia by NICE guidelines and a method combining maternal factors and biomarkers: results of SPREE. Ultrasound Obstet Gynecol. 2018;51(6):743-50. 16. Akolekar R, Beta J, Picciarelli G, et al. Procedure‐related risk of miscarriage following amniocentesis and chorionic villus sampling: a systematic review and meta‐analysis. Ultrasound Obstet Gynecol. 2015;45(1):16-26. 17. KaganKO,SrokaF,SonekJ,etal.First‐trimesterriskassessment based on ultrasound and cell‐free DNA vs combined scree ning: a randomized controlled trial. Ultrasound Obstet Gynecol. 2018;51(4):437-44. 18. Taylor-PhillipsS,FreemanK,GeppertJ,etal.Accuracyofnon- invasive prenatal testing using cell-free DNA for detection of Down, Edwards and Patau syndromes: a systematic review and meta-analysis. BMJ Open. 2016;6(1):e010002.
- 65. CHAPTER 7 Second TrimesterScreening and Antenatal Care Pratima Mittal, Sumitra Bachani INTRODUCTION Goal of antenatal care (ANC) is to ensure birth of a healthy baby with minimal risk for the mother. Antenatal care aims at accurate estimation of gestational age, monitoring of fetal growth, and identification of pregnancies at increased risk of maternal or fetal morbidity and mortality. It is ideal to register the pregnancy as soon as a woman misses a period, so that an accurate assessment is possible. Evaluation involves history, physical examination, and basic investigations (as explained in first trimester screening). If the first ANC visit is in second trimester then all the investigations advised in first trimester should be done in second trimester and further management is done as described later. Goals for antenatal care in second trimester are: To provide an ongoing screening program to confirm that pregnancy continues to be low risk. To provide ongoing primary preventive health care and identify the high risk cases. To prevent, detect, and treat complications at the earliest, if any. To educate the mother about the physiology of pregnancy, labor, newborn care, and lactation. To provide advice, reassurance, education, and support for woman and family. Main focus of second trimester ANC care is to screen for any genetic or structural congenital anomalies in the fetus and to identify high risk pregnancy. SCREENING FOR FETAL ANEUPLOIDY Fetal aneuploidies are less common than structural defects however they have profound impact on the quality of life. The most common congenital cause of mental retardation is Down syndrome (DS).1,2 These fetuses do not have any pathognomonic criteria on sonography, 50% may have soft markers which are nonspecific. The definitive way of diagnosing DS is by karyotyping the fetal cells obtained by amniocentesis, chorionic villus biopsy or fetal blood sampling. This is expensive, labor intensive, and is associated with a risk of abortion. Screening for aneuploidies can differentiate those women who are in highriskcategoryandwillneedtoundergoinvasivetesting. Protocolsforscreening:Presentlyscreeningforaneuploidies has not been incorporated in a national program hence it is most important to have a uniformity in the screening protocols to prevent confusion amongst caregivers and the clients. Table 7.1 lists the details of the various screening tests in second trimester. The Dual test (11−13 weeks), the triple test, and quadruple tests (16−22 weeks) are routinely recommended. “Penta” screening [alfa-fetoprotein (AFP), human chorionic gonadotropin (hCG), unconjugated estriol (uE3), dimeric inhibin A (DIA), hyperglycosylated- hCG (h-hCG)], adding a fifth element (hyperglycosylated hCG) to the Quad screen, has been recently introduced but there is limited data to compare Penta with Quad screening’s accuracy.3 Table 7.2 lists the maternal serum marker pattern in selected fetal syndromes. Recommendations: Every pregnant woman should be informed and counseled about the available screening tests and the conditions for which they can be done. A clearly defined and appropriate screening program can be tailored as per the local situation. Each test should be preceded and followed up by a pre-test and post- test counseling. The woman and her partner should be assisted to make an informed decision to participate in the screening program. SCREENING FOR STRUCTURAL ANOMALIES Screening is advocated at 18−20 weeks of pregnancy. Box 7.1 lists components of assessment of structural anomalies. ANC Visits in Second Trimester WHO (2016 WHO ANC model for positive pregnancy experience) has recommended minimum of eight contacts
- 66. FOGSI FOCUS: AdbhutMatrutva42 Table 7.2: Maternal serum marker pattern in selected fetal syndromes. Second trimester markers First trimester markers Genetic disorder AFP uE3 hCG Inh A PAPP-A β-hCG Nuchal translucency Down syndrome ↓ ↓ ↑ ↑ ↓ ↑ ↑ ↑ Trisomy 18 ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↑ ↑ Trisomy 13 ↓ ↓ ↓ ↑ Turner syndrome with hydrops ↓ ↓ ↑ ↑ ↓ ↑ ↓ ↑ ↑ Turner syndrome without hydrops ↓ ↓ ↓ ↓ ↓ ↑ ↓ ↑ ↑ Triploidy (paternal) ↓ ↑ ↑ ↓ ↑ ↑ ↑ ↑ Triploidy (maternal) ↓ ↓ ↓ ↓ ↑ ↓ ↓ ↑ Smith-Lemi-Opitz syndrome ↓ ↓ ↓ ↓ NR NR NR NR Box 7.1: Fetal anatomic survey. ■■ Head, face, and neck ■■ Lateral cerebral ventricles, choroid plexus, midline falx, cavum septi pellucidi, cerebellum, cistern magna, upper lip ■■ Chest: Shape/size of chest and lungs ■■ Heart: Four-chamber view, left ventricular outflow tract, right ventricular outflow tract ■■ Abdomen: Stomach (visualization, size, and situs), kidneys, urinary bladder ■■ Umbilical cord insertion site into the fetal abdomen ■■ Spine: Cervical, thoracic, lumbar, and sacral spine ■■ Extremities: Legs and arms. Table 7.1: Screening tests in second trimester. Test Variables Adequate POG Detection Drawbacks Remarks Triple test AFP, β-hCG, uE3 BPD 32−52 Mm 65−70% Transport of blood or serum may result in higher false positives Being replaced by quadruple screen with higher detection rate Quadruple test AFP, β-hCG, uE3, DIA BPD 32−52 Mm 80% Transport of blood or serum may result in higher false positives Standard of care of combined first trimester screen is missed Integrated test NT ,PAPP-A in first trimester AFP, β-hCG, uE3, DIA in second trimester As per the visits in each trimester 94% Dilemma of partial reporting, patient anxiety lost to follow-up Less practical utility can be used, if woman in high risk category not willing for invasive testing NIPT Cell free fetal DNA from maternal blood 9−18 weeks 99% 4% no call rate. Effectively 95%. Not cost-effective for low risk population Can be used for women in intermediate risk category after triage based combined screen (AFP: alfa fetoprotein; BPD: biparietal diameter; β-hCG: beta-human chorionic gonadotropin; DIA: dimeric Inhibin A; NIPT: noninvasive prenatal test; PAPP-A: pregnancy associated plasma protein-A; uE3: unconjugated estradiol) in pregnancy, with healthcare provider to reduce perinatal mortality (at 12, 20, 26, 30, 34, 36, 38, and 40 weeks). The recommended visits in the second trimester are at least two visits.4 If the first ANC visit is in second trimester, do all investigations advised in first trimester screening in addition to ones advocated in second trimester screening. Confirm period of gestation by history of amenorrhea and examination. If last menstrual period (LMP) is not known then confirm period of gestation as per first time pregnancy was confirmed by urine pregnancy test (UPT)/ultrasonography (USG)/last obstetric examination: Review medical, obstetrical, and past history Register any present complaints. Assess: Measurement of weight, height, blood pressure General physical and systemic examination Assess fetal growth through measurement of fundal height/ultrasound
- 67. Second Trimester Screeningand Antenatal Care 43 Evaluation of women with risk factors for fetal growth restriction Assessment of maternal perception of fetal activity and documentation of fetal heart rate, if heard. Review investigations: Check routine antenatal investigations (Box 7.2) Screening and testing for genetic abnormalities/ aneuploidies/neural tube defects (NTD) Quadruple marker: 16−22 weeks Level II USG/Anomaly scan: 18−20 weeks of ges tation for fetal structural anomalies (see Box 7.1). Also assess: ŠŠ Fetal number, multiple gestations: Chorionicity, amnionicity, comparison of fetal sizes, estimation of amniotic fluid volume (increased, decreased, or normal) in each gestational sac. ŠŠ Qualitative or semi-quantitative estimate of amniotic fluid. ŠŠ Placental location, appearance, and relationship to the internal cervical os. ŠŠ Umbilical cord: Number of vessels in the cord, and placental cord insertion site. ŠŠ Measurements: Biparietal diameter, head circumference, abdominal circumference, and femoral diaphysis length. ŠŠ Transvaginal assessment of cervical length as short cervical length (<24 mm at 24 weeks) is associated with spontaneous preterm birth.5 ŠŠ Maternal anatomy: Evaluation of the uterus, adnexal structures, and cervix should be performed when appropriate. Second trimester screening algorithm is described in Flowchart 7.1. Selective screening: Thyroid profile [T3, T4, thyroid-stimulating hormone (TSH), antithyroid globulin] Box 7.2: Routine antenatal investigations. ■■ Hemoglobin (Hb): If Hb <10.5, investigate for anemia including thalassemia, if MCV<80 ■■ Blood group, If Rh-negative recommend husband’s BG ■■ If wife Rh-negative and husband Rh-positive recommend indirect Coombs test ■■ Oral glucose tolerance test at 24–26 weeks. If normal to be repeated at 32 weeks in women at risk for diabetes in pregnancy. ■■ Thyroid-stimulating hormone and antithyroid globulin as per protocol ■■ Venereal disease research laboratory, HIV, and HBsAg ■■ Qualitative assessment of urine protein ■■ Urine culture and sensitivity (mid stream clean catch sample) ■■ Screening for cervical cancer as per protocol. Box 7.3: Selective infection screen. ■■ Hepatitis C ■■ Tuberculosis ■■ Toxoplasmosis ■■ Bacterial vaginosis ■■ Trichomonas vaginalis ■■ Herpes simplex virus ■■ Cytomegalovirus ■■ Zika ■■ Chagas disease ■■ Documentation of rubella and varicella immunity. Flowchart 7.1: Second trimester screening algorithm. Hemoglobinopathies Lead level Infection screen (Box 7.3) Screening for depression: Pregnant women should be assessed at least once during pregnancy or the postpartum period for depression and anxiety symptoms using a validated screening tool.6 Screening for GBS by vaginorectal culture at 37−38 weeks is recommended by ACOG.7 Counseling: Nutrition, dietary and food hygiene. Recommended weight gain in pregnancy (Table 7.3). Pregnant women of normal weight with a singleton pregnancy need to increase daily caloric intake
- 68. FOGSI FOCUS: AdbhutMatrutva44 Table 7.3: Recommended weight gain in pregnancy. Category BMI Weight gain (kg) Low <19.5 12.5–18 Normal 19.8–26 11.5–16 High 26–29 7–11.5 Obese >29 ≥ 7 Table 7.4: Recommended calorie and protein intake. Particulars kcal/d Protein (g/d) Fat (g/d) Nonpregnant 2,200 50 20 Pregnant +300 +15 30 Lactating +550 +25 45 +400 +18 Box 7.4: Warning signs for emergency consultation. ■■ Vaginal bleeding ■■ Leakage of fluid per vagina ■■ Decreased fetal activity ■■ Signs of preterm labor (e.g. low backache; increased uterine activity compared to previous patterns; menstrual-like cramps; diarrhea; increased pelvic pressure; vaginal leaking of clear fluid, spotting or bleeding, contractions) ■■ Signs of pre-eclampsia (e.g. headache not responsive to acetaminophen, visual changes that do not resolve after a few minutes, persistent right upper quadrant abdominal pain) ■■ Signs or symptoms suggestive of a medical or surgical disorder. by 340 and 450 additional kcal/day in the second and third trimesters, respectively, for appropriate weight gain. Recommended daily allowance (RDA) for an Indian reference woman 20–29 years, weighing 50 kg (Table 7.4). Exercise during pregnancy: In the absence of any contraindication—regular, moderate intensity physical activity for 30 min/day is recommended for pregnant women. Travel: Pregnant women need to be counseled regarding the risk of pregnancy complications away fromtheirusualsourceofmedicalcare,aswellasthe availability of medical resources and their medical insurance coverage at their destination. There is an increased risk of venous thromboembolism during pregnancy and with prolonged immobility during the trip. Counsel regarding issues related to air travel (e.g. access to medical providers, lower oxygen environment, and restricted movement). There is also a potentially increased risk of exposure to infectious diseases. Sexual intercourse: In the absence of pregnancy complications(e.g.vaginalbleeding,rupturedmem branes),thereisinsufficientevidencetorecommend against sexual intercourse during pregnancy. Warning signs necessitating emergency consul tation (Box 7.4). Recommendations: Elemental iron: 100 mg + folic acid 400−500 µg/day supplementation starting in second trimester and continuing for the rest of pregnancy. Prophylactic iron and folic acid (FA) given for 180 days in pregnancy and 180 days after delivery. ŠŠ Nonanemic pregnant women: 100 mg elemental iron and 500 µg of FA daily ŠŠ Anemic pregnant women: 200 mg elemental iron and 1 mg folic acid/day. Immunization: Tetanus toxoid: 2 doses at 4−6 weeks interval Influenza vaccine recommended in all women, regardless of trimester, who will be pregnant during influenza season. Though FOGSI recommends giving it after first trimester as immunity for 6 months is transmitted to fetus also. Immunity for this vaccination lasts for 1 year. Vaccines which can be given and those which are contraindicated are described in Table 7.5. Radiation: No increased risk of malformations, growth restriction or abortion from a radiation dose of less than 5 rad. Employment: Any occupation causing severe physical strain should be avoided. Women with previous/present pregnancy complication (IUGR, preterm delivery) should minimize physical work. Women with uncomplicated pregnancy can continue work till onset of labor. Smoking and alcohol consumption: Abstinence is recommended. CONCLUSION Prenatal screening should be performed within frequent established intervals to allow adequate time for follow- up of screening tests, performance of diagnostic tests, counseling about test results, so that management options can be discussed and early intervention is executed in high risk cases.
- 69. Second Trimester Screeningand Antenatal Care 45 Table 7.5: Recommended vaccination in pregnancy. Strongly recommended Recommended Not recommended TT:2 doses or Tdap TT 1st dose: Between 16–20 weeks, 2nd dose: 4–6 weeks after the 1st dose. Tdap ŠŠ Can replace TT (wherever available) ŠŠ Single dose replaces both doses of TT: Administered 28–36 weeks, if previously immunized but if not immunized two doses of TT and one dose of Tdap Influenza vaccine (during flu season) Intramuscular Can be given at any gestation but FOGSI recommends after 1st trimester. Immunity of this vaccination lasts for 1 year and baby remains immune against flu for 6 months, if vaccine is given to mother, 6 months before delivery HPV MMR varicella Vaccination for which indication is not altered by pregnancy : Rabies, Pneumococcal/Meningococcal/Hepatitis. REFERENCES 1. Audibert F, De Bie I, Johnson JA, et al. No. 348-Joint SOGC- CCMG Guideline: Update on prenatal screening for fetal aneuploidy, fetal anomalies, and adverse pregnancy outcomes. J Obstet Gynaecol Can. 2017;39(9):805-81. 2. Vasilica P. Down Syndrome-Genetics and Cardiogenetics. Maedica(Buchar). 2017;12(3):208-13. 3. ACOG Practice Bulletin No. 162: Prenatal Diagnostic Testing forGeneticDisorders. ObstetGynecol.2015;27(5):e108-e122. 4. World Health Organization (2016). WHO recommendations on antenatal care for a positive pregnancy experience. New Guidelines Nov 2016. [online] Available from https:// www.who.int/reproductivehealth/publications/maternal_ perinatal_health/anc-positive-pregnancy-experience/en/ [Accessed December 2018]. 5. Society for Maternal-Fetal Medicine (SMFM). The role of routine cervical length screening in selected high- and low- risk women for preterm birth prevention. AJOG. 2016;215(3): B2-B7. 6. Learman LA. Screening for depression in pregnancy and the postpartum period. Clin Obstet Gynecol. 2018;61(3):525-32. 7. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Prevention of early-onset group B streptococcal disease in newborns. Committee Opinion No. 485. Obstet Gynecol. 2011;117:1019-27.
- 70. CHAPTER 8 Third TrimesterWorkup Jayam Kannan, Prashitha Panneerselvam INTRODUCTION Screening in third trimester is done in both low-risk pregnant mother and high-risk for diagnosing of late pregnancy complications such as late onset intrauterine growth restriction (IUGR), pre-eclampsia, gestational diabetes, anemia, and infections. SCREENING FOR HEMATOLOGICAL CONDITIONS Complete blood count is repeated again at 28 weeks which allows enough time for treatment of anemia. Pregnant women with anemia are at a 4-fold increase risk of anemia, 2.2-fold risk of low birth weight, and 1.8-fold risk of low APGAR. WHO estimates 591,000 perinatal deaths and 1,150,000 maternal deaths globally, directly or indirectly related to anemia.1 IndirectCoombstestinRh-negativemotherisrepeated again at 28 weeks and if found positive, the mother should bereferredtoappropriatecenterforfurtherinvestigations.2 SCREENING FOR INFECTIONS Screening for asymptomatic bacteriuria is done at 12–16 weeks; if not done earlier, it can be done at 28 weeks. Venereal disease research laboratory (VDRL)/human immunodeficiency virus (HIV)/Hepatitis B are repeated in third trimester. Third-trimester testing has the potential to prevent pediatric HIV infection and universal testing should be considered in high-prevalence areas.3 Testing pregnant women for group B Streptococcus is done at 35–37 weeks and if found positive, they are treated with antibiotics. It is a simple test and clinicians use a sterile swab to collect sample from vagina and rectum. SCREENING FOR MEDICAL CONDITIONS Hypothyroidism is usually detected in first trimester screening;ifthemotherdoesnothaveathyroid-stimulating hormone (TSH) report it can be repeated in third trimester normal cut-off TSH—less than 3 mU/L. Hyperglycemia in Pregnancy The recent concept is to screen for hyperglycemia in the first trimester itself as the fetal beta cell recognizes and responds to maternal glycemic level as early as 16th week of gestation.4 If the first trimester screening is negative it is performed again at 24–28th weeks and 32–34th weeks. The diagnostic test for gestational diabetes mellitus (GDM) advised by the Diabetes in Pregnancy Study Group of India (DIPSI) is an estimation of plasma glucose after 2 hours of 75 g glucose load irrespective of meal timings and the threshold plasma glucose level of more than or equal to 140 mg/dL is taken as cut off for diagnosis of GDM. This has also been included in the guidelines issued by the Ministry of Health and Family Welfare, Government of India.5 FIGO declaration 2018 recommends universal screening for all pregnant mothers at first visit and at 24–28 weeks. It recommends WHO 2013 criteria for diagnosis of GDM [fasting plasma glucose (between 92 mg/dL and 125 mg/ dL) and 1-hour plasma glucose (180 mg/dL) and 2-hour plasma glucose (between 153 mg/dL and 199 mg/dL) following a 75 g oral glucose load] and diabetes mellitus [fasting plasma glucose (greater than 126 mg/dL) and 2-hour plasma glucose (higher than 200 mg/dL) following a 75 g oral glucose load or random plasma glucose (200 mg/dL) in the presence of diabetes symptoms. Monitoring Glycemic Control If the target blood glucose level is achieved, blood sugars are monitored at least once in 2 weeks from 28 weeks to 32 weeks, and once a week till delivery after 32 weeks. In uncontrolled blood glucose level, frequency of monitoring depends on the glucose levels. The patients are thought self-monitoring of blood glucose. In women with pre- existing diabetes, retinal assessment and renal assessment is repeated at 28 weeks. Gestational Hypertension and Pre-eclampsia Blood pressure assessment and urine protein estimation is done at each antenatal visit to screen for pre-eclampsia
- 71. Third Trimester Workup47 and all pregnant women should be made aware of the imminent symptoms of eclampsia.6 Significant proteinuria is considered if the dipstick reading is 1+ and protein/ creatinine ratio greater than equal to 0.3 or greater than or equal to 300 mg per 24 hours urine collection. In the absence of proteinuria, high blood pressure associated with thrombocytopenia (<100,000/mL), elevated serum creatinine more than 1.0 mg/dL or elevated blood liver transaminases to twice normal are diagnostic of pre- eclampsia. In gestational hypertension and pre-eclampsia women, ACOG task force recommends daily serial assessment of symptoms and fetal movements, twice weekly BP measurement and weekly platelet count and liver enzymes. Ultrasonography is done to determine fetal growth every 2 weeks and amniotic fluid volume is assessed weekly.7 Fetal Growth Restriction Symphysis fundal height is to be measured every visit from 24 weeks. Evidence does not support routine ultrasound scanningandDopplerafter24weeksinlow-riskpregnancy through it is important in diabetes or hypertension complicating pregnancy. Fetal growth restriction (FGR) is one of the most common and complex problems in obstetrics and the perinatal complication are preventable if diagnosed early. There is increased risk of perinatal mortality and morbidity for infants with FGR. Hence, screening, diagnosis, and management is important for clinicians. Cochrane review could not conclude the effectiveness of symphysis fundal height (SFH) measurement in detecting FGR,8 SFH measurement is routinely used in developing countries, especially in low-risk cases. In a prospective cohort study conducted in 4,000 pregnant women showed that routine third trimester scan tripled the identification of small for gestational age (SGA) infants and could detect growth restricted infants9 while Cochrane review 2015 does not show benefit in performing routine third trimester ultrasound unless indicated (Box 8.1). Identifying small for gestational age (estimated fetal weight EFW <10th centile) and large for gestational age (LGA) (EFW > 90th percentile) is important in patients with medical disorders complicating pregnancy especially in low resource settings so that the patients can be referred to higher center for appropriate management. If the FGR is identified, Doppler studies are done further to assess the uteroplacental insufficiency and additional Doppler studies like middle cerebral artery, ductus venous, and aortic isthmus are done at specialized fetal medicine centers, but there use in monitoring growth restricted fetus needs more evidence. The timeline for hypoxia with abnormal arterial Doppler (CIA, MCA is approximate 2 weeks and abnormal venosus Doppler is 2 days). The periodicity of antepartum testing largely remains unclear, since there are no large clinical trials, however, fetal well-being tests [nonstress tests (NSTs), biophysical profile (BPP) and umbilical artery Doppler] is repeated once or two times weekly and growth estimation done every 2 weeks. FETAL SURVEILLANCE In low-risk pregnancy, regular growth and fetal heart rate monitoring during antenatal visit and maternal monitoring of kick count (10 movements in a period of 2 hours) every day is done. Other fetal surveillance tests like NST, contraction stress test (CST), BPP, modified BPP, and umbilical artery Doppler are done in high risk pregnancy for fetal wellbeing and to plan the time and mode of delivery. Nonstress Test Normal acceleration during fetal movements is good indicator of fetal autonomic function. Reactive NST is with normal beat to beat variability, with minimum two acceleration of 15 beats from baseline lasting up to 15 seconds in a 20-minute trace. 15% of normal 28–32 weeks fetus can show abnormal NST. Cause of nonreactive NST includes fetal sleep cycle or fetal distress. If NST is nonreactive it is extended to 40 minutes or vibro acoustic stimulation of fetus is done. Contraction stress test is the response of fetal heart rate to contraction of uterus.11 Biophysical Profile Five components [NST, fetal breathing movements, fetal movements, tone and amniotic fluid volume (single vertical pocket >2 cm)], each is assigned a score of 2. A score of 8–10 is normal, 6 is equivocal, and less than 4 is abnormal. Modified BPP includes only NST and amniotic fluid assessment only. Umbilical artery Doppler velocimetry plays a significant role in monitoring growth restricted fetus. Box 8.1: Third trimester ultrasonography indications.10 ■■ Fetal growth: Estimation and fetal well-being ■■ Antepartum hemorrhage, placental position ■■ Abdominal or pelvic pain evaluation ■■ Multiple gestation ■■ Suspected small for gestational age/large for gestational age ■■ Amniotic fluid abnormalities ■■ Preterm premature rupture of the membranes or preterm labor
- 72. FOGSI FOCUS: AdbhutMatrutva48 Normal umbilical artery wave form shows high velocity diastolic flow. In growth restricted fetus, there can be decreased diastolic flow and severe growth restriction is absent or reversed diastolic flow is seen.11 MENTAL HEALTH The prevalence of antenatal depression is reported up to 42.7%. Research has reported that 33% of postnatal depression begins in pregnancy. Diagnosis of antenatal depression is made difficult by the physiological signs that overlap with symptoms of depression. The clinicians should identify the risk factors like lack of social support, stress, fear of pregnancy problems and childbirth, domestic violence and if the pregnant women show any signs of depression, prompt referral to psychiatry services will help the patient to cope up with stress and prevent postpartum depression.12 REFERENCES 1. Management of Iron Deficiency Anemia in Pregnancy— FOGSI General Clinical Practice Recommendation. 2. National Institute for Health and Care Excellence (2008). Antenatal care for uncomplicated pregnancies. Clinical Guidelines CG62. Available from http://www.nice.org.uk/ guidance/cg62 [Accessed December 2018]. 3. Williams B, Costello M, McHugh E, et al. Repeat antenatal HIV testing in the third trimester: A study of feasibility and maternal uptake rates. HIV Med. 2014;15(6):362-6. 4. Seshiah V, Das AK, Balaji V, et al. Diabetes in Pregnancy Study Group. Gestational Diabetes Mellitus—Guidelines. J Assoc Physicians India. 2006;54:622-8. 5. Maternal Health Division, Ministry of Health & Family Welfare. New Delhi: Government of India; 2014. National guidelines for diagnosis and management of gestational diabetes mellitus. Available from http://nhm.gov.in/ New_updates_2018/NHM_components/RMNCH_MH_ Guidelines/Gestational-Diabetes-Mellitus.pdf [Accessed December 2018]. 6. The Federation of Obstetric and Gynecological Societies of India. Good Clinical Practice Recommendations—Routine Antenatal Care for Healthy Pregnant Women. June 2015. Available from https://www.fogsi.org/fogsi.icog-good- clinical-practice-recommendatios/[Accessed December 2018]. 7. Hypertensioninpregnancy.ReportoftheAmericanCollegeof ObstetriciansandGynecologists’TaskForceonHypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122-31. 8. Robert Peter J. Ho JJ, Valliapan J, et al. Symphysial fundal height (SFH) measurement in pregnancy for detecting abnormalfetalgrowth.CochraneDatabaseSystRev.2015;8:9. 9. Sovio U, White IR, Dacey A, et al. Screening for fetal growth restriction with universal third trimester ultrasonography in nulliparous women in the Pregnancy Outcome Prediction (POP) study: a prospective cohort study. Lancet; 2015. 10. ACOG Practice Bulletin. Clinical management guidelines for obstetricians-gynecologists. Number 175, December 2016: Ultrasound in pregnancy. Obstet Gynecol. 2016;128(6). 11. ACOG Practice Bulletin. Clinical management guidelines for obstetricians-gynecologists. Number 145, July 2014: Antepartum Fetal Surveillance. Obstet Gynecol. 2014;124(1). 12. Zeng Y, Cui Y, Li J. Prevalence and predictors of antenatal depressive symptoms among Chinese women in their third trimester: a cross-sectional survey. BMC Psychiatry. 2015;15:66.
- 73. CHAPTER 9 Diet andNutrition during Pregnancy Shilpa Joshi INTRODUCTION Nutrition is important in all stages of life. But it has special importance in pregnancy as it is critical in maintaining good health of mother and well-being of unborn child. Inadditiontochangesintheanatomyandphysiologyof the mother, there are adjustments in nutrient metabolism. Thesechangesaretosupportfetalgrowthanddevelopment while maintaining maternal homeostasis and preparing for lactation. These adjustments in nutrient metabolism are complex and evolve continuously throughout pregnancy. The changes in nutrient metabolism can be described by several general concepts—adjustments in nutrient metabolism are driven by hormonal changes, fetal demands, and maternal nutrient supply; more than one potential adjustment exists for each nutrient; maternal behavioral changes augment physiologic adjustments; and a limit exists in the physiologic capacity to adjust nutrient metabolism to meet pregnancy needs, which when exceeded, fetal growth and development are impaired.1 IS NUTRITION DURING PREGNANCY ONLY IMPORTANT FOR MATERNAL WELL-BEING? Prenatal nutrition is important to prevent metabolic diseases in fetus later in their life. Famine studies from Dutch winter hunger showed that the rates of obesity at 19 years of age were significantly higher in offsprings whose mothers were exposed to famine in first half of pregnancy as compared to those who were exposed to famine in first trimester of pregnancy. The offsprings who were exposed in their last trimester, had lower rate of obesity and hence metabolic diseases. Furthermore, recent studies from the Dutch famine population showed that low-energy intake (<900 kcal per day) during pregnancy was associated with higher weight and greater fat deposition at several sites in female offspring at ~58 years of age, but not in males.2 The associations were stronger when exposed to famine during themiddle20weeksofgestationthanwhenexposedduring thefirstandlast10weeksofgestation.Anotherinvestigation found that exposure to famine during pregnancy increased offspring’s BMI and waist circumference in women at ~50 years of age, but not in men.3,4 There may also be some small and weak positive associationsbetweenexposuretofamineduringpregnancy and energy balance, physical activity and percent energy from fat for their offspring in later life in the Dutch famine population. These observations have lead us to strengthen the belief that maternal nutrition has more than a short-term impact of maternal and fetal health, but the real and long- term impact is that of prevention of metabolic disease in offspring. Hence, maternal diets are responsible for lesser metabolic burden of nation. Effect of Prepregnancy Weight There is a considerable information documenting the effect of increased prepregnancy weight on pregnancy outcome. Obesity leads to an increase in rates of infertility (often associated with polycystic ovary syndrome) and a negative impact on infertility treatments.5 For those who successfully conceive, early pregnancy is characterized by an increased risk of spontaneous miscarriage. Rates of congenital malformations increase with increasing obesity. For every unit (kg/m2 ) increase in BMI, the risk of neural tube defect (NTD) increases by 7%.5 Obesity and overweight is characterized by increase in insulin resistance. It therefore comes as no surprise that the rate of gestational diabetes (GDM) is increased in pregnancy of overweight and obese women. There are increased rates of gestational hypertension, pregnancy-induced hypertension, and pre-eclampsia in obese and overweight women during pregnancy. The rate of stillbirth has increasinglybeenrecognizedtobeassociatedwithobesity. There is very little data on the effect of underweight on pregnancy. Generally, low BMI are correlated with nutritional deficiencies both in macronutrients and micronutrients. Low BMI are at risk of intrauterine growth restriction, preterm birth, and iron deficiency anemia.6
- 74. FOGSI FOCUS: AdbhutMatrutva50 NUTRITION IN PREGNANCY Pregnancy is categorized by additional energy require ments of 300 kcal per day.7 Rather than traditional belief of eating for two, the emphasis should be on eating twice as well in terms of quality of food. Therefore, nutrient density of food is very important. Nutrient density is defined as the quantity of protein, vitamins, and minerals per 100 kcal of food.8 Many women especially in India have diets rich in low-density nutrient foods. This is due to cultural factors, food preference, economics and also the traditional food patterns. Various studies in India have shown that Indians eat very little proteins in their diets.9,10 The protein intake in traditional Indian diet of both vegetarians and non-vegetarians is about 12% , as opposed to recommended of 20%. These studies are not on pregnant women. But it has been observed that women who are pregnant tend to eat the same foods cooked at home, it probably increased in quantities. Also, it has been observed that Indians consume very limited quantities of vegetables and fruits. Research all over the world have shown that birth weight of infant is dependent on mother’s intake of green leafy vegetables and fruits rather than energy dense foods they tend to consume.11 Also, research has shown that in India the traditional preference for eating food during pregnancy is rich in sugar, which in excess can be detrimental for growth and development of the baby.12 In summary, caloric needs increase, but the increase is less than that of other nutrients. Small frequent meals and more nutrient-dense foods should be emphasized, especially as pregnancy progresses. Women should be encouraged to choose milk or yogurt (change to low fat), choose lower fat meats, minimize juice (fruits and vegetables), choose whole grains, and drink water instead of processed drinks like sherbet, aerated drinks or sport drinks. Fresh fruits and vegetables should be stressed. Highly processed foods like fried foods should be avoided, and other added fats and sugars minimized, to maximize high nutrient density with lower caloric count.13 Prenatal vitamins (multivitamin/multimineral) are recommended for those who have higher than average needs (women pregnant with multiples, women who have HIV, and women who smoke, drink alcohol, or take drugs) or those who eat little or no animal products.14 For others, they are used as insurance, not as a substitute for a good diet. CONCLUSION In India, it is consistently seen that women who are pregnant are culturally fed for two. There is a lot of emphasis on quantity of food rather than quality. Time has come to change the thought process of women and their families to not only to ensure well-being of mother and child but also preventing metabolic burden of this nation. REFERENCES 1. King JC. Physiology of pregnancy and nutrient metabolism. Am J Clin Nutr. 2000;71(suppl):1218S-25S. 2. Stein AD, Kahn HS, Rundle A, et al. Anthropometric measures in middle age after exposure to famine during gestation: evidence from the Dutch famine. Am J Clin Nutr. 2007;85:869-76. 3. Ravelli AC, Van Der Meulen JH, Osmond C, et al. Obesity at the age of 50 years in men and women exposed to famine prenatally. Am J Clin Nutr. 1999;70:811-6. 4. Ravelli GP, Stein ZA, Susser MW. Obesity in young men after famine exposure in utero and early infancy. New Engl J Med. 1976;295:349-53. 5. Yu CKH, Teoh TG, Robinson S. Obesity in pregnancy. BJOG. 2006;113:1117-25. 6. Siega-Riz AM, Siega-Riz AM, Laraia B. The implications of maternal overweight and obesity on the course of pregnancy and birth outcomes. Matern Child Health J. 2006;10(5 suppl):S1530-6. 7. Mehta S. Nutrition and pregnancy. Clin Obstet Gynecol. 2008;51(2):409-18. 8. Abrams B, Minassian D, Pickett K. Maternal Nutrition. In: Creasy RK, Resnik R, Iams JD (Eds). Maternal-Fetal Medicine: Principles and Practice, 5th edition. Philadelphia: W.B. Saunders; 2004. pp. 155-62. 9. Joshi SR, Bhansali A, Bajaj S, et al. Results from a dietary survey in an Indian T2DM population: a STARCH study. BMJ Open. 2014;4:e005138.[ 10. Mohan V, Radhika G, Sathya RM, et al. Dietary carbohydrates, glycaemic load, food groups and newly detected type 2 diabetes among urban Asian Indian population in Chennai, India (Chennai urban rural epidemiology study 59). Br J Nutr. 2009;102:1498-506. 11. Rao S, Yajnik CS, Kanade AN, et al. Intake of micronutrient- rich foods in rural Indian mothers and size of their babies at birth: Pune Maternal Nutrition Study. J Nutr. 2001;131:1217-24. 12. Kanade AN, Rao S, Kelkar RS, et al. Maternal nutrition and birth size among urban affluent and rural women in India. AJCN. 2008;1:137-45. 13. Cox JT, Phelan ST. Nutrition in pregnancy. Obstet Gynecol Clin N Am. 2008;35:369-83. 14. Kaiser L, Allen LH. Position of the American Dietetic Association: nutrition and lifestyle for a healthy pregnancy outcome. J Am Diet Assoc. 2008;108(3):553-61.
- 75. CHAPTER 10 Feel GoodYoga for Body, Mind and Soul BK Shubhada Neel, Sonal Richharia, Pushpa Pandey, Sunita Lodaya INTRODUCTION In this electronic age, where on one hand we have made great materialistic developments, on the other hand in this electronic age, undue stress during pregnancy is likely to affect the physical fitness of mother, the physical and mental development of the baby as well as the process of delivery. Yoga has an answer to address these issues as it works on the mind, body, and soul. To have healthy body, we need a peaceful mind and enlightened soul, union between the body, mind, and soul offers a positive balanced life. In antenatal period to have healthy and intelligent baby, it is required to empower expectant mothers with good thoughts and have flexible body for easy and safe delivery. So yoga improves functional capacity of mother’s body and mind. Yoga achieves union between the body, mind, and soul and offers a positive, balanced lifestyle. It enhances the physical and mental health of the pregnant women. Yoga can be practiced in all the stages of pregnancy. It has three basic principles: 1. Asanas: It increases mother’s flexibility, stretchability, muscle tone, and joint flexibility. 2. Pranayama and Om chanting: i. It will regulate mother’s breathing ii. Maintain emotional balance iii. Ensure proper oxygen supply to the breathing fetus during labor and delivery. 3. Rajyoga meditation: i. Connects the self to supreme ii. Helps mother to relax and calm down mind and body. Yogic practices will improve the functional capacity of mother’s body and mind and will heighten the neuron− muscular coordination which will help in natural delivery process. Physical and mental, stresses are very often the main causes of difficult and obstructed delivery. Expectant mother has to be physically, mentally, and emotionally empowered and healthy. So that baby will be physically, mentally, and emotionally empowered and healthy. This can be easily managed by undertaking certain regular yogic practices like asanas, pranayama and meditation especially under supervision of yoga expert, so as to avoid any harm to the expectant mother or the growing baby in the uterus. With the yogic practice, expectant mother approaches with confidence the ordeal of delivery process with relaxed frame of body and mind. This presentation on the subject is very crucial for all expectant mothers and I am sure this information will serve as a guideline for both expectant mothers as well as the antenatal healthcare providers. Feel good yoga and meditation for mother and baby will become popular and acceptable soon. Come One! Come All! Come and learn how to keep yourself fit and fine. Enjoy and experience yogāsanas, pranayama, and meditation, something unique which you have been missing! WHAT IS YOGA? The word “Yoga” is derived from the Sanskrit root “yuj” meaning “to join”, “to connect” or “to unite”. Achieve union between the body, mind, and soul to attain self-realization. Leads to the union of an individual consciousness with the universal consciousness. It overcomes all kinds of sufferings and leads to holistic health, happiness, and harmony in all walks of life. WHAT IS THE REQUIREMENT OF YOGA IN PREGNANCY? In ancient India, at the time of our grandmothers, preg nancy and childbearing occurred at very early age so muscle and joint flexibility used to be more, hence vaginal delivery was easy. Secondly they used to do all house hold works like cooking, cleaning, washing clothes, which
- 76. FOGSI FOCUS: AdbhutMatrutva52 automatically strengthened their thigh and calf muscle. In today’s scenario, marriages occur late and due to carrier constrain one plans baby late, so joints are stiffer. One enjoy pleasure of machines and maids so no household activities, that‘s why to improve on flexibility, it is required to do yoga and asanas during pregnancy. For Mental Development and Sanskar Highly intelligent child is aim of all parents nowadays, but for that what they can do, nobody knows. 80% of brain and nervous system is developed in intrauterine period, to have spiritually and mentally evolved child it is required that pregnant lady should live in satvik environment— means stress-free and happy. By different methods of pranayama, mother can have proper oxygenation which is important for brain development. OM chanting helps in neuromuscular synapses formation and we know more synapses that mean more intelligence. HOW YOGA CAN HELP DURING ANTENATAL PERIOD? Medical research has shown marked benefits of yoga to the mother and fetus. Adverse effects of stress in preg nancy are pregnancy-induced hypertension, pregnancy- induced diabetes, abortion, preterm labor, eclampsia, and intrauterine growth restriction (IUGR). Yoga is multi- dimensional, physical, mental, emotional, intellectual, and thus provides total answer to the challenge of stress. Yoga is a technique for total personality development at physical, mental, emotional, and spiritual levels. The chief aim of these exercises is to improve the overall elasticity and strength of the body’s muscles and more importantly those sets, which are vital for delivery like muscles of lower back, waist, lower abdomen, leg, and pelvic floor. The exercises also improve blood circula tion. Regularly doing these exercises also prepares you mentally for the process of childbirth as well as dispels misconceived fears and notions. GENERAL GUIDELINES FOR YOGA PRACTICE Before the Practice Cleanliness of surroundings, body, and mind. Calm and quiet atmosphere with a relaxed body and mind. Empty stomach or light stomach—small amount of honey in lukewarm water if you feel weak. Bladder and bowels should be empty. A mattress, yoga mat, durrie or folded blanket. Light and comfortable cotton clothes. Do not do yoga in a state of exhaustion, illness, in a hurry or in acute stress conditions. Chronic disease/pain/cardiac problems, during preg nancy and menstruation, a physician or a yoga thera pist should be consulted. During the Practice Start with a prayer to create a conducive environment to relax the mind. Slow, in a relaxed manner, with awareness of the body and breath. Do not hold the breath unless instructed. Breathing through the nostrils unless instructed otherwise. Do not hold the body tightly, or jerk the body. Practice with own capacity. Persistent and regular practice. Keep in mind contraindications/limitations. End with meditation/deep silence/Sankalpa Shanti path. After Practice Bath may be taken only after 20−30 minutes of practice. Food may be consumed only after 20−30 minutes of practice. Food for Thought A satvik, balanced vegetarian diet recommended. Over 30 years, two meals a day should suffice. As the food, so the mind, As the mind, so the life. Satvik—full of positive energy (Prepared and consumed in positive state of mind in Godly remembrance) Balanced diet = Proteins + carbohydrates + fats + vitamins + minerals in appropriate quantities. Daily Sadhana Prayer Stretching exercise Yogāsanas Om chanting Pranayama Rajyoga meditation Sankalpa Shantipath.
- 77. Feel Good Yogafor Body, Mind and Soul 53 Prayer Everybody should be happy, everybody should be healthy. There should be divinity everywhere. Nobody should be in distress. Loosening Practices Ankle/toe movement Butterfly Neck movement Shoulder movement Wrist/finger movement Knee movement. Ankle/Toe Movement Butterfly
- 78. FOGSI FOCUS: AdbhutMatrutva54 Neck Bending Shoulder’s Movement Hand and Wrist Movement Trunk Movement
- 79. Feel Good Yogafor Body, Mind and Soul 55 Knee Movement YOGASANAS Points to Remember Starting position of asana Reach slowly to final position Hold for sometimes in final position Slow release of asana Relax. Standing Pose Sitting Pose Dandasana Bhadrasana (The firm/auspicious pose) Sukhasana Parvatasana (The mountain pose) Sukha Purva Kativakrasana Chakki chalan Upavista Konasana Parsva Uttanasana Janushirasana Matsyendrasana Vajrasana (The thunder bolt pose)
- 80. FOGSI FOCUS: AdbhutMatrutva56 Supine Pose What is Pranayama? Also known as “yogic breathing” or “controlled deep breathing”. “Prana” means energy in Sanskrit. “Ayama” means distribution of energy. Pranayama teaches you to breathe well, with an equal balance of nourishing oxygen inhaled and unwanted carbon dioxide exhaled. This keeps your body oxygenated giving you more energy. Benefits of Pranayama Improves the circulation of blood. Increases the oxygen level in your blood. Helps your body to remove waste effectively; reduces stress. Cope during labor by calming you and distracting you from pain. Breathing deeply now will help to prepare you for giving birth. Your body produces increasing amounts of adrenaline when you are afraid, which can prevent the production of oxytocin, a hormone that helps labor along. Deep breathing in labor can help you fight the urge to panic when you feel the pain of contractions. Keeping your body relaxed means you can save your energy for when it is needed. Om Mantra
- 81. Feel Good Yogafor Body, Mind and Soul 57 Benefits of Chanting the Powerful Om Mantra Helps reduce stress Improves concentration Sets your mood right Strengthens spinal cord Helps in detoxifying your body Takes care of your heart and digestive system Helps in getting you enough sleep Enables you to have control over your feelings Helps you in getting rid of negativity. RAJYOGA MEDITATION All are welcome in this miraculous journey of life. To make this journey comfortable practice the following commentaries for 10 minutes three times in a day. If possible, early in the morning, at about 4−5 AM. Early morning is the most auspicious time. Also do this before going to bed too. The meaning of Yog is to establish a connection, reunion of self (soul) with Supreme. The practice of remembering/visualizing Supreme, with love, affection, and experiencing every possible relation with him is Rajyoga meditation. COMMENTARY FOR RAJYOGA EXPERIENCE I am spiritually empowered soul which is different than this body. I am seated between the two eyebrows and shining like a star. This body is like a motor car…… and I am a soul working as its driver. This body is made up of perishable five elements. But I am the imperishable soul ever young and indestructible. I am the master of the house called the “Body”. I am the soul in the form of tiny point of light. I feel more and more powerful as I become light, radiating light. On the screen of my mind, I begin to sense a warm, golden-red glow. My home, I travel far beyond to my home of peace. In my home I am so free, light, and peaceful. I feel the presence of a powerful light. As I come closer and closer to the source of immense energy spiritual power, a brilliant light, a wave of love showers over me. I am in the presence of the Supreme soul, the Supreme father, the Unlimited, the purest, most immaculate soul of all. The Supreme is the ocean of all these treasures, bliss, knowledge, peace, love, happiness, purity, power. Going deeper into this peace I feel so still and light. I begin to explore this soft aura of peace. I am filling with feelings of warmth, love and comfort from God the Supreme whose gentle waves of golden, tender love, pass over me and soothe my mind. I become so still and quiet, peaceful, powerful …… Om Shanti…. Om Shanti….. Om Shanti
- 82. FOGSI FOCUS: AdbhutMatrutva58 Sankalpa I am a divine soul. My every thought, word, and action is full of happiness for others. Today throughout the day whomsoever I will meet, I will give peace, love, and happiness to everyone. As I think like this, baby in the womb is getting empowered with peace, love, and happiness. He/She is coming in this world to give peace, love, and happiness to others. He/She is coming to change this world. Like Shree Krishna and Shree Radhe my baby will remain ever happy and empowered with all virtues/values. My body is perfect, healthy “As we think, so we become”. My blood pressure is normal, my sugar is normal. Every cell of my body is full of love and purity. Everything is perfect. The world is beautiful. I will do this meditation every day, due to which me and my baby will remain physically and mentally healthy. Every moment GOD is with me, as GOD is my companion, my day is going to be successful. My career is extremely successful. I am GOD’s angel. I am spreading vibrations of peace, love, and happiness, in entire Universe, due to which this World will again become Golden age/paradise. Shantipath Lord Almighty, please show us the light which travels us from falsehood to truth, from the darkness of ignorance to the light of knowledge, from mortality to immortality. Walking Walking is safe all 9 months of pregnancy and one of the easier ways to start exercising. At least 30 minutes a day, preferably outdoors for the fresh air, sunlight, and natural surroundings. Time table for morning walk in pregnancy Benefits of walking Pregnancy safe walking tips. Pregnancy Safe Walking Tips Drink about half glass of milk/half a piece of apple/ dry fruit before you start your walk. Always remember to carry a water bottle along with you. Get your doctor’s approval before starting. When pregnant you have to be more careful. Look forward while walking, to avoid sudden falls. Walk at a comfortable pace that is not too fast. Slow down if you are not able to walk with your grow ing belly. If in case you feel hot, breathless or tired, take a break. Do not walk in extremely humid or hot conditions. Benefits of Walking during Pregnancy Retrospective data suggest that exercise may prevent gestational diabetes, reduce the risk of developing pre- eclampsia, and prevent excessive weight gain during pregnancy. Gaining weight at a steady rate can lower your chances of having— Hemorrhoids Varicose veins Stretch marks Backache Fatigue Indigestion Shortness of breath during pregnancy. A review of the evidence suggests that, in most cases, exercise is safe for both mother and fetus during pregnancy and women should therefore be encouraged to initiate or continue exercise to derive the health benefits associated with such activities. Overall the body of literature in this field thus far is provocative, and when taken as a whole, suggests that exercise during pregnancy may be associated with a reduced risk of cesarean delivery. BENEFITS OF EXERCISE IN PREGNANCY Pregnancy usually leaves women feeling tired; exercise gives you more energy to make through the day. Exercise allows you to sleep better. Improves your mood, lessens mood swings, improves yourself image, and gives you some sense of control. Prepares you for childbirth. Studies show shorter labor, fewer medical interventions, and less exhaustion during labor. Easier to lose weight after baby is born. IMPORTANT POINT TO REMEMBER Women with miscarriages or abortions in the past or those who have conditions like “placenta previa” should do exercises only according to their doctor’s advice. Routine sonography during the third month is useful.
- 83. Feel Good Yogafor Body, Mind and Soul 59 BENEFITS OF YOGA IN PREGNANCY It minimizes common pregnancy symptoms like morning sickness and constipation. Effective for reducing pregnancy-related back and leg pains. Strengthen abdominal organs and muscles. Better sleep, prevents excessive weight gain, and have more energy overall. Improves balance, increases flexibility, and better blood circulation. It increases secretion of endorphin (happy hormone) that keeps mother energetic and positive so decreases erratic mood swings. Reduces cortisol levels so rate of prematurity also decreases. CONCLUSION So in Adbhut Matrutva programme we want to emphasize about the role of different asanas to prepare mother for process of delivery and to have intelligent baby, a peaceful mind by pranayama and meditation. Always remember you are having a pure soul in your womb and God gave you an opportunity to create it in better way. We as a doctor have major role in all this process, we know that subconscious mind of baby is always alert in womb, so we can teach a fetus more easily and can make a whole generation intelligent and Sanskarwan. It is time for action so try to teach everyone about the methods and spread the knowledge. OM SHANTI
- 84. CHAPTER 11 Role ofMeditation during Pregnancy BK Shubhada Neel, Pushpa Pandey, BK EV Swaminathan, Manju Gupta, Awantika To the mind that is still, the whole world surrenders —Anonymous When meditation is mastered, the mind is unwavering like the flame of lamp in a windless place —Bhagavad Gita INTRODUCTION Meditation and medicine have come from the Greek word “medri”, which means “to heal”. It is a mental exercise, which has many physiological and psychological benefits in mind and body. Pregnancy is a condition in which women undergo various physiological changes and is accompanied by unique physical and psychological demands. Maternal stress and anxiety, which are very common even in uncomplicated pregnancy is associated with a host of negative consequences for the fetus and subsequent development. Hence, there is a need to manage the various physical, emotional, and mental pain that arise throughout the stages of pregnancy and labor. Meditation not only takes care of physical and emotional health, but also helps to improve the state of spiritual health. The word “Holistic”, means “whole” or “complete”. Around 70–80 years back, when the dichotomy in the state of being of the human being used to be emphasized, i.e. “spirit” the psyche and consciousness energy that drives the force “being”. So, the multidimensional health model is the need of the hour. Spiritual health refers to that part of the individual, which reaches out and strives for meaning and purpose in life. However, present medical scenario is devoid of this aspect. We need to understand spirituality to comprehend and become spiritual healthy. Spirituality is to know oneself and the higher self, i.e. to explore “swa”, the inner self (soul) and “sth”, the consciousness. Ipso facto, the Hindi word for health “swasth” literally means “the inner self-consciousness”. The inner self- consciousness encompasses aspects of the enduring and the immortal spirit. Practicing this fact will lead to stability and security, which, in turn, would lead to peace, love, and happiness. On the contrary, the outer self-consciousness encompasses aspects, role, or material things that are ever- changing and mortal. Focusing merely on the of the outer leads to instability and insecurity, which, in turn, leads to anger, anxiety, depression, type-A behavior, isolation, and chronic life stresses. By abstraction, we can conclude that a healthy lifestyle means an “inner self-conscious lifestyle”.1 Meditation enables us to look within and make contact with our inner truth. The inner peace and silence that emanate during meditation also affect our physical bodies. Various types of meditation are practiced by the individuals, few of them are: Mantra meditation: Wiki describes “Mantra” as a sacred utterance, a numinous sound, a syllable, word or phonemes, or group of words in Sanskrit believed by practitioners to have psychological and spiritual powers. An alternate meaning of the sacred word is “advice”. The mantra “Om Shanti” advises us to be conscious of our essential spirituality. We should chant this mantra with its true understanding—“I am a spiritual being and my essence is peace”. Dhyan meditation: Aimed at developing concentration on a sacred object. When one focuses upon a sacred
- 85. Role of Meditationduring Pregnancy 61 object for a long period of time, the impact of that vision can bring an internal state of sacred awareness. Pranayam: Meditation upon breath is a favored technique, because breath is considered to be sacred life force. Pranayama improves our physical health. Rajyoga meditation: Rajyoga meditation is the communion of inner self with supreme. It is also known as “Sahaja yoga” and taught by Brahma Kumaris. “Yoga” means “union”. It is the science and art of harmonizing spiritual, mental, and physical energy through a connection with the ultimate source of spiritual energy called the “supreme soul” (power house of spiritual energy).1 It is the state of soul consciousness and a positive lifestyle. Rajyoga has two components: Soul:Soulisthemetaphysicalenergy,whichcontrols the body. Soul is eternal, immortal, imperishable, and divine metaphysical entity. It should be clear; fetus in womb has a same life as an adult. Every human being either adult or fetus is made up of physical energy and metaphysical energy. Human being − Human + being Up to 3 month’s body of fetus formed completely in mother’s womb. “Soul” enters in body, which is imperishable entity with subconscious mind (Sanskar) carrying from previous birth. Soul is located in the center of forehead between hypothalamus, pituitary gland, and pineal gland. Surface marking is center of forehead. Soul has seven innate qualities—(1) knowledge, (2) purity, (3) love, (4) peace, (5) happiness, (6) bliss, and (7) power. These innate qualities (metaphysical energies) are manifesting as thoughts forms a quantum field, which has no mass. Thoughts are not mere vibrations, but they are definite electrochemical phenomenon occurring in hypothalamus of brain. This metaphysical energy acts through the mind “thoughts, judgments, feelings, and emotions”, integrates with the biological energy of the body through the nervous and endocrine system, thereby nourishing every cell of body.2 So physical health is dependent on positive vibration of metaphysical energy. In fact, mind radiates its energy to each cell of body. Scientific evidence of soul: In 40 epileptic patients while practicing meditation positron-emission tomography (PET) scan was done. It was observed that during meditation, the prefrontal area of the seat of the soul showed increased light energy. The scientists termed this as “God’s Spot”. Near death experiences and out of body experiences— Dr Raymond Modi in his book recorded 100 cases about near death and out of body experiences and came to conclusion that death is not the end of life. Past birth regression therapy—Dr Ian Stevenson devoted 40 years to the scientific documentation of past life memories of children. He has over 3,000 cases in the files and found that reincarnation is true. Supreme: It is a powerhouse. He is ocean of knowledge, peace, purity, power, bliss, love, and happiness. The most accepted form of Supreme is point of light and might in all religions. METHOD OF RAJYOGA MEDITATION Meditation is practiced while sitting in morning and evening two times at least for 20 minutes. Everyday sit in a clean and pure spot with no TV or other distractions. In this simple yoga, we can sit quietly in the lotus posture or the half lotus posture. Sit comfortably and relax your body from head to feet. Take a few deep breaths. During inhalation, visualize positive energy from the environment entering in your body. Negative energy is going out during exhalation. Experience calmness and watch your thoughts. Thoughts are slowing down. Visualize a point of light, symbolic of your spirit, in center of your forehead. This peaceful light is emitting rays of tranquility, rays of peace. These rays are reaching my brain, which is now filled with divine peaceful rays. I am now becoming peaceful. The rays have spread throughout
- 86. FOGSI FOCUS: AdbhutMatrutva62 my body. I am relaxed and peaceful. Now, I am shifting my attention to the space outside the body, where exists another powerful point of light that is the ocean of peace and ocean of love. Different colored rays are falling upon me; I am absorbing love, peace and healing energy from the supreme surgeon, the Godfather. The energy is entering through my face and eyes and is spreading out to fill every cell of my body. I am now feeling restored and healed. Healing energy is radiating from within me to my baby inside the womb. He/she is also a point of divine light playing a part in his/her body. The baby inside the womb is also experiencing unconditional love and peaceful vibrations. Staying connected to the ocean of peace is making my child’s mind powerful and his/her body is becoming healthier. Experiment 1 Offer water and meal to supreme father and surgeon, God, before taking it. Experience that the powerful rays coming from supreme energy are charging water and food. This healing energy in the food and water is healing your baby now. Experiment 2 At night and early morning after meditation, visualize God’s power falling on your hands. Touch your abdomen, while thinking healing energy of God is entering to my baby through my hand. Rajyoga can also be practiced while walking and moving around which changes the aura (thought, emotions, attitude, and memory) of person that affects the health of expectant mother and her fetus inside the womb. With continuous practice of meditation life changes. When we want to join two wires, we must remove the insulating rubber. Similarly, when we remove the rubber of the body from the mind and concentrate on supreme (God is not the body or the rubber) then spiritual current flows easily. BENEFITS OF MEDITATION—PHYSIOLOGICAL BENEFITS Meditation decreases metabolic rate and lowers the heart rate, thus indicating a state of deep rest and regeneration. Meditation reduces stress by decreasing stress hormones. In various studies, it was found that the number of preterm labor and pregnancy induced hypertension with associated intrauterine growth restriction (IUGR), were significantly lower, in the group of mothers that practiced yoga and meditation.3 Endorphins and enkephalins are secreted due to yogic lifestyle, which helps in detaching oneself from the various kinds of pains. It raises energy level and strengthens the immune system to ward of infections. Positive changes in electrocardiogram (ECG) and electromyogram (EMG) and increases skin resistance. Creates a state of deep relaxation and reduces anxiety due to decreased level of blood lactate. Improves sleep and digestion. It helps to give up addictions, and decrease depression anxiety, diabetes, hypertension, and migraine tension headache.4 Psychological Benefits of Meditation It enhances positivity of a person and reduces stress; lessen catastrophic reaction, caused by adverse environment, unwanted pregnancy, and economic problems by changing attitude and belief system. It strengthens patients to tolerate various types of pains during antenatal period as well as during labor and promotes vaginal delivery. Meditation improves memory. Meditation increases the subjective feeling of happiness and contentment. Meditation increases emotional stability. Increases concentration and strengthens the mind. Spiritual Benefits of Meditation Studies show that people who meditate are likely to report a shift in their outlook and goals in life toward growth and spiritual fulfillment rather than more materialistic goals. Pure vibrations give healing touch to others. As subconscious mind becomes active, visualization power increases which can be used for self-progress and self-healing. Meditation increases the spiritual energy within, neutralizesthecauseandeffectofkarma,andimproves birth outcome. By nourishing fetus with spiritual energy, it can be protected from the negative environment and by nourishing brain and body make the baby healthy. CONCLUSION Meditation is a simple technique that brings profound results. Rajyoga meditation makes the process of self-transformation light and natural and helpful in reducing stress. Thus, it contributes in decreasing the
- 87. Role of Meditationduring Pregnancy 63 risk of premature delivery or low birth weight babies, the complications like pregnancy-induced hypertension (PIH) and IUGR and eventually would decrease: Developmental and behavioral problems in the children, as a toddler and adolescent. Risk of developing depression later in life. Mental health problems in the mother. Fetaloriginofadultdiseasessuchasinsulin-dependent diabetes mellitus, hypertension, and coronary heart disease. All the suffering, stress and addiction come from not realizing you already are what you looking for —Jon Kabat-Zinn REFERENCES 1. Gupta S, Sawhney RC, Rai L, et al. Regression of coronary Atherosclerosis through healthy life style. Indian Heart J. 2011;63:461-9. 2. Nair N. Eternal Play of Physical and Metaphysical Energies. Brahma Kumaris P, Vishwavidyalaya I (Eds). Mystery of Universe.MountAbuRajasthan:OmShantiPress,Gyanamrit Bhawan; 2008; pp. 10-1. 3. NeelS,MalhotraN,SwaminathanEV,etal.Studyofintegrated approach of antenatal care to improve the gestational age at birth. World J Anemia. 2018;2(1);1-10. 4. Kiran, Girgla KK, Chalana H, et al. Indian effect of rajyoga meditation on chronic tension headache. Indian J Physiol Pharmacol. 2014;58(2):157-61.
- 88. CHAPTER 12 Ultrasound inPregnancy Rajat Ray INTRODUCTION Routineultrasoundexaminationhasbecomeanestablished part of antenatal care (ANC). It is beneficial in detection of congenital malformations, multiple pregnancies, placenta previa, and for confirmation of period of gestation. The prevalenceofcongenitalanomaliesrangesfrom2%to4%of allbirths,buttheyaccountfor20–25%ofallperinataldeaths and an even higher percentage of perinatal morbidity. Diagnosis of malformations by routine ultrasound provides early information and helps in making timely decisions during pregnancy for termination, appropriate treatment at birth, and prompt transfer to units specialized in the care of the newborn, thereby reducing perinatal mortality and morbidity. Certain conditions such as ectopic pregnancy, multiple gestations, and placenta previa, which may lead to potential life-threatening complications, can be identified earlier and appropriately managed with the help of ultra sonography (USG). Accurate gestational dating from ultrasound can assist in the management of abnormal fetal growth in pregnancies, which is a leading cause of perinatal morbidity and mortality in both developed and developing countries. NUMBER OF ULTRASOUND IN PREGNANCY At least one obstetric ultrasound should be done during pregnancy between 18 weeks and 22 weeks of pregnancy. If affordability is not an issue, additional ultrasound in 1st trimester and 3rd trimester improves the clinical manage ment. No prior preparation of the woman is required for the ultrasound examination. As far as possible, the day of ultrasound should coincide with ANC examination day and fixed days for USG should be avoided, as this may lead to multiple visits by the pregnant women. PURPOSE FOR ULTRASONOGRAPHY To detect chromosomal abnormalities, fetal structural defects, and other abnormalities Estimationofgestationalagewhichresultsinreduction of post-term pregnancies To detect number of fetuses and their chorionicity Evaluation of placental position and abnormalities Assessment of cervical canal and diameter of internal os to detect incompetent os. CLASSIFICATION OF ULTRASOUND IN PREGNANCY Standard1sttrimesterultrasound:Astandardultrasound in 1st trimester includes the evaluation of presence, size, location, and number of gestational sacs (GSs). The GS is examined for presence of yolk sac and embryo or fetus inside it. When an embryo is seen, it is measured for estimation of gestational age by measuring crown-rump length (CRL). Its viability is seen by documenting fetal cardiac activity. The uterus, cervix, adnexa, and pouch of Douglas are examined to rule out any pathology. Standard 2nd and 3rd trimesters ultrasound:Itincludes evaluation of fetal number, cardiac activity, presenta tion, placental position, amniotic fluid volume, fetal biometry, and anatomical survey. Maternal cervix and adnexa should also be examined. Specialized ultrasound examination: A detail anatomic evaluation of fetus considered to be at risk for anomalies isdone,e.g.incasesofadvancedmaternalage,pregnancy conceived by artificial reproductive techniques, abnor mal biochemical markers, or a suggestive history for anomalies. Other examples of specialized ultrasounds are fetal echocardiogram, nuchal translucency scan, cervical length, Doppler ultrasound, etc. Most common indications for 1st trimester ultrasound are: Confirm an intrauterine pregnancy and to rule out an ectopic pregnancy Confirmation of viability Estimation of gestational age Confirmationofmultiplepregnancyandtheirchorioni city
- 89. Ultrasound in Pregnancy65 To diagnose gestational trophoblastic disease To ascertain cause of vaginal bleeding or pain Measurement of nuchal translucency To diagnose certain fetal anomalies To evaluate uterine or ovarian masses and uterine anomalies. Gestational Sac At around 31st day, transvaginal sonography (TVS) allows the detection of a GS representing the chorionic cavity, as small as 2–3 mm in diameter. GS is usually round or elliptic with a smooth rounded contour. As the sac grows, it gradually deforms the central cavity echo complex, giving rise to characteristic double decidual sac sign formed by two echogenic rings. Yolk Sac The secondary yolk sac is the earliest embryonic landmark that can be recognized within the GS. The diagnosis of intrauterine gestation can be made with certainty after yolk sac is visible. By TVS, it is visible as early as at 5th week. It is spherical in shape with echogenic periphery and sonolucent center. Embryo and Cardiac Activity Between 34th day and 35th day, the developing embryo may be seen as line of echoes or a subtle area of focal thinking along the periphery of yolk sac. Cardiac contrac tions begin around 36–37 days GA. Cardiac rates are relatively slow at 6 weeks, typically between 100 beats/ min and 115 beats/min. By 8 weeks, it measures around 144–176 beats/min. Subsequently, heart rate declines to 150–160 beats/min by 12 weeks. Amnion Two blebs representing the amnion and yolk sac and in between them, the embryonic disk can be identified as earlyas5weeks3dayswhenCRLis2mm.Theechogenicity of yolk sac is more than that of amnion. Musculoskeletal System Theupperlimbsstarttodevelopduringthelatterpartof6th week followed by lower limbs. From 7th week onward, the upper and lower limb buds can be imaged. The tail section usually protrudes caudally and exceeds the lower limbs in length at this time. Spine is seen as parallel echogenic lines starting from 7 weeks. The toes form during the 8th and 9th weeks, and by 10th week, they are fully developed. The fingers assume their final shape during the 8th week. Others Scanning of the facial structures becomes practical only after 11th week. Urinary bladder becomes visible after 8th week, but kidneys cannot be identified until the end of 1st trimester. At 7–8th weeks, the cranium can be distinguished from the abdomen. Head appears larger than the trunk. By 10th week, head size is almost half of the embryo. The symmetrical brain anatomy within the developing calvarium can be appreciated by TVS. Placenta Asplacentaldevelopmentbeginsduring8thweek,thehyper echogenic ring surrounding the sac becomes asymmetric with focal peripheral thickening, which becomes future placenta. Umbilical Cord The umbilical cord can be detected by TVS by 7–8th weeks. Nuchal translucency measurements along with serum biochemistry should be used to determine the risk of having a fetus with aneuploidy or other abnormalities during 11 weeks to 13 + 6 weeks gestational age. VIABILITY CRITERIA IN 1ST TRIMESTER PREGNANCY The following criteria have been suggested for predicting a nonviable pregnancy: For the initial scan: An empty GS of mean sac diameter (MSD) more than or equal to 25 mm An embryo with no heart activity and a CRL more than or equal to 7 mm Beyond 70 days gestation, an MSD more than or equal to 18 mm with no embryo. For repeat scans: A pregnancy with an embryo with no heart activity on initial scan and a repeat scan more than or equal to 7 days later A pregnancy with no embryo and an MSD less than 12 mm if sac size had not doubled after more than or equal to 14 days A pregnancy with no embryo and an MSD more than or equal to 12 mm with no embryo heart activity after more than or equal to 7 days. DATING OF A PREGNANCY Most accurate time of dating a pregnancy is 1st trimester, as the biologic variation is minimal at this time. First structure to be measured is the GS. The measurement of
- 90. FOGSI FOCUS: AdbhutMatrutva66 a GS is expressed as MSD, which is the average of three dimensions (length, width, and depth) measured from inner edge to the other inner edge. A yolk sac without an embryo detected by TVS corresponds to 5.5 weeks GA. Between 6 weeks and 12 weeks, CRL is considered as most accurate for dating, which is measured as the maximum straight line length of the fetus. The 1st trimester dating is accurate up to ± 3–5 days. Beyond 1st trimester, the following sonographic parameters can be used to estimate gestational age and for fetal size assessment: Biparietal diameter (BPD) Head circumference (HC) Abdominal circumference (AC) or diameter Femur diaphysis length (FDL). Second and third trimesters ultrasound mainly focuses on fetal biometry and anatomy. Fetal cardiac activity, fetal number, and presentation should be documented. In case of multiple pregnancies, chorionicity is determined. Comparison of fetal sizes and evaluation of amniotic fluid in each sac should be determined. Fetalanatomicsurveyshouldbecarriedouttoevaluate the followings: Fetal head: The standard axial fetal brain planes include the BPD, the transventricular plane, and the cerebellar plane. Many of the fetal measurements are taken from these planes including the BPD and HC. Measurements of the cerebellum, cisterna magna, and nuchal fold can be useful. Biparietal diameter plane: The continuous midline echo representing the falx is broken in the anterior third by the cavum septum pellucidum. Behind this in the middle of the falx, a thin slit representing the third ventricle is often visible. The BPD measurement is obtained from outer skull bone to inner skull bone perpendicular to the falx at the maximum diameter. The HC is measured as an ellipse around the outside of the skull bones. Slight gaps in the echogenic skull bone outline are evident and represent the skull sutures. There should be a normal oval skull shape with no depression of the petrous temporal bones and no angulation near the sutures. The normal bone density of the skull should be more echogenic than the falx. Transventricular plane: This image is a cross‐section of the head just above the BPD plane, at the level of the atrium of the lateral ventricles. The lateral ventricular measurement can be taken from inner wall to inner wall at the level of the glomus of the choroid plexus. Over the gestational range of 15–40 weeks, 10 mm or larger is considered abnormal. Cerebellar plane: This plane is inferior to the BPD plane. The cerebellum is a dumbbell-shaped structure, with symmetrical lobes. The central vermis is slightly more echogenic than the lateral lobes. The cisterna magna can be measured from the posterior margin of the cerebellar vermis to the inside of occipital bone in the midline. A measurement of 2–10 mm is normal in the 2nd and 3rd trimesters. The nuchal fold is a measurement taken from outer skin line to outer bone in the midline. Less than 6 mm is considered normal up to 22 weeks. Fetal face: The facial structures can be examined both coronallyandaxially.Theorbits,nose,andmouthneed to be separately visualized. The orbits should be equal in size with the gap between each orbit approximately the same as the width of each orbit. The lenses can be seen as central circles with no internal echogenicity. The two nostrils and an intact upper lip and hard palate should be seen. By visualizing all structures, i.e. the forehead, the nose, upper lip, lower lip, and chin in sagittal section rules out nasal bone, chin, and forehead abnormalities. Fetal chest and heart: It is important to establish situs. Both the heart and stomach should be seen to be on the left side of the fetus. Both hemidiaphragms can be visualized sagittally. The lung fields should be carefully inspected for cystic or echogenic areas. Heart: The heart should be positioned on the left side of the chest, with the interventricular septum at about a 45° angle and is of normal size. Four-chamber view, left and right outflow tracts, and three vessel trachea view should be assessed. The heart rate should be noted to look for arrhythmias. Diaphragm and lungs: This sagittal image demonstrates intact diaphragms on each side especially posteriorly nearthespine,acommonsitefordiaphragmaticdefects. The stomach is visible beneath and heart above the diaphragm.Itisalsobeneficialtoidentifyhomogeneous appearing lung fields to attempt to exclude echogenic or cystic lung lesions. Fetal abdomen: The AC is a standard biometry measure ment. The stomach should be visualized in the left side of the abdomen. A “J”-shaped hypoechoic structure is seen in the midline, which represents the internal portion of the umbilical vein branching to the right portal vein. The AC is measured around the outside of the skin line. The section should be circular not oval, the kidneys should not be visible in the section, the cord insertion should not be visible, and the “J” should not extend all of the way to the skin line anteriorly. Occasionally, the gallbladder is visible as a tear- shaped hypoechoic structure situated to the right anterior of the umbilical vein. The adrenal glands can sometimes also be seen in this section. There should be no cystic dilatation of the bowel or abdominal cysts visible.
- 91. Ultrasound in Pregnancy67 The umbilical cord insertion should be imaged to look for abdominal wall defects. The renal tract is reviewed by imaging urine in the bladder with surrounding umbilical arteries and assessing the kidneys. The fetal kidneys should be imaged in two planes, both coronal and axial. Fetal musculoskeletal system: It is beneficial to image thefetalspinethroughoutitslengthandthespineisbest imagedinthreeplanes:(1)Coronal,(2)Sagittal,and(3) Axial. There should be an intact skin line overlying the back, especially over the sacral region. There should be no spinal angulation or deformity. At the inferior end, there should be sacrococcygeal tapering of the spine. In axial section, the three ossification centers forms an approximately equilateral triangle throughout the length of the spine. Each of the 12 long bones should be separately visualized. Although both femurs could be measured, usually only one is measured provided both have been seen to be of similar lengths. The femur is measured horizontally across the ossified diaphysis down the middle of the shaft of the bone avoiding any triangular echogenic extensions. Hands and feet should be separately imaged taking particular care to ensure that both left and right sides are separately seen. Other structures: A qualitative or semiquantitative estimation of amniotic fluid (like amniotic fluid index or single deepest pocket) should be done to rule out oligohydramnios or polyhydramnios. Umbilical cord should be evaluated to look for number of vessels in the cord, and placental cord insertion site. The placenta should be visualized throughout to look for abnormalities, placenta previa, or hemorrhages. The presence of succenturiate lobe should be excluded. The position of the placenta in relation to the internal os should be ascertained. The maternal cervical canal can also be measured. The presence of any myoma or adnexal mass should be documented. Presence of uterine anomalies should also be documented. Cervical length measurement by TVS is done for prediction of preterm birth. Color Doppler ultrasound is done to predict preeclam psia and fetal growth restriction and also to diagnose fetal jeopardy. SAFETY Diagnostic ultrasound in pregnancy is generally consi dered safe. CONCLUSION Ultrasonography is now an established tool in the clinical managementofpregnancy.Toensureappropriatematernal and neonatal health, it is important that the quality of ANC is optimized with addition of ultrasound. BIBLIOGRAPHY 1. Abramowicz JS, Kossoff G, Marsal K, et al. Safety Statement, 2000 (reconfirmed 2003). International Society of Ultrasound in Obstetrics and Gynecology (ISUOG). Ultrasound Obstet Gynecol. 2003;21(1):100. 2. AIUM-ACR-ACOG-SMFM-SRU practice parameter for the performance of standard diagnostic obstetric ultrasound examinations. J Ultrasound Med. 2018;37(11):E13-24. 3. Belizán JM, Cafferata ML. (2011). Ultrasound for fetal assess mentinearlypregnancy:RHLCommentary.[online]Available from http://cms.kcn.unima.mw:8002/moodle/downloads/ Department%20of%20Maternal%20%20Child%20Health/ who%20videos/apps.who.int/rhl/pregnancy_childbirth/ fetal_disorders/prenatal_diagnosis/jbcom/en/index.html. [Last Accessed February, 2019]. 4. Chudleigh T. The 18 + 0–20 + 6 Weeks Fetal Anomaly Scan National Standards. Ultrasound. 2010;18(2):92-8. 5. Kongnyuy EJ, van den Broek N. The use of ultrasonography in obstetrics in developing countries. Trop Doct. 2007;37(2): 70-2. 6. Salomon LJ, Alfirevic Z, Berghella V, et al. Practice guidelines forperformanceoftheroutinemid-trimesterfetalultrasound scan. Ultrasound Obstet Gynecol. 2011;37(1):116-26. 7. Stanton K, Mwanri L. Global maternal and child health outcomes: the role of obstetric ultrasound in low resource settings. J Prev Med. 2013;3(1):22-9. 8. Whitworth M, Bricker L, Neilson JP, et al. Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev. 2010;4:CD007058.
- 92. CHAPTER 13 Immunization duringPregnancy Richa Baharani, Sonam Baharani, Pushpa Pandey INTRODUCTION Vaccination during pregnancy plays an important role for the health of mother and the baby. It reduces their chances of morbidity and mortality from vaccine preventable diseases. It protects newborn infant at a critically vulnerable time and before neonates can be vaccinated. After vaccinating a pregnant woman, antibodies (immunoglobulin G) cross the placenta from mother to fetus especially in the final weeks of pregnancy that protects against the disease. Additional antibodies are transferred from the mother to infant via breast milk. VACCINATION TO PREVENT TETANUS, DIPHTHERIA, AND PERTUSSIS Vaccines routinely recommended during pregnancy are to prevent tetanus, diphtheria, and pertussis (Tdap). Tetanus isanacute,oftenfataldiseasecausedbyexotoxinproduced by Clostridium tetani. Neonatal tetanus may occur in neonates who have low levels of antitetanus antibody due to lack of passively transferred maternal antibody. Diphtheria is an infectious disease caused by the bacterium corynebacterium diphtheria, which primarily infects the throat and upper airways and produces a toxin affecting other organs. Complications may include myocarditis, inflammation of nerves, kidney problems, and bleeding problems due to low levels of platelets.1 Pertussis also known as whooping cough is a highly contagious respiratory disease. It is caused by bacterium Bordetella pertussis. Initially, symptoms are those of common cold with a runny nose, fever, and mild cough. This is followed by weeks of severe coughing fits. Children less than 1 year may have little or no cough and instead have periods where they do not breathe.2 Tdap vaccination—The American College of Obstetricians and Gynecologists (ACOG) recommends giving diphtheria toxoid, tetanus toxoid, and acellular pertussis vaccine to pregnant women.3 To maximize maternal antibody response, passive antibody transfer and levels in the newborn optimal time for Tdap administration is between 27 weeks and 36 weeks of gestation although Tdap may be given at any time during pregnancy. It is safe to administer Tdap to breastfeeding women. If Tdap was not administered during pregnancy, it should be administered immediately postpartum. INFLUENZA VACCINATION Influenza is a contagious respiratory illness caused by human influenza virus. The influenza virus type A, B, and C and their various subtypes and strains cause seasonal epidemics.4 Influenza is more likely to cause severe illness in pregnant women than in women who are not pregnant. Changes in the immune system make pregnant women more prone to severe illness from influenza as well as hospitalizations and death. Influenza vaccination is the best way to prevent influenza and its consequences. It is given well before influenza viral exposure occurs, when pregnant women get influenza the risk of preterm labor and birth defects increases. Centers for Disease Control and Prevention (CDC) and ACOG recommend inactivated influenza vaccination for women who will be pregnant during the influenza season.4 Live attenuated influenza vaccine, which is available as intranasal spray is not recommended for pregnancy women but is safe for use in the postpartum period. Inactivated influenza vaccine is safe for pregnant women and their fetus and can be given during any trimester. It is recommended for mothers from 26 weeks onwards.5 VACCINES, WHICH ARE CONTRAINDICATED DURING PREGNANCY Measles, mumps, and rubella (MMR) vaccine, varicella vaccine, oral polio vaccine, and human papillomavirus (HPV) vaccine are not recommended to be given during pregnancy. Most live attenuated vaccines are contraindicated and not recommended during pregnancy. Women should
- 93. Immunization during Pregnancy69 avoid becoming pregnant until 3 months after receiving the MMR vaccine.5 Incidence of congenital rubella syndrome following inadvertent vaccination of pregnant mother has been evaluated through rubella registers in the USA and Europe.6-13 By administration of oral polio vaccine containing live attenuated polio virus type 1, 2, and 3 to pregnant women has shown possible development of viremia following immunization and cases suggestive of vaccination- associated anomalies have been reported.14,15 VACCINES, WHICH MAY BE GIVEN IN PRESENCE OF SPECIFIC RISK FACTORS Yellow fever vaccine is not recommended for pregnant women and lactating mothers unless there is an epidemic or the women is traveling to a high-risk area.16 Hepatitis A: If women have specific risk factors for hepatitis A, they may receive vaccine. It is given in 2 doses, 6–12 months apart.17 Hepatitis B: Pregnant women who are at risk for this diseaseandhavetestednegativefortheviruscanreceive this vaccine. A series of 3 doses is required to have immunity. Birth dose vaccination is a key intervention of preventionofhepatitisBvirus(HBV)infectionininfants. Universal HBV vaccination in newborn has dramatically changed the epidemiology of chronic HBV infection.18 Hepatitis C: The World Health Organization (WHO) estimates that 3–4 million people annually are infected with hepatitis C virus (HCV) and approximately 130– 170 million people with chronic disease may go on to develop cirrhosis or hepatocellular carcinoma. There is no pre-exposure prophylaxis, vaccine or postexposure prophylaxis for HCV and immunoglobulin is not effective in preventing infection. Mothers and children with chronic hepatitis C should be immunized against hepatitis A and B.18 Hepatitis D: It is caused by hepatitis delta virus. A coinfection with HBV or a super infection on chronic HBVinfectioniswaysofgettinginfected.Immunization against HBV prevents (HDV) infection.18 Hepatitis E: Waterborne epidemics of hepatitis in developing countries are mostly caused by hepatitis E virus (HEV) infection. Pregnant patients may have fulminant hepatitis. Mortality from acute infection is in range of 20% in the third trimester. The recombinant hepatitisEvaccinewasapprovedinChinainDecember 2011 although there is no global recommendation. Immunoglobulins are not effective. Women traveling to HEV endemic countries should strictly follow food and water precautions.18 Meningococcal A, meningococcal B, and pneumo coccal vaccine may be given, if certain risk factors. SIDE EFFECTS Likeallmedicines,vaccinescanhavesideeffects.However, the chance of a life-threatening reaction is small. The CDC says the dangers of developing pertussis, tetanus, or diphtheria far outweigh the risks of vaccination. Side effects of Tdap may include: Pain, redness, or swelling in the arm where the shot was given, mild fever, headache, tiredness, stomach upset, including nausea, vomiting, or diarrhea, muscle aches and pains and swollen glands. Someone may have a severe allergic reaction to an ingredient in the Tdap or Td vaccine. This generally happens in less than one in a million doses. Most of the time,suchreactionsoccurwithinafewminutesofreceiving the vaccine. The following can be signs of a severe allergic reaction, called anaphylaxis: Behavior changes Breathing difficulty, including wheezing Dizziness Hoarse voice High fever and pale skin Rapid heart beat Weakness. One should seek immediate medical care, if any of these signs after receiving the Tdap are noticed. Flu vaccines have a good safety record. Hundreds of millions of Americans have safely received flu vaccines over the past 50 years, and there has been extensive research supporting the safety of flu vaccines. CONCLUSION Vaccination during pregnancy is a cost-effective strategy to improve pregnancy outcomes in India. All live vaccines should be avoided during pregnancy. Common barriers regarding vaccination during pregnancy are lack of awareness regarding benefits and lack of concerns about vaccine safety. REFERENCES 1. Atkinson W, Hamborsky J. Diphtheria, Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th edition. Maryland: Public Health Foundation; 2012. pp. 75-85. 2. Centers for Disease Control and Prevention. Pertussis (Whooping Cough) Signs Symptoms. [online] Available from: https://www.cdc.gov/pertussis/about/signs-symptoms. html [Accessed December, 2018]. 3. Committee on Obstetric Practice. ACOG Committee Opinion No. 521: Update on immunization and pregnancy: tetanus,
- 94. FOGSI FOCUS: AdbhutMatrutva70 diphtheria, and pertussis vaccination. Obstet Gynecol. 2012;119(3):690-1. 4. Arora M, Sharma A, Chauhan M. Influenza in Pregnancy: Pal Bhasker (Ed)., Infections in Obstetrics Gynaecology. FOGSI FOCUS, 2017. 5. FOGSI GCPR. (2014). Vaccination in women, September 26, 2014. [online] Available from: https://www.fogsi.org/ wp-content/uploads/2015/11/vaccination_women.pdf [Accessed December, 2018]. 6. Bar-Oz B, Levichek Z, Moretti ME, et al. Pregnancy outcome following rubella vaccination: a prospective controlled study. Am J Med Genet A. 2004;130A(1):52-4. 7. Da Silva e Sa GR, Camacho LA, Stavola MS, et al. Pregnancy outcomes following rubella vaccination: a prospective study in the state of Rio de Janeiro, Brazil, 2001-2002. J Infect Dis. 2011;204(Suppl 2):S722-8. 8. Badilla X, Morice A, Avila-Aguero ML, et al. Fetal risk associated with rubella vaccination during pregnancy. Pediatr Infect Dis J. 2007;26(9):830-5. 9. Minussi L, Mohrdieck R, Bercini M, et al. Prospective evaluation of pregnant women vaccinated against rubella in southern Brazil. Reprod Toxicol. 2008;25(1):120-3. 10. Pardon F, Vilariño M, Barbero P, et al. Rubella vaccination of unknowingly pregnant women during 2006 mass campaign in Argentina. J Infect Dis. 2011;204(Suppl 2):S745-7. 11. Soares RC, Siqueira MM, Toscano CM, et al. Follow-up study of unknowingly pregnant women vaccinated against rubella in Brazil, 2001-2002. J Infect Dis. 2011;204(Suppl 2):S729-36. 12. Hamkar R, Jalilvand S, Abdolbaghi MH, et al. Inadvertent rubella vaccination of pregnant women: evaluation of possible transplacental infection with rubella vaccine. Vaccine. 2006;24(17):3558-63. 13. Sato HK, Sanajotta AT, Moraes JC, et al. Rubella vaccination of unknowingly pregnant women: the Sao Paulo experience, 2001. J Infect Dis. 2011;204(Suppl 2):S737-44. 14. Horstmann DM, Opton EM, Klemperer R, et al. Viremia in infants vaccinated with oral polio vaccine (Sabin). Am J Hygiene. 1964;79:47-63. 15. Burton AE, Robinson ET, Harper WF, et al. Fetal damage after accidental polio vaccination of an immune mother. J R Coll Gen Pract. 1984;34(264):390-4. 16. World Health Organization. International travel and health. Geneva: World Health Organization; 2012. 17. ACOG. (2018). ACOG committee opinion—Immunization, Infectious Disease and Public Health preparedness Expert Work Group. [online] Available from: https://www.acog.org/ Clinical-Guidance-and-Publications/Committee-Opinions/ Immunization-Infectious-Disease-and-Public-Health- Preparedness-Expert-Work-Group/Maternal-Immunization [Accessed December, 2018]. 18. Gandhi AB, Kamale VV. Hepatitis in Pregnancy: Pal Bhaska (Ed). Infections in Obstetrics Gynaecology. FOGSI FOCUS, 2017.
- 95. CHAPTER 14 The Roadto Birth Naturally Evita Fernandez INTRODUCTION There is a rapidly growing lobby of women who are screaming for the freedom to birth naturally. These voices are not restricted to any socioeconomic group or supposedly educated women. There is a strong desire in every woman to birth normally despite the deep fear she holds of the pain she needs to endure. Women’s voices need to be heard. A woman’s body is built to nurture a baby within her womb. Nature has ensured a woman is capable of birthing her baby if only she is left alone to do what comes naturally. In the last six decades, birth has been medicalized and dehumanized. With women all around the globe, being encouraged to birth in healthcare facilities, we have institutionalized birthing into a “conveyor belt” like environment. We, the obstetric fraternity have grown interventional and have begun to look at pregnancy and childbirth as a medical catastrophe waiting to happen. Our entire training prepares us for life-threatening emergencies, and somewhere in this journey, we have lost our belief in the woman’s ability to birth. We have unfortunately also lost our sense of wonder and awe at the mystery of childbirth. In the 1940s, Dr Grantly Dick-Read, an obstetrician, authored a book titled “Childbirth without Fear: The Principles and Practice of Natural Childbirth” where he claimed if a woman is prepared antenatally to cope with the pain of labor, and has a supportive companion, this woman would birth with confidence and less fear.1 These women would certainly have a higher possibility of birthing normally. Later in the 1950s, Dr Fernand Lamaze, a French obstetrician, was influenced by childbirth practices in the Soviet Union where midwives supervised breathing and relaxation techniques for women in labor. This observation led to the popular Lamaze classes for pregnant women. The objective was to teach expectant mothers various methods of coping with the discomfort/pain of labor and childbirth in order to enjoy a physiological birth. WHAT DO WE MEAN BY NATURAL BIRTH? The ability to give birth without routine medical interventions.2 Over the years, the obstetric community may not have witnessed in private hospitals, a birth without any intervention. It is indeed a rare occurrence. Due to the government’s policies, Janani Shishu Suraksha Karyakaram (JSSK) and Janani Suraksha Yojana (JSY) there is an increase in the number of institutional births in our country. Women birthing in public facilities where there is overcrowding, limited access to analgesics, and inadequate staff are more likely to experience birth without interventions. These circumstances as described, offer women no choice but to birth naturally. The Maternity Care Working Party, comprised of National Childbirth Trust (NCT), Royal College of Midwives (RCM), and Royal College of Obstetricians and Gynaecologists (RCOG), issued a consensus statement in November 2007 defining a normal birth as:3 A birth without: Induction Medication Use of instruments Episiotomy Not by cesarean section. In the year 2012, the consensus statement by American College of Nurse-Midwives (ACNM), Midwives Alliance of North America (MANA), and National Association of Certified Professional Midwives (NACPM) defined a physiological birth as follows:4 Spontaneous onset No restriction on time Eat and drink during labor Mobility assured Nonmedical pain relief Freedom of choice Pushing/birthing position Delayed cord clamping Skin-to-skin contact.
- 96. FOGSI FOCUS: AdbhutMatrutva72 When a pregnant woman is empowered with knowledge, given the right information based on evidence, offered a companion of her choice during labor and childbirth, seeks alternative nonmedical options for pain relief, births in the position she finds most comfortable, then this woman has indeed stepped into motherhood with a deep sense of accomplishment, empowerment, and confidence. Furthermore, if this woman has indulged in holding her baby close to her skin and has successfully breastfed her newborn within an hour of its birth, this woman has firmly established her bond with her baby. This woman has truly enjoyed a natural birth, but more importantly a positive birthing experience. The World Health Organization (WHO) (2018) empha sizedthatapositivechildbirthexperienceasonethatfulfills or exceeds a woman’s prior personal and sociocultural beliefs and expectations, including giving birth to a healthy baby in a clinically and psychologically safe environment with continuity of practical and emotional support from a birth companion(s) and kind, technically competent clinical staff.5 Women who have experienced a negative or traumatic birth experience will request an elective cesarean section in their subsequent birth despite having no medical indications.6 HOW CAN WE ENSURE EVERY PREGNANT WOMAN IS GIVEN THE OPTION TO BIRTH NATURALLY? To make this vision a reality, we the obstetric fraternity first need to unlearn our old practices, relearn the physiology of normal labor and birth to understand, accept with conviction and believe in a woman’s ability to birth without interventions. Unless this first step is taken, the journey cannot begin. The second vital step is to empower every pregnant woman, regardless of her socioeconomic status, literacy level, caste, creed or religion—with knowledge and honest information based on evidence. Women should be encouraged to be physically fit and eat a healthy diet. Weight gain should be restricted based on the body mass index (BMI) of the woman. Such women who are prepared antenatally with childbirth preparation classes that teach them comfort measures to use during labor are more confident and determined to birth naturally. The third important step is to ensure every woman is given the choice of a birth companion. Research has suggested that women with support in labor had shorter labors, less cesarean births and augmentation of labor increasing the chance of a normal birth.7 Further evidence has consistently demonstrated that women greatly value and benefit from the presence of someone they trust. A supportive companion will help provide emotional, psychological, and practical support and may reduce fear and stress for women who birth in unfamiliar environments.8,9 A birth companion helps provide comfort measures like a massage, ensures the woman is hydrated with adequate fluids to drink, helps the woman stay mobile, upright and more importantly becomes an advocate for the woman. Oxytocin, the love hormone, is released freely in such an environment where trust, kindness, and compassion reduce fear to a minimum. Oxytocin we know helps in the progress of labor. It is important to remember that no woman should birth alone as this is a violation of her fundamental human rights in childbirth. The fourth step is to offer professional midwifery care to every childbearing woman. A professional midwife is a unique healthcare professional who offers highly skilled, knowledgeable, and compassionate care for childbearing women, newborn infants, and families across the continuum, throughout prepregnancy, pregnancy, birth, postpartum, and the early weeks of life.10 She is especially trained to focus on normality. Women allocated to continuous support are more likely to have a spontaneous vaginal birth, less likely to use pain medications, more likely to be satisfied with their birthing experience, and have slightly shorter labors.1 Professional midwifery care is essentially woman-centered. There is no sense of urgency on the woman to birth in a time convenient for the midwife. WHO (2016) highlighted the importance of midwifery led, continuity of care during pregnancy and childbirth.11 Cochrane review (2016)12 reinforced the evidence that low-risk women must be offered midwifery led continuity ofcare.Thesewomenaremorelikelytoexperienceanatural birth, less likely to use analgesics or synthetic oxytocin. Women are happier with their birthing experience. The birth environment is also a concept to be considered to promote normal births. Normalizing the birth environment ensuring it is more woman friendly may help the in promoting normal birth.13 Sheila Stubbs has beautifully quoted “The midwife considers the miracle of childbirth as normal, and leaves it alone unless there’s trouble. The obstetrician normally sees childbirth as trouble; if she leaves it alone, it is a miracle”. The fifth step is for the obstetric community to step out of the arena of caring for low-risk pregnant women who form almost 80% of the pregnant population. These women must be cared for by professional midwives who will support them through their labor and birth.
- 97. The Road toBirth Naturally 73 We should use our time and expertise to look after high- risk complicated pregnancies. We obstetricians should open our minds, hearts, and our birthing rooms to professional midwives and accept them as professional colleagues. When we work with mutual respect and trust, only then will women feel respected and be assured of birthing naturally. The Indian government in the recent Global Partners Forum hosted in December 2018, announced a policy Guidelines on Midwifery Services in India. This is a big step forward on the road to helping mothers’ birth naturally.14 CONCLUSION It is a woman’s fundamental right to choose the circumstances under which she wishes to birth. It is her basic human right to have a companion of her choice. Professional midwives and obstetricians must begin a new working relationship built on mutual respect and trust. This calls for a serious change in attitude. It calls for us obstetricians to admit with grace and humility the urgent need to change childbirth practices in India. Only then, will women be able to walk on the road to birth naturally. Only then will women feel respected, cherished, and believe their voices are indeed being heard. As John Bowlby said “If a community values its children, it must cherish its mothers”.15 REFERENCES 1. Bohren MA, Hofmeyr GJ, Sakala C, et al. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2017;(7):CD003766. 2. Dick-Read G. Childbirth Without Fear: The Principles and Practice of Natural Childbirth. London: Heineman; 1933. Republished by Printer Martin; 2004. 3. National Childbirth Trust, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists. Making Normal BirthaReality:ConsensusStatementfromtheMaternityCare Working Party; our shared views about the need to recognise, facilitate and audit normal birth. London: NCT; 2007. 4. Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, AND NACPM. J Perinat Educ. 2013;22(1):14-8. 5. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018. 6. Waldenstrom U, Hildingsson I, Ryding EL. Antenatal fear of childbirth and its association with subsequent cesarean section and experience of childbirth. BJOG. 2006;113:638-46. 7. Klaus M, Kennell J, Robertson S, et al. Effects of social support during parturition on maternal and infant morbidity. Br Med J. 1986;293:585-7. 8. Hodnett ED, Gates S, Hoffmeyer GJ, et al. Continuous support for women during childbirth; a systematic review. Am J Obstet Gynaecol. 2013;186(5):S160-72. 9. Mander R. Supportive Care and Midwifery. London: Blackwell Science; 2002. 10. Renfrew MJ, Homer C, Soo D, et al. Midwifery: An Executive Summary for the Lancet’s Series. The Lancet; 2014. 11. WHO. (2016). Standards for improving quality of maternal and newborn care in health facilities. [online] Available from https://www.who.int/maternal_child_adolescent/docu ments/improving-maternal-newborn-care-quality/en/ [Accessed December 2018]. 12. Sandall J, Soltani H, Gates S, et al. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev. 2016;(4):CD004667. 13. Brodie P, Leap N. From ideal to real: the interface between birth territory and the maternity service organisation. In: Fahy K, Froureur M, Hastie C (Eds). British Territory and Midwifery Guardianship. Edinburgh: Butterworth Heinemann/Elsevier; 2008. 14. Ministry of Health and Family Welfare, Government of India. Guidelines on Midwifery Services In India; 2018. 15. Bowlby J, World Health Organization (1952). Maternal care and mental health: a report prepared on behalf of the World Health Organization as a contribution to the United Nations programme for the welfare of homeless children/John Bowlby, 2nd edition. [online] Available from http://www. who.int/iris/handle/10665/40724 [Accessed December 2018].
- 98. CHAPTER 15 How toReduce Cesarean Section Rate? Shakuntla Kumar, Somnath Bhattacharya, Keerti Parashar INTRODUCTION One of the most commonly performed surgeries in obstetrics—cesarean section has revolutionized maternity care and saved lives of millions of women and babies. However, over the last few decade, cesarean rates have increased owing in part to the widespread perception that the procedure is of little or no risk to healthy women. In 2011, one in three women who gave birth in the United States did so by cesarean delivery.1 Although cesarean delivery can be life saving for the mother, the fetus or for both in some cases, the rapid rise in rate of cesarean births without concomitant decline in maternal or neonatal morbidity or mortality raised doubts on overuse of cesarean delivery.2 In parts of rural India, the cesarean rates are as low as 2–3% accounting for high maternal and perinatal mortality. Whereas in urban India, even in public sector hospitals of Delhi, the cesarean section rates are as high as 19–35% and in private sector the rate is still higher accounting for 40–70% of the deliveries. Accord ing to World Health Organization (WHO), an increase in cesarean section rates above 10–15% does not improve maternal or neonatal outcomes. Therefore, healthcare providers should understand that cesareans must be performed only when medically indicated and should not be a surgical tool of convenience for the doctor or the patient. RISKS OF CESAREAN SECTION A large population-based study from Canada found that there was a threefold increase in risk of severe maternal morbidities—like hemorrhage, uterine rupture, anesthetic complications, venous thromboembolism, and major infection for cesarean delivery as compared with vaginal delivery (2.7% versus 0.9%, respectively). There are also long-term risks associated with cesarean delivery, parti cularly those associated with subsequent pregnancies. The incidence of placental abnormalities, such as placenta previa and morbidly adherent placenta previa in future pregnancies increases with each subsequent cesarean delivery, from 1% with one prior cesarean delivery to almost 3% with three or more prior cesarean deliveries. These complications increase maternal morbidity but also increase the risk of adverse neonatal outcomes.3-6 Maternal factors, such as age, weight, and ethnicity, do not fully account for the increase in the cesarean delivery rate.7,8 Certain potentially modifiable factors have led to escalation in cesarean delivery rates such as patient preferences, practice variation among hospitals, systems, and healthcare providers. The variation in the rates of nulliparous term singleton vertex (primary) cesarean births indicates the clinical practice patterns in hospitals. For instance in private sector hospitals in India, the percentage is as high as 40–70% as compared to public sector 19–35%. Indications of Primary Cesarean Deliveries (FIG. 15.1) Labor arrest (34%) Nonreassuring fetal heart rate (23%) Malpresentation (17%) Multiple gestation (7%) Macrosomia (4%) Maternal request (3%) Preeclampsia (3%) Maternal fetal (5%) Other obstetric indications (4%). Fig. 15.1: Indications for primary cesarean delivery.
- 99. How to ReduceCesarean Section Rate? 75 Nonprogress of labor and fetal distress (abnormal or indeterminate fetal heart rate tracings) are two major indications leading to more than 50% of all primary cesarean deliveries. Therefore, safe reduction of the rate of primary cesarean deliveries will require different appro aches for each of these indications. What is driving this upward trend? Rising maternal obesity, age, and chronic disease More multiple births Higher birth weight babies Perception of safety Pressure on physicians to practice “defensive medicine” (Sprague, 2014; Joseph et al 2003; Zhang 2010) (Tables 15.1 to 15.3). Factors Responsible for Rising Primary Cesarean Rates in India The concept of solo (consultant centric) practice especially in private hospitals. Lack of assigned labor room team (nurses, doula, etc.). Continuous rotation of staff. Lack of fixed clinical protocols or labor manuals. Not much emphasis paid on patient education (importance of exercises in pregnancy, timely check- ups, identifying warning signs, antenatal workshops, etc.). Poor doctor or nurse to patient ratio. Overburdened health providers especially in public sector. Inefficient cardiotocography (CTG) training. Lack of audits. Lack of continuous time-to-time training and upgrad ing knowledge of doctors and paramedics especially in private sector. How to reduce second-stage cesarean section rates? The second stage of labor begins with full dilatation of cervix and ends with delivery of the neonate. Parity, delayed pushing, use of epidural analgesia, maternal body mass index, birth weight, occipital posterior position, and fetal station at complete dilation all are shown to affect the length of the second stage of labor.9 In the era of electronic fetal monitoring, adverse neonatal outcomes generally have not been associated with the duration of the second stage of labor. In a multi center randomized study of fetal pulse oximetry of 4,126 nulliparous women who had a longer duration of active labor, pushing was not associated with adverse neonatal outcomes, even in women who pushed for more than 3 hours.10 However, a longer second stage of labor more than 3 hours is associated with adverse maternal outcomes, such as higher rates of puerperal infection, third and fourth-degree perineal lacerations, and postpartum hemorrhage. Moreover, for each hour of the second stage, the chance for spontaneous vaginal delivery decreases progressively. However, the consequences of prolonged second stage duration appear to be low with appropriate moni toring. Here comes the role of operative vaginal delivery (via either vacuum or forceps), which has decreased significantly during the past 15 years.11 In addition to greater expectant management of the second stage, two other practices could potentially reduce Table 15.1: Risk of adverse maternal and neonatal outcomes by mode of delivery. Outcome Risk Maternal Vaginal delivery Cesarean delivery Overall severe morbidity 8.6% 9.2% and mortality 0.9% 2.7% Maternal mortality 3.6:100,000 13.3:100,000 Amniotic fluid embolism 3.3–7.7:100,000 15.8:100,000 Third-degree or fourth-degree perineal laceration 1.0–3.0% NA Placental abnormalities Increases with each subsequent Cesarean delivery Urinary incontinence No difference at 2 years of delivery Postpartum depression No difference Respiratory morbidity 1.0% 1.0–4.0% (without labor) (Source: Caughey AB, Cahill AG, Guise JM, et al. ACOG, Society for Maternal-Fetal Medicine. Safe prevention of primary cesarean delivery. Am J Obstetric Gynecol. 2014;210(3):179-93).
- 100. FOGSI FOCUS: AdbhutMatrutva76 Table 15.2: Change in approach—in order to reduce the primary cesarean section rates. Organizational changes: Care providers Clinical interventions: Expecting mothers Following standard clinical practice Eliminate elective deliveries/inductions 39 weeks for low risk pregnancies Antenatal education (workshops and handouts) New clinical leadership No nonmedically indicated cesarean or inductions Partner support and education throughout pregnancy and labor delivery Quality department—conducting Audits time-to-time Setting protocols and labor room manuals Counseling Close collaboration with IHI's perinatal community Standardized definition-failed induction and arrest of labor Physiotherapy and exercise Adopting the Robsons classification in data analysis Effective trial in second stage of labor Labor support 1:1 CTG training of staff (doctors/nurses) Admitting low risk pregnancies in labor at dilatation 3 cm Quiet solo practice, adopting group practice by consultants in private sectors (CTG: cardiotocography; IHI: Institute for Healthcare Improvement) Table 15.3: ACOG recommendations for safe prevention of primary cesarean delivery. Recommendations Grade of recommendations First stage of labor A prolonged latent phase (20-hour in nulliparous women and 14-hour in multiparous women) should not be an indication for cesarean delivery 1B Strong recommendation and moderate quality evidence Slow but progressive labor in the first stage of labor should not be an indication for cesarean delivery 1B Strong recommendation and moderate quality evidence Cervical dilation of 6 cm should be considered the threshold for the active phase of most women in labor 1B Strong recommendation, and moderate quality evidence Cesarean delivery for active phase arrest in the first stage of labor should be ≥6 cm of dilation with ruptured membranes who fail to progress despite 4-hour of adequate uterine activity, or at least 6-hour of oxytocin administration with inadequate uterine activity and no cervical change 1B Strong recommendation and moderate quality evidence Second stage of labor A specific absolute maximum length of time spent in the second stage of labor beyond, which all women should undergo operative delivery has not been identified 1C Strong recommendation and low quality evidence Before diagnosing arrest of labor in the second stage, if the maternal and fetal conditions permit, allow for the following: ŠŠ At least 2-hour of pushing in multiparous women and 3-hour of pushing in nulliparous ŠŠ Women (1B). Additional 1-hour in case epidural analgesia is used 1B Strong recommendation and moderate quality evidence Operative vaginal delivery in the second stage of labor by experienced and well-trained physicians should be considered 1B Strong recommendation and moderate quality evidence Contd...
- 101. How to ReduceCesarean Section Rate? 77 Recommendations Grade of recommendations Manual rotation of the fetal occiput in the setting of fetal malposition in the second stage of labor is a reasonable intervention to consider before moving to operative vaginal delivery or cesarean delivery 1B Strong recommendation and moderate quality evidence Fetal heart rate monitoring Amnioinfusion for repetitive variable fetal heart rate decelerations may safely reduce the rate of cesarean delivery 1A Strong recommendation and high quality evidence Scalp stimulation can be used as a means of assessing fetal acid-base status when abnormal or indeterminate fetal heart patterns are present and is a safe alternative to cesarean delivery 1C Strong recommendation and low quality evidence Induction of labor Before 41 0/7 weeks of gestation, induction of labor generally should be performed based on maternal and fetal medical indications 1A Strong recommendation and high quality evidence Cervical ripening methods should be used when labor is induced in women with an unfavorable cervix 1B Strong recommendation and moderate quality evidence If the maternal and fetal status allow, cesarean deliveries for failed induction of labor in the latent phase can be avoided by allowing longer durations of the latent phase (up to 24-hour or longer) and requiring that oxytocin be administered for at least 12–18 hours after membrane rupture before deeming the induction a failure 1B Strong recommendation and moderate quality evidence Fetal malpresentation Fetal presentation should be assessed and documented beginning at 36 0/7 weeks of gestation to allow for external cephalic version to be offered 1C Strong recommendation and low quality evidence Suspected fetal macrosomia Cesarean delivery to avoid potential birth trauma should be limited to estimated fetal weights of at least 5,000 g in women without diabetes and at least 4,500 g in women with diabetes, particularly late in gestation, are imprecise. In Indian scenario cut off is 4,500 g in women without diabetes and 4,000 g in women with diabetes 2C Weak recommendation and low quality evidence Excessive maternal weight gain Women should be counseled about the maternal weight guidelines in an attempt to avoid excessive weight gain 1B Strong recommendation and moderate quality evidence Twin gestations Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation is not improved by cesarean delivery. Thus, women with either cephalic or cephalic-presenting twins or cephalic or noncephalic presenting twins should be counseled to attempt vaginal delivery 1B Strong recommendation and moderate quality evidence Other Individuals, organizations, and governing bodies should work to ensure that research is conducted to provide a better knowledge base to guide decisions regarding cesarean delivery and to encourage policy changes that safely lower the rate of primary cesarean delivery 1C Strong recommendation and low quality evidence Contd...
- 102. FOGSI FOCUS: AdbhutMatrutva78 cesarean deliveries in the second stage—(1) operative vaginal delivery and (2) manual rotation of the fetal occi put for malposition. OPERATIVE VAGINAL DELIVERY In a large, retrospective cohort study, the rate of intra cranial hemorrhage associated with vacuum extraction did not differ significantly from that associated with either forceps delivery [odds ratio (OR), 1.2; 95% confidence interval (CI), 0.7e2.2] or cesarean delivery (OR, 0.9; 95% CI, 0.6e1.4).12 In a more recent study, forceps-assisted vaginal deliveries were associated with a reduced risk of the combined outcome of seizure, intraventricular hemorrhage, or subdural hemorrhage as compared with either vacuum-assisted vaginal delivery (OR, 0.60; 95% CI, 0.40e0.90) or cesarean delivery (OR, 0.68; 95% CI, 0.48e0.97), with no significant difference between vacuum delivery or cesarean delivery.13 Fewer than 3% of women in whom an operative vaginal delivery has been attempted go on to deliver by cesarean.14 Performing low or outlet procedures in fetuses that are not believed to be macrosomic is likely to safely reduce the risk of cesarean delivery in the second stage of labor. However, the number of healthcare providers, who are adequately trained to perform forceps and vacuum deliveries, is decreasing. In one survey, most (55%) resident physicians in training did not feel competent to perform a forceps delivery upon completion of residency.15 Thus, training resident physicians in the performance of operative vaginal deliveries and using simulation for retraining and ongoing maintenance of practice would likely contribute to a safe lowering of the cesarean delivery rate.16 Hence, operative vaginal delivery in the second stage of labor by experienced and well-trained physicians should be considered a safe, acceptable alternative to cesarean delivery. Training in, and ongoing maintenance of, practical skills related to operative vaginal delivery should be encouraged. MANUAL ROTATION OF THE FETAL OCCIPUT Occiput posterior and occiput transverse positions are associated with an increase in cesarean delivery and neonatal complications. Historically, forceps rotation of the fetal occiput from occiput posterior or occiput trans verse was common practice. Today this procedure, although still considered a reasonable management approach, has fallen out of favor. An alternative approach is manual rotation of the fetal occiput, which has been associated with a safe reduction in the risk of cesarean delivery.17,18 To consider an intervention for a fetal malposition, the proper assessment of fetal position must be made. To safely prevent cesarean deliveries in the setting of malposition, it is important to assess the fetal position in the second stage of labor, particularly in the setting of abnormal fetal descent. NONOPERATIVE INTERVENTION IN FETAL DISTRESS Given the known variation in interpretation and manage ment of fetal heart rate tracings, a standardized approach is a logical potential goal for interventions to safely reduce the cesarean delivery rate. Category I—fetal heart tracings are normal and do not require intervention unlike the category 3 CTG tracings which are abnormal, demanding immediate intervention. Category II—most intrapartum fetal heart rate tracings are category II, which is where the dilemma arises. Most cesarean deliveries done for nonreassur ing fetal heart rates belong to this category. These are indeterminate, require evaluation, continued surveillance, and initiation of appropriate corrective measures.19 Scalp stimulation can be done when the cervix is dilated to assure that the fetus is not acidotic. Conserva tive measures—position change and amnioinfusion with normal saline also have been demonstrated to resolve variable fetal heart rate decelerations20,21 and reduce the incidence of cesarean delivery. FETAL MALPRESENTATION Breech presentation at more than 37 weeks of gestation is estimated to complicate 3.8% of pregnancies, and more than 85% of pregnant women with a persistent breech presentation are delivered by cesarean.22 In one recent study, the rate of attempted external cephalic version was 46% and decreased during the study period.23 Thus, external cephalic version for fetal malpresentation is likely underutilized, especially when considering that most patients with a successful external cephalic version will give birth vaginally.23 Fetal presentation should be assessed and documented beginning at 36 0/7 weeks of gestation to allow for external cephalic version to be offered. Before a vaginal breech delivery is planned, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned, and the patient’s informed consent should be documented.
- 103. How to ReduceCesarean Section Rate? 79 SUSPECTED FETAL MACROSOMIA Suspected fetal macrosomia is not an indication for delivery and rarely is an indication for cesarean delivery. To avoid potential birth trauma, American College of Obstetricians and Gynecologists (ACOG) recommends that cesarean delivery be limited to estimated fetal weights of at least 5,000 g in women without diabetes and at least 4,500 g in women with diabetes.24 This recommendation is based on estimations of the number needed to treat from a study that modeled the potential risks and benefits from a scheduled, nonmedically indicated cesarean deli very for suspected fetal macrosomia, including shoulder dystocia, and permanent brachial plexus injuries.25 Screening ultrasonography performed late in pregnancy has been associated with the unintended consequence of increased cesarean delivery with no evidence of neonatal benefit.26 Thus, ultrasonography for estimated fetal weight in the third trimester should be used sparingly and with clear indications. TWIN GESTATION The rate of cesarean deliveries among women with twin gestations increased from 53% in 1995 to 75% in 2008.27 Even among vertex-presenting twins, there was an increase from 45%–68%.27 Perinatal outcomes for twin gestations in which the first twin is in cephalic presenta tion are not improved by cesarean delivery. Thus, women with either cephalic or cephalic-presenting twins or cephalic or noncephalic-presenting twins should be counseled to attempt vaginal delivery.28 To ensure safe vaginal delivery of twins, it is important to train residents to perform twin deliveries and to maintain experience with twin vaginal deliveries among practicing obstetric care providers. KEY TO SUCCESS—CONTINUOUS LABOR AND DELIVERY SUPPORT A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery. Modal for education of patients and families should be developed. Education should begin from the early antenatal period, in the form of handouts explaining benefits of healthy eating habits and exercise. Conducting workshops for preparation for normal labor and normal delivery is helpful. Families especially husbands were encouraged to participate in care and in promoting concept of normal delivery. Team-based clinical care to be promoted for a stress free work environment. Our journey of reducing interventions in maternity care is a complex ongoing challenge. The culture change in the department with emphasis on the physiological basis of pregnancy and childbirth is the guiding principles, which will make us walk on the road of success. REFERENCES 1. Hamilton BE, Hoyert DL, Martin JA, et al. Annual summary of vital statistics: 2010-2011. Pediatrics. 2013;131:548-58. 2. Gregory KD, Jackson S, Korst L, et al. Cesarean versus vaginal delivery: whose risks? Whose benefits? Am J Perinatol. 2012;29:7-18. 3. Liu S, Liston RM, Joseph KS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Maternal Health Study Group of the Canadian Perinatal Surveillance System. CMAJ. 2007;176:455-60. 4. Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am J Obstet Gynecol. 2011;205:262. 5. Smith GC, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet. 2003;362:1779-84. 6. Solheim KN, Esakoff TF, Little SE, et al. The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med. 2011;24:1341-6. 7. Declercq E, Menacker F, MacDorman M. Rise in “no indi cated risk” primary caesareans in the United States, 1991- 2001: cross-sectional analysis. BMJ. 2005;330:71-2. 8. Rouse DJ, Weiner SJ, Bloom SL, et al. Second-stage labor duration in nulliparous women: relationship to maternal and perinatal outcomes. Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Am J Obstet Gynecol. 2009;201:357. 9. Piper JM, Bolling DR, Newton ER. The second stage of labor: factors influencing duration. Am J Obstet Gynecol. 1991;165:976-9. 10. Cheng YW, Shaffer BL, Bianco K, et al. Timing of operative vaginal delivery and associated perinatal outcomes in nulli parous women. J Matern Fetal Neonatal Med. 2011;24:692-7. 11. Srinivas SK, Epstein AJ, Nicholson S, et al. Improvements in US maternal obstetrical outcomes from 1992 to 2006. Med Care. 2010;48:487-93. 12. Towner D, Castro MA, Eby-Wilkens E, et al. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med. 1999;341:1709-14. 13. Werner EF, Janevic TM, Illuzzi J, et al. Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol. 2011;118:1239-46. 14. O’Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev. 2010;11:CD005455.
- 104. FOGSI FOCUS: AdbhutMatrutva80 15. Powell J, Gilo N, Foote M, et al. Vacuum and forceps training in residency: experience and self-reported competency. J Perinatol. 2007;27:343-6. 16. Shaffer BL, Caughey AB. Forceps delivery: potential benefits and a call for continued training. J Perinatol. 2007;27: 327-8. 17. Shaffer BL, Cheng YW, Vargas JE, et al. Manual rotation to reduce cesarean delivery in persistent occiput posterior or transverse position. J Matern Fetal Neonatal Med. 2011;24:65-72. 18. Cargill YM, MacKinnon CJ, Arsenault MY, et al. Guidelines for operative vaginal birth: clinical practice obstetrics committee. J Obstet Gynaecol Can. 2004;26:747-61. 19. American College of Obstetricians and Gynecologists. Management of intrapartum fetal heart rate tracings: practice bulletin no. 116. Obstet Gynecol. 2010;116:1232-40. 20. Miyazaki FS, Nevarez F. Saline amnioinfusion for relief of repetitive variable decelerations: a prospective randomized study. Am J Obstet Gynecol. 1985;153:301-6. 21. Strong TH Jr, Hetzler G, Sarno AP, et al. Prophylactic intrapartum amnioinfusion: a randomized clinical trial. Am J Obstet Gynecol. 1990;162:1370-5. 22. LeeHC,El-SayedYY,GouldJB.Populationtrendsincesarean delivery for breech presentation in the United States, 1997- 2003. Am J Obstet Gynecol. 2008;199:59. 23. Clock C, Kurtzman J, White J, et al. Cesarean risk after successfulexternalcephalicversion:amatched,retrospective analysis. J Perinatol. 2009;29:96-100. 24. American College of Obstetricians and Gynecologists. Fetal macrosomia: ACOG practice bulletin no. 22. Washington, DC: ACOG; 2000. 25. Rouse DJ, Owen J, Goldenberg RL, et al. The effectiveness and costs of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound. JAMA. 1996;276:1480-6. 26. Little SE, Edlow AG, Thomas AM, et al. Estimated fetal weight by ultrasound: a modifiable risk factor for cesarean delivery? Am J Obstet Gynecol. 2012;207:309. 27. Lee HC, Gould JB, Boscardin WJ, et al. Trends in cesarean delivery for twin births in the United States: 1995-2008. Obstet Gynecol. 2011;118:1095-101. 28. Barrett JF, Hannah ME, Hutton EK, et al. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy: twin birth study collaborative group. N Engl J Med. 2013; 369:1295-305.
- 105. CHAPTER 16 Designer Baby BKEV Swaminathan, BK Shubhada Neel, Gayatri Singh A BEAUTIFUL AND UNIQUE JOURNEY OF MOTHERHOOD A student of engineering spends approximately four years and thereafter works with machines, a student of law studies for five years and later on dabbles with law, similarly a MBA student spends another two years after graduation so as to deal with various resources, a MBBS graduate studies for so many years to master dealing with human anatomy. Just think, an expectant mother has a span of only nine months to create a life which ought to be physically, mentally, socially, and spiritually developed and moreover she has no structured guidance whatsoever. This project is an effort in this holistic direction to formulate a syllabus which the expectant mother can bank upon for guidance and empowerment. DESIGNER CONCEPT If you ask any mother what dream you have for your child, then the answer would be they want the child to be healthy, wealthy, happy, successful, and bestowed with all divine values and qualities. But they are not aware of the process or flowchart. Just as we design any product, there are some design parameters and they are as follows: Quality Procedure Process. Let’s analyze these parameters: Quality Quality of life depends on the quality of TEAM which means TEAM: T—Thoughts E—Emotions A—Attitude M—Memories. If the internal team of the baby is positive then the child born would be bestowed with all positive qualities. These shape the personality and thereby the destiny of the child. It is referred as sanskars in Hindi language. Positive sanskars are inculcating the good qualities and doing away with bad qualities or in other words, adding the good and subtracting the bad. Self-transformation process can be initiated at different functional levels of the soul of mind, intellect and karma. Procedure—Formation of Sanskars There is a flowchart as to how sanskars are formed (Flowchart 16.1). Process To inculcate new and positive sanskars the mother has to communicate with the baby inside the womb and therefore she should understand the language of the mind which is as follows: Music Color Images. Music A baby in the mother’s womb is influenced by the heart beat of the mother. It respond to the soothing music at later stages in life, perhaps associating it with the safe, relaxing, protective environment provided by the mother. Music restores, maintains and improves emotional, physiological and psychological well-being. The arti culation, pitch, tone and specific arrangement of swars (notes) in a particular raga stimulates, alleviates and
- 106. FOGSI FOCUS: AdbhutMatrutva82 cures various ailments inducing electromagnetic changes in the body. Therefore, the mother is motivated to listen to sooth ing music and different meditation songs which influence the child very positively. We all are blessed with the gift of Indian classical music which is very melodious. Mostly sitar, santoor, and flute constitute the rhythm of classical music, and it said that babies love that rhythm; music touches the soul. It calms you from inside, the rhythmic music makes the baby move rhythmically. As researches have proved that the baby can hear the surrounding music also, the mantras, the recitation of mantras whichever language you feel comfortable are to be chanted daily, e.g. omkar mantra, namaskar mantra, gayatri mantra, any mantra you can chant in your own voice. It is said that if youarerecitingwithyourhusband,theyaremoreeffective. Doing meditation with music will nourish and soothe the baby’s soul. The jazz and fast music is known to increase hyperactivity of the fetus, so quiet and classical music is helpful for your baby. Color Color is a form of vibrational energy and each color of the spectrum is associated with a range of wavelength. In Divine Garbh Sanskar, we give the expectant mothers to color various drawings to invoke the necessary emotions, which in turn, will nourish, heal and empower the baby. Red: Symbolizes power Orange: Symbolizes purity Yellow: Symbolizes happiness Green: Symbolizes love Blue: Symbolizes peace Indigo: Symbolizes knowledge Violet: Symbolizes bliss. In Divine Garbh Sanskar, the education is imparted through painting and the mother is inspired to draw different painting through colors thereby making the child very healthy as each quality effects the functioning of a particular system. While drawing and using the colors, every thought that is created by the mother influences the baby. So the mother should experience the value and the color simultaneously. Power strengthens our muscular system Purity for circulatory system Flowchart 16.1: Formation of sanskars.
- 107. Designer Baby 83 Happinessfor digestive system Love for cardiovascular system Peace for respiratory system Knowledge for neuro system Bliss for endocrine system. Seven colors and their values: 1. Red color—Power: As I fill this picture with red color, my mind and heart towards the ultimate artist who is the creator of this world, the “Almighty Authority”, my father. And so all his values are mine as well. Originally, I too possess all of his values. Through visualization, let’s imagine: vibrations of extremely powerful rays from the Almighty is entering my entire body and reaching the baby in my womb through me, making the soul in the baby’s body strong and powerful. The “muscular system” of my body and the baby is getting stronger. 2. Orange color—Purity: Orange is the symbol of purity. Purity means cleanli ness of mind, heart and soul. As I fill this color I feel like all the impurity in my mind and heart are going away. “I am a divine and pure soul”. Originally “I am a pure soul”. My heart is filled with love, respect, kind ness and equality for all the people. I feel a sense of respect towards the soul in the body of my baby. My roleasamotherwiththisbabyisgoingtobewonderful, which I begin from now. This feeling is sending out pure vibrations to the baby making its circulatory system healthy and keeping it well in control. 3. Yellow color—Happiness: As I fill in yellow color, it is creating some happy thoughts in my mind. I always searched for happiness as I feel comfortable when I’m happy. Happiness is my original quality. “I am a happy soul”. I now look at the soul which is in the costume of a baby in my womb. We both share a lovely relationship. This divine soul for whom we all are waiting so eagerly is going to fill our lives with happiness. He himself is “a peaceful and happy soul” and this thought is spreading the vibrations of happiness. This is making the digestive system of the baby healthy and keeping it in good shape. 4. Green color—Love: Green color is directing my mind towards mother nature. There are so many colors in our surrounding. As I think of the different trees, plants and greenery, it makes my mind light. There is so much harmony in our mother nature. This body of mine which is made up of 5 elements of nature is a gift of Mother Nature to me. “I the soul” in this body have played a wonderful relationship with Mother Nature in the world drama. Slowly, my mind is going towards the Almighty who is the creator of the world. He is the ocean of love. I am his child. And so I possess all of his qualities. I feel a sense of respect and love for everyone. This divine Thought is creating a pathway to good qualities for the baby. It is filling the baby’s heart with love. The “Heart and cardiovascular system” of the baby is becoming healthy and keeping it well in control.
- 108. FOGSI FOCUS: AdbhutMatrutva84 5. Blue color—Peace: As I fill in blue color, my mind goes towards the blue sky. As the sky is a shelter to us, similarly the baby experiences absolute silence and peace in his mother’s shelter. The vibrations of peace are spreading through my entire body. The baby is also under this shelter of peace. These vibrations of peace are making the baby’s respiratory system healthy and in control. 6. Indigo—Knowledge: Indigo is the symbol of knowledge. Knowledge is also known as wisdom. The Almighty Authority is the only one who can give the entire world true knowledge. He is the ocean of knowledge. Now I concentrate my mind on that Almighty Authority who is my Father. His values are my values as well. Thought for visualization: I take my mind away from all the boundaries of limitations and concentrate on the Almighty. We all are his children. My heart is filled with unconditional and pure love for everyone. We are all one big family. My mind and thoughts are broadening and becoming pure with every single thought. These pure thoughts are helping in the proper functioning of my neuro system. I am experiencing a feeling of divinity in me and these pure vibrations are making the baby’s neuro system healthy and keeping it well in control. 7. Violet color—Bliss: As I fill in this color, I feel as if the most beautiful moments of my life are about to begin where there is a lot of happiness. “I am a blissful and a blessed soul”. All the worries of my life have vanished. My life is filled with color of bliss. My mind and heart is flowing towards the ocean of bliss. Who is the bestower of bliss, who takes away all our worries merciful and forgiver; who is remembered by different people by different names. He is the supreme soul the Almighty God Father. We both look the same. He is a point of light and I am a point of light. Originally, our values are also the same but he is the ocean of all good values. He is my father-mother, friend, companion, brother, sister, teacher, role model. As I create these thoughts, my heart is filled with lots of love for the Almighty. These pure vibrations are spreading in my entire body and going to the baby in my womb. That soul is also becoming aware of his original values. His endocrine system is becoming healthy and keeping it well in control.Ourbodyismadeupoffiveelements:water,air, fire, earth, and sky. We also consume a lot of vitamins and minerals to stay healthy. Now the question is what am “I”? What am I made up of? The answer is I am a tiny point of light “soul”. And I possess 7 qualities, i.e. power, happiness, purity, love, peace, knowledge and bliss. To replenish I “the soul”, we need to consume or feel all the above qualities from the ocean of all virtues, i.e. God and that can be possible through pure, positive and powerful thoughts through Raj Yoga Meditation. Images We have seen earlier that our beautiful thought is the seed that we implant for our better and beautiful future. In the same way, we often think as to how our baby will be. What qualities and values should he possess, or the way he’ll walk, the way he will talk, how will he behave with others, how beautiful our child will be, how good our child will be in studies, his thinking process, and his overall per sonality. Or how does his or her mother wish to see her child in future; these things depend on our strong thought process that we make towards our child today. From now
- 109. Designer Baby 85 onwards,the thought process that we create and implant in our babies mind, the baby will imbibe all those values and qualities in him. This actually means that we can create a beautiful dream for our baby which will culmi nate into reality when our baby comes into this world. And not only this, but the baby use these values to create a beautiful world of his or her own imagination. These images and thoughts will get imprinted on the subconscious mind of the mother, which willed finitely create a bright and a beautiful future of the baby. The mind understands the language of the images. It is rightly said that imagination is more powerful than knowledge. Whatever the mother visualizes she creates that kind of emotions and feelings which in turn programs the psyche of the baby. Designer baby chart is a tool in which the mother prepares the chart with the feeling of wanting a baby similar to the personality. In the process of preparing the designer baby chart, she is able to think and feel the value or the quality of the personality. Whatever the mother feels, the baby is automatically programmed with that quality or virtue. Given below is a designer baby chart for all the expecting mothers. It is a sample chart provided through Divine Garbh Sanskar. Mothers can also make their own charts. CONCLUSION So to design a baby with all positive qualities, the expec tant mother should adopt a healthy lifestyle wherein the meditation should play a significant role. The mother should experience soul consciousness and empower herself and the baby with all positive energies.
- 110. CHAPTER 17 Role ofObstetrician in Creating Divine World Keerti Parashar, Sangita Rani, BK EV Swaminathan, BK Shubhada Neel, Veena Sinha “Change is the only constant” INTRODUCTION Divineworldaworldofpeace,harmonyandthushappiness remembered by us as the heaven. Thereisaworldofpeace,harmony,andthushappiness, remembered by us as the heaven. This is actually the golden age (new world) when everything of this world was “new” or just made. This is when world cycle starts all souls are “Satopradhan” (pure and perfect). The world of happiness is such a perfect world where is no trace of sorrow, where everyday is a festival, nature is perfect and peace giving, we human souls are pure, loving, blissful, and powerful fully filled with all divine virtues. It is possible to create such a divine world? Definitely yes! It is the call of time. We need a multipronged approach to deal with the ongoing crisis. Strengthening the primary healthcare framework along with technological aid just deals with targeting the symptoms of the problem. In order to address the cause of it and eliminate if from its roots we need to focus on capacity building measures of the individuals. One way to go for it is to learn from our historical heritage and energize the individuals with spiritual energy so that the external negative influences cannot penetrate within. The advantage with this approach is that the individual does not need a complex technical knowledge and training for it and it would be easier for him to relate to and have faith in this strategy. The best starting point of this exercise would be the birth stage. It is important to impart spiritual energy to child as well as mother so that she can overtime herself inculcate such values within her and her children as they grow up and the most eligible agent to bring this change is an obstetrician taking care of the prenatal and postpartum period. ACTION PLAN FOR OBSTETRICIAN Divine garbhsanskar There are three prongs action plan for obstetrician in antenatal clinic and labor room, which are discussed below: Raise your Vibration “Modern science has concluded that everything that exists in the universe is made of vibration.” —Hiroshi Doi Senei Raising one’s vibration is an effective way to live a more balanced and happy life, and also a way to send positive energy out into the universe. While emitting a lower vibration or frequency, one will never really come into harmony and balance and experience a more peaceful and happylife.Itisthelifeofdiscord/dissonancethatfacilitates lower vibration energy, and can be sensed manifesting in the world today. In 2008, Emoto published his findings in the Journal of Scientific Exploration, a peer reviewed scientific journal of the Society for Scientific Exploration.1 Emoto said that water was a “blueprint for our reality” and that emotional “energies” and “vibrations” could change the physical structure of water.2 Emoto’s water crystal experiments consisted of exposing water in glasses to different words, pictures, of music, and then freezing
- 111. Role of Obstetricianin Creating Divine World 87 and examining the aesthetic properties of the resulting crystals with microscopic photography. Emoto made the claim that water exposed to positive speech and thoughts would result in visually “pleasing” crystals being formed when that water was frozen and that negative intention would yield “ugly” frozen crystal formation.3 It can be concluded how important it is to raise our vibration as fetus live in amniotic fluid which is 98% water and we come in direct contact of the pregnant women with the womb. What is “Vibration”? As described by Cassandra Sturdy,4 “Your vibration is a fancy way of describing your overall state of being. Everything is the universe is made-up of energy vibrating at different frequencies. Even things that look solid are made up of vibrational energy fields at the quantum level. This includes you”. From a scientific and metaphysical perspective, Sturdy further explains that we are a “being” that is made-up of different energy levels: physical, mental, emotional, and spiritual. Each of these levels has a vibrational frequency, which combine to create your overall vibration of being. As you can see, positivity, love, compassion, and hope are of higher vibrations than negativity, fear, and hate. Looking at the cymatics experiments and the Dr Emoto’s water crystals, it is easy to understand why you would want to raise your vibration. There are many ways to raise your vibration. You could try any number of meditations, exercises, spiritual practices, and energy healing. In the end, it is the focusonloveandcompassionthatwillraiseyourvibration. Some routes just get you there faster and easier. Everyone is different, so try a few different methods and see how you feel. You will know your vibration is raising because you will feel more confident, calm, joyful, and kind. Raj Yoga Meditation Gupta5 defines Brahma Kumaris’ Rajyoga meditation is a science and art of harmonizing spiritual energy (energy of soul), mental energy (energy of mind), and physical energy (energy of physical body), through the connection with ultimate source of spiritual energy, i.e. supreme soul, for enjoying ever healthy, ever-wealthy, and ever-happy life. Establishing Divine Doctor-Patient Relationship “To attend those who suffer, a physician must possess not only the scientific knowledge and technical abilities, but also an understanding of human nature. The patient is not just a group of symptoms, damaged organs, and altered emotions. The patient is a human being, at the same time worried and hopeful, who is searching for relief, help, and trust. The importance of an intimate relationship between patient and physician can never be overstated because in most cases an accurate diagnosis, as well as an effective treatment, relies directly on the quality of this relationship.”6 The Role of Spirituality in Health Care7 The technological advances of the past century tended to change the focus of medicine from a caring, service- oriented model to a technological, cure-oriented model. Technology has led to phenomenal advances in medicine and has given us the ability to prolong life. However, in the past few decades physicians have attempted to balance their care by reclaiming medicine’s more spiritual roots recognizing that until modern time’s spirituality was often linked with health care. Spiritual or compassionate care involves serving the whole person—the physical, emotional, social, and spiritual. Such service is inherently a spiritual activity. Rachel Naomi Remen, MD who has developed Commonweal retreats for people with cancer, described it well: Serving patients may involve spending timewiththem,holdingtheirhands,andtalkingaboutwhat is important to them. Patients value these experiences. Integrated Approach of Antenatal Care Stress management through Rajyoga Meditation (Brahma Kumaris) Nutritious and satwik food Antenatal physical and breathing exercises. WHO has issued a new series of recommendations to improve quality of antenatal care to reduce the risk of stillbirth and pregnancy complications and give women a positive pregnancy experience.8 ROLE OF OBSTETRICIAN IN CREATING PRENATAL DIVINE CONDITIONS An obstetrician besides prescribing medicines can also prescribe daily sessions of yoga and meditation to shape mother’s attitude towards the whole process. Special meditation facilities can be opened in the hospital or in vicinity of the premises so that a mother can daily practice it and develop positivity towards various spheres of life. This will not only keep the mother physically and mentally fit, but also provide her motivation to deal with pregnancy complications. The mother has complete trust on words of obstetrician and if he encourages her to take a proactive
- 112. FOGSI FOCUS: AdbhutMatrutva88 role in this exercise it would surely lead to compliance without friction. Just like the Hindu mythological character Abhimanyu learnt how to invade a “Chakravyuh” while he was in his mother’s womb. This daily routine would surely have a trickle-down effect on the baby providing positive vibrations of spiritual energy, which would later helps him survive the negativity of the external influences of the world. ROLE OF OBSTETRICIAN IN CREATING POSTPARTUM DIVINE CONDITIONS Afterthebirthofthechild,theobstetriciancanperiodically monitormother’sactivitiesandsuggestcontinuationofthe spiritual exercise taught during the prenatal stage. Keeping a track of the evolutionary mother child relationship and preventing any negative influence of the environment shall be a prime duty of the obstetrician along with helping the mother coping up with the postpregnancy issues. Minor advices like keeping the child in a peaceful place without and disturbance or noise, not leaving the child alone for too long, passionate breastfeeding, etc. can have a big impact of child’s perception of the bonding with the mother. A strong bond will ensure easy transfer of the inculcated spirituality of the mother to the baby. A spiritual journey of the child and mother from the prenatal to postpartum stage facilitated by the obstetrician will make the mother physically and mentally fit and help her cope up the stress period. It will also sow the seeds of an empathetic, positive, and compassionate attitude within the child along with all the divine virtues ultimately leading to a new era of optimism, full of life, a world with less anxiety, and more spiritualism, a divine world. REFERENCES 1. SSE. (2008). Society for Scientific Exploration. [online] Availablefromhttp://www.scientificexploration.org/journal/ volume-22-number-4-2008 [Accessed December 2018]. 2. Donna G. Message in the Water. Calgary, Alberta: Calgary Herald; 2003. p. S8. 3. The Irish Times. (2011). The pseudoscience of creating beautiful (or ugly) water. [online] Available from https:// www.irishtimes.com/news/science/the-pseudoscience-of- creating-beautiful-or-ugly-water-1.574583[AccessedDecember 2018]. 4. The holistic ingredient. (2015). 8 ways to raise your vibration (your positive energy). (online) Available from https:// www.theholisticingredient.com/blogs/wholesome- living/13587702-8-ways-to-raise-your-vibration-your- positive-energy [Accessed December 2018]. 5. Gupta SK. Soul-Mind-Body Medicine for Healthy Happy Living: For Prevention of Angina and Heart Attacks. World Congress on Clinical and Preventative Cardiology; 2006. pp. 22-4. 6. Hellín T. The physician-patient relationship: recent developments and changes. Haemophilia. 2002;8(3):450-4. 7. Puchalski CM. The role of spirituality in health care. Proc (Bayl Univ Med Cent). 2001;14(4):352-7. 8. WHO. (2016). WHO recommendations on antenatal care for positive pregnancy experience. [online] Available from https://www.who.int/reproductivehealth/publications/ maternal_perinatal_health/anc-positive-pregnancy- experience/en/ [Accessed December 2018].
- 113. CHAPTER 18 Beauty inPregnancy Neelam Gulati INTRODUCTION Pregnancy is a really beautiful period of a woman’s life. First of all there is the joy, the miracle of creating a new life that adds a brilliant glow to your face. And the changes that take place in your body, especially the hormonal changes, enhance your beauty manifold. But let not this nice side effect of pregnancy make you forget that you still have to take care and look after your hair, skin, nails, and actually your whole body! Here are a few points to guide you. Your body goes through many changes during the 9 months of pregnancy, as do your skin and hair. At one time the skin may be oily, another time it may be dry. It could even be mixed—oily in some places and dry in others. It is critical that all that you do and all the products that you use are not only safe for you and baby, but also suitable for your skin at the time. Therefore, do visit a cosmetologist at least once in 3 months, learn about your skin type, and get recommendations about products to use. FIRST TRIMESTER It is early days; you are still ecstatic with your discovery that you are pregnant. But the morning sickness may be hitting you; the vomiting can have a dehydrating effect on your body causing various problems associated with dryness. Sometimes, the hormonal changes in the body cause the skin to become oily, with its own problems. It is very important to care for your skin and hair right from day one, just as you take care of your baby by having correct diet and medicines. Appearance plays a very large role in a woman’s happiness quotient, and always remember that only happy mothers can have happy babies, so it is very important for you to stay happy. Problems Associated with Dryness Dry flaky skin (Fig. 18.1): Face Elbows Knuckles Knees Heels Dry eyes Chapped lips Dandruff Brittle and dry hair. Fig. 18.1: Dry flaky skin.
- 114. FOGSI FOCUS: AdbhutMatrutva90 Problems Associated with Oiliness Acne on the face (Fig. 18.2) and back Body rashes especially on the back and legs Blackheads and whiteheads. Problems Associated with either Oily or Dry Skin Pigmentation Dark circles around the eyes. Taking Care of Yourself First and foremost, avoid chemicals as far as possible; use only natural products. Even with natural products, always try on a small area first to make sure you are not allergic, even if you have used in the past. Remember that even natural products such as lime, sugar, and curds are quite harsh and must be used with care and in moderation. For dry skin conditions, you can use products such as compressed coconut oil, almond (badam) oil, aloe vera gel, etc. For oily skin, you can use the traditional haldi chandan (turmeric and sandalwood) paste. Whether your skin is oily or dry, keep yourself well hydrated. Drink plenty of water, nimbu pani (be careful about your sugar and salt intake), coconut water, etc. Remember that fruit juice has lot of vita mins, but also lot of sugar, and most canned or bottled juices also have plenty of chemicals as preservative. It is most advisable to consult a cosmetologist to know the products exactly suited to your skin type. SECOND AND THIRD TRIMESTERS By now the vomiting is over or at least reduced, but keep hydrating yourself with plenty of fluids. Hormonal changes continue, and now your body also starts growing. Keep close track of your diet and weight; be sure to consult a nutritionist; keep in mind that over nourishment is just as harmful for you and the baby as is under nourishment. Appearance wise, the major concerns during this period are: Stretch marks: These are caused by the skin losing its elasticity and can appear on your belly, thighs, arms, etc. wherever you put on weight (Fig. 18.3). To prevent them, first of all be sure not to put on more weight than recommended by your doctor. Keep your skin elastic by regular, gentle massage with aloe vera gel or a good oil like coconut or badam (avoid creams and moisturizers as they may contain chemicals). Pigmentation: You could develop dark patches on your face (Fig. 18.4), body, and limbs. Mostly these are caused by hormonal changes and clear up by themselves as your body starts normalizing after delivery. While you are still carrying, you should just ensure that you keep yourself clean and protect yourself from the sun. In case the pigmentation does not clear up within 4–6 months after delivery, your cosmetologist will have many treatments available that will quickly solve the problem. Lineanigra,adarkverticallinerunningfromthepubisto thenavel,issocommonandisalsoknownaspregnancy line (Fig. 18.5). This also mostly reverses by itself after delivery; just keep the area clean and moisturized. Hairfallisverycommoninthethirdtrimester(Fig.18.6). Again, it is caused by hormonal changes. Keep the scalp clean and apply good oil regularly. Your cosmeto logist can suggest oil that will suit your skin type. The hair growth should improve in 4–6 months after the baby comes; if it is does not, your cosmetologist will suggest a suitable treatment. Fig. 18.2: Acne on the face. Fig. 18.3: Stretch marks during pregnancy.
- 115. Beauty in Pregnancy91 Nail fungus in the toes is a frequent occurrence in the last few months of pregnancy simply because it is difficult to reach your feet to dry them properly (Fig. 18.7). Be particularly careful to dust your feet and toes with an antifungal powder. Your body is your baby’s first and most important home. You love your baby; you must also love your baby’s home and look after it really well. The most important prescription—keep your body clean and dry at all times. Bath frequently, wash off sweat quickly, dry thoroughly, and wear clean clothes. And above all, do not worry if there is any change in your body that does not reverse after delivery, there is a treatment available for it and you will soon be back to your original beauty, with the added glow of motherhood!! Fig. 18.4: Dark patches on face. Fig. 18.5: Linea nigra. Fig. 18.6: Hair fall. Fig. 18.7: Nail fungus in the toes.
- 116. CHAPTER 19 Harmony inRelationships and Anger Management BK Shubhada Neel, Pushpa Pandey, Bharati Ghivalikar, Asha Thakare The highest education is that which does not merely gives us information but makes our life in harmony with all existence. —Rabindranath Tagore INTRODUCTION No man is on an island, we live in societies. We all want to live in a better society where everyone is happy, respected and loves each other because our wellness depends upon the quality of relationships. Harmony in relationships should be needed not only with family and personal friends, but also with the wider groups and communities we belong to. Relationships also play a major role in shaping our character, personality and life as a whole. Anger is one of the negative emotions. It not only spoils many relations but is also harmful for physical, mental, social and spiritual health of the expectant mother and her unborn child. If anger is suppressed it may lead to depression. Aggression may cause heart attack, various types of pains in the body and also reduces immunity power due to excessive release of cortisol and other steroid hormones but assertiveness, i.e. expressing in a right way at right time, is healthy. Anger is temporary insanity; for those moments the person becomes irrational and illogical. Hence, learning the art of prevention and control anger, improve the harmonious relationships and promote mental, emotional and physical well-being. The higher option to keep harmony in relationship is not to experience anger at all. The expectant mother should understand that she has been given the task of making a living idol at this time. She is an architect of her child. Whatever energy she sends in the form of thoughts, words or action to anyone it will be absorbed by the subconscious mind of her own child which will become his or her Sanskar. She should keep herself away from anger during the nine months of this precious time. “There once was a little boy who had a bad temper. His father gave him a bag of nails and told him that every time he lost his temper, he must hammer a nail into the fence. The first day the boy had driven 37 nails into the fence. Over the next few weeks, as he learned to control his anger, the number of nails hammered daily, gradually dwindled down. He found it was easier to hold his temper than to drive those nails into the fence. Finally, the day came when the boy didn’t lose his temper at all. He told his father about it and the father suggested that the boy now pull out one nail for each day that he was able to hold his temper. The days passed and the young boy was finally able to tell his father that all the nails were gone. The father took his son to the fence and said “you have done well, my son, but look at the holes in the fence. The fence will never be the same. When you say things in anger, they leave a scar just like this one.”You can put a knife in a man and draw it out. It won’t matter how many times you say I’m sorry, the wound is still there.” It is better to control anger at the thought level before coming into words and action, so not to repent later. Here are few simple steps to control anger and consciously create harmonious relationships. ACCEPT EVERYONE AS THEY ARE One of the main causes of anger is that people do not behave according to our desires. In this universe every human being is unique, has different sanskars and may have different opinions about things. We should respect others’ ideas and working patterns, else, we may get irritated, creating negative energy that radiates to the other person either at a subtle or a gross level (thoughts, words, action). He will also get irritated and the relationship will be damaged. Thus, acceptance means understanding the other person’s nature and not getting disturbed by it. BECOME TRUSTY Become a trusty and earn a fortune. This story written in scriptures captures the essence beautifully. King Janak was called ‘Vaidehi’. He looked after his kingdom as a trusty. Though he was living in palace, he felt detachment towards life. Many saints and ascetics used to ask themselves why
- 117. Harmony in Relationshipsand Anger Management 93 was he called Vaidehi? Why is he put in the category of a saint when he lives in a palace and enjoys all the pleasures? An ascetic once asked the king—why are you called Vaidehi? The king said we will discuss this in the evening, this is the time for business. Till then, go and see my new palace. It is beautifully made and the engraving is also very beautiful. But it is always dark, so take a lamp with you. While returning make sure that the lamp does not blow out. While seeing the palace suddenly strong winds started blowing. The ascetic got scared that the lamp might be blown out. In the evening when he returned to the king, the king asked him how was the palace, and how was the engraving. The ascetic replied that he did not notice the engraving because all the time his attention was on the lamp. The king said—similarly I live in the palace but living there in a detached stage. CONTENTMENT AND POSITIVE ATTITUDE Contentment is a great virtue. The list of complaints is long if there is dissatisfaction in life with self and others or have excessive desires. Such people even grumble after waking up in the morning, “Why does the sun rise so early?” Something to learn from the following incident. A few children were playing near a newly constructed building.Theyusedtoplay“train-train”bygrabbingothers’ shirts one by one and become engine and themselves becoming the train bin. They would change their positions daily, except for the one child who always became the guard. Someone asked this child why he would become guard daily. The boy answered, “I don’t have a shirt, how can I become the engine and train bins, so I enjoy daily by becoming the guard.” Hence, it is the attitude which determines our lives. Lessenyourdesires,youwillbecontented.Contentment is reflected by a cheerful and happy personality. Happiness and contentment go hand in hand. We should focus on the things we have in our lives. DETERMINATION Making a determination that I have to conquer anger to keep good relations. This is one of the important steps in building harmonious relationships. EMPOWER YOURSELF Empowerment can be achieved by energizing life at a physical, emotional and spiritual level. Physical Empowerment It needs a healthy diet and exercise which releases endorphins. Emotional Empowerment With the help of positive thoughts, emotional empower ment is done; feelings and emotions associated with anger can be minimized. Spiritual Empowerment Be an introvert and practice silence. Spiritual empower ment is important to improve relationships with self and with the supreme. Relationship starts with the self. Those who respects and love themselves are the only ones who can give unconditional love and respect to everyone. If one has control over self, control over the outer world is very easy. This needs introspection and a lot of practice. Once Gautam Buddha sent his disciple, Ananda, to fetch water from a nearby stream. He came back without the water because animals had bathed in the stream and the water was muddied. He was sent back three times. The fourth time the water was clear so he brought back the clean water. Lord Buddha explained that life was similar. We must never be afraid of bad thoughts but observe them arising from the mind with total awareness and watching the direction they take. With this practice, the mind will start becoming quiet, just like a mischievous child soon calms down if observed quietly. Be an introvert and observe the flow of thoughts the entire day and then change their direction. Do it every hour. With practice the incoming thoughts will naturally become pure. Even if you do not want them to be. Thepracticeofsilenceisdonebypracticingmeditation. Meditation also helps in healing life in all three extents, i.e. physical, emotional and spiritual. Our healing will then heal humanity. FORGIVENESS AND MERCY Forgiveness and mercy are acts of the wise and brave. They increase the power of humility and patience. Practice “I am a compassionate soul. I understand that people’s sanskars and way of working are different from mine. I follow discipline with love. I forgive them for their mistakes… my mind is clean… I radiate love and respect… I appreciate their goodness… then I give correction and direction.” GIVING ATTITUDE AND GRATITUDE The purpose of human life is to give. Giving attitude creates happiness in our lives. By replacing the energy of taking by
- 118. FOGSI FOCUS: AdbhutMatrutva94 giving,anyonecannoticethepositiveshiftinday,weekand month with regular practice. Give unconditional love to everyone is an antidote for anger. Making gratitude a daily practice is like a vitamin, says David Destine, professor in psychology at Northeastern University in Boston and the author of the book “Emotional Success”.1 Robert Emmons, professor in psychology at University of California and the author of the book, “The little book of gratitude”, in one study, asked a group of volunteers to write down five things they are grateful for once a week for 10 weeks. The other group recorded either small hassles or neutral daily events. At the end of the study the blessing- counters reported feeling 25% happier and had fewer health complaints, but the rest of the findings were far more tangible. Practice “I am a loving being. I thank God for what I have. I thank everyone whom I met and everything I used today. I thank the elements of nature for sustaining me today. I thank my body for being healthy today.” Let us express our gratitude not only to people but also to things. We will create a beautiful karma with objects also; the house, car, mobile and everything that is there for us. The attitude of gratitude will finish our Sanskar of complaining and criticizing. GIVE UP EGO Become a trusty and earn a fortune. True renunciation means to let go of the consciousness of ‘mine’. The point is aptly delineated by the following story: An artist saw death coming, so he made 10–12 replicas of himself. When Yamraj sent his men to get him, he stopped his breath and hid amongst the statues. The messengers could not recognize him so they returned. Yamraj asked them why had they returned without the man? The messengers answered—“Maharaj, there, there were 10–12 people looking alike, we tried but could not recognize the real person”. Yamraj then decided to go himself. When he too started getting confused, he thought of a trick. He said, “Wow, what a good artist in this mortal world I have never seen such an artist who is able to fool my messengers. If I can meet the artist once I would like to thank him”. On hearing this the artist got up and said, “I have made these statues”. On which Yamraj replied, “let’s go! I have come to get you”. If the artist’s body consciousness (self-esteem and ego) had not come to the forefront then he would have been saved. These words, ‘Me’ and ‘Mine’, give birth to ignorance. HAVE FAITH IN GOD AND FOCUS ON YOUR DUTY Surrender every relation and every action to God and perform your duties. Time to quote the very beautiful story of ‘THE PREGNANT DEER’! In a forest, a pregnant deer is about to give birth. She finds a remote grass field near a strong-flowing river. This seems a safe place. Suddenly labor pains begin. At the same time, dark clouds gather around above, and lightning starts a forest fire. She looks to her left and sees a hunter with his bow extended pointing at her. To her right, she spots a hungry lion approaching her. What can the pregnant deer do? She is in labor! What will happen? Will the deer survive? Will she give birth to a fawn? Will the fawn survive? Or will everything be burnt by the forest fire? Will she perish to the hunters’ arrow? Will she die a horrible death at the hands of the hungry lion approaching her? She is constrained by the fire on the one side and the flowing river on the other and boxed in by her natural predators. She focuses on giving birth to a new life. The sequence of events that follow are: Lightning strikes and blinds the hunter. He releases the arrow which zips past the deer and strikes the hungry lion. It starts to rain heavily, and the forest fire is slowly doused by the rain. The deer gives birth to a healthy fawn. In our lives too, there are moments of choice when we are confronted on all sides with negativity and possibilities. We should focus on what is in our hands. Maybe we can learn from the deer. The priority of the deer, in that given moment, was simply to give birth to the baby. The rest was not in her hands; any action or reaction that might have changed her focus would have likely resulted in death or disaster. We should have faith in the Almighty and his creation. We are the instrument of God we must focus on the work which is allotted to us, rest is taken care of by Him. INCREASE TOLERANCE POWER Tolerance is a way of showing respect for the essential humanity in every person. Tolerance means to accept differences and changes with grace. It means to be calm amid people and situations that we may not be in agreement with. POSTPONE ANGER Postponing anger for a few minutes dilutes anger. In that moment of surge, practice, “I am a peaceful being”. Absence of peace is anger.
- 119. Harmony in Relationshipsand Anger Management 95 SIMPLICITY AND SWEETNESS Simplicity is the nature of great souls. They are simple and sweet in thoughts words and deeds thus create harmony in society. REPROGRAMMING OF MIND Our consciousness is like a computer. Program the consciousnesses, well in advance, to remain stable and peaceful in midst of anger provoking situations. RENOUNCE JEALOUSY AND HATRED Jealousy and hatred not only ruin relationships but also are root causes of many health problems. Jealousy can be a major relationship problem—a survey of marital therapists reported that romantic jealousy was a serious problem for a third of their clients.1,2 TAKE RESPONSIBILITY TO CULTIVATE HARMONIOUS RELATIONSHIPS We cannot change the past. Put stop to rethink the past negative behaviors of others. We cannot change the way people act. We have control over our ‘responses’. Even if the other person harmed, betrayed, belittled, disrespected, or ignored us, that was their part. Our response of anger, hurt, and resentment was our choice and creation. When we stop blaming the other person and look at our role in creating the conflict, healing begins. CONCLUSION Harmony in relationships can be achieved by learning the art of managing self, by keeping harmony in thoughts, words and actions. Changing new way of thinking, sweetly speaking and doing good for others helps in healing relationships. Expectant mother should focus on the present task of making a living idol in the womb. Keep fast of anger and negativity for nine months. REFERENCES 1. The healing power of gratitude, Prevention.com Nov. 2018. (cited 2018 Dec 26). Available from: https://in.pinterest. com/pin/451767406366943293/. 2. White GL. Romantic Jealousy: Therapists’ Perceptions of Causes, Consequences, and Treatments. J Couple Relation ship Therapy. 2008;7(3):210-29.
- 120. CHAPTER 20 Gestational DiabetesMellitus Uma Pandey, Anupama Singh INTRODUCTION It is defined1 as carbohydrate intolerance of variable severity with onset or first diagnosed during present pregnancy [American College of Obstetricians and Gyne- cologists 2013 (ACOG 2013)].2 This definition includes womenwhoseglucosetolerancewillreturnbacktonormal after pregnancy and also those who will develop type 2 diabetes. The latter group also includes those females who had pre-existing type 2 diabetes. Gestational diabetes mellitus (GDM) usually presents in the second or during third trimester. EPIDEMIOLOGY The prevalence of GDM in India varies from 3.8–21% and it is more in urban than rural areas.3-10 Risk Factors Positive family history of diabetes (parents, sibling, aunts, uncles, grandparents) History of GDM or impaired glucose tolerance test11 Age 30 years Ethnic group (East Asian, Pacific island ancestry) Obesity Historyofoverweightbaby(≥4kg)inpreviouspregnancy Unexplained perinatal loss or malformed infants Previous history of stillbirth with pancreatic hyper plasia (revealed on autopsy) Persistent glycosuria Presence of polyhydramnios or recurrent vaginal candidiasis in present pregnancy Polycystic ovarian syndrome, cardiovascular disease, hypertension, hyperlipidemia. Screening12 Every pregnant female, fasting or random blood glucose during the first antenatal visit (universal screening).13-18 Compared to selective screening, uni versal screening for GDM detects more cases and improves maternal and neonatal prognosis.19-21 Hence, universal screening for GDM is essential, as women of Asian origin and especially ethnic Indians are at a higher risk of developing GDM and subsequent type. Type 2 diabetes.22-24 Fifth International Workshop-Conference on Gesta tional Diabetes25 endorsed Selective Screening26,27 in pregnant females based on risk assessment for detec ting GDM using either: Two step procedure (Flowchart 20.1):2,12,26 One step procedure:31-34 Diagnostic 100 g oral glucose tolerance test (OGTT) performed on all subjects. If high risk; blood glucose test is done as early as possible, using the procedures described previously. If GDM is not diagnosed, blood glucose testing should be repeated at 24–28 weeks’ gestation or at any symptoms or signs suggesting hyperglycemia. GDM Risk Assessment25 It should be ascertained at the first prenatal visit (Table 20.1). DIAGNOSIS There are various diagnostic criteria for diagnosis of GDM: Criteria for diagnosis of GDM with 100 g oral glucose Flowchart 20.1: Two step procedure for screening of gestational diabetes.
- 121. Gestational Diabetes Mellitus97 [O’Sullivan and Mahan Modified by carpenter and Coustan]35 and National Diabetes Data Group (NDDG)36 has been described in Table 20.2. Criteria for diagnosis of impaired glucose tolerance and diabetes with 75 g oral glucose (WHO)37 has been described in Table 20.3. International Association of Diabetes and Pregnancy Study Groups (IADPSG) (75 g oral glucose) (mg/dL): Diagnosis of GDM is made when one or more threshold values are met or exceeded (Table 20.4). DIABETES IN PREGNANCY SOCIETIES OF INDIA (DIPSI) One step diagnostic procedure for all pregnant females (universal screening) in antenatal clinic with 75 g oral glucose irrespective of her fasting status or timing of previous meal. A venous plasma glucose level of greater than 140 mg/dL, 2 hr later is diagnosed as GDM. This is both a screening as well as diagnostic procedure; and is approved by the Ministry of Health, Govt. of India and also recommended by World Health Organization (WHO). The recommendations of the American Diabetes Association (ADA) and International Association of Diabetes and Pregnancy Study Groups (IADPSG) in 2011 for diabetes in pregnancy was combined and algorithm40 was proposed which is specified in Flowchart 20.2. MATERNAL AND FETAL EFFECTS48 Maternal Effects During Pregnancy Preeclampsia: One of the most severe complication of GDM; occurs in 10% of patients with GDM. Factors asso Table 20.1: GDM risk assessment. Low-risk Average-risk High-risk If all of the following are present: ŠŠ Age 25 years ŠŠ No history of diabetes in first degree relative ŠŠ Weight normal at birth ŠŠ Weight normal prior to pregnancy ŠŠ No history of abnormal glucose metabolism ŠŠ Ethnicity with low prevalence of GDM ŠŠ No history of poor obstetrical outcome ŠŠ Age 25 years ŠŠ Diabetes in first degree relative ŠŠ High weight at birth ŠŠ Overweight since nonpregnant stage ŠŠ Ethnicity with high prevalence of GDM If 1 or more of these present: ŠŠ Strong family history of type 2 DM ŠŠ Previous history of GDM or impaired glucose tolerance test or glucosuria or macrosomic baby ŠŠ Severe obesity (DM: diabetes mellitus; GDM: gestational diabetes mellitus) Flowchart 20.2: The recommendations of the ADA and IADPSG in 2011 for diabetes in pregnancy. (HbA1c: glycosylated hemoglobin;41-47 FPG: fasting plasma glucose; RPG: random plasma glucose; OGTT: oral glucose tolerance test; DM: diabetes mellitus; GDM: gestational diabetes mellitus) Table 20.3: Criteria for diagnosis of impaired glucose tolerance and diabetes with 75 g oral glucose (WHO).37 Time Normal tolerance Impaired glucose tolerance Diabetes Fasting 100 ≥100 and 126 ≥126 2 hr post- glucose 140 ≥140 and 200 ≥200 Note: (1) Venous whole blood values are 15% less than the plasma values;38,39 (2) mmol/L = mg% × 0.0555. Table 20.2: Criteria for diagnosis of GDM with 100 g oral glucose (O’Sullivan and Mahan modified by Carpenter and Coustan)35 and National Diabetes Data Group (NDDG).36 Glucose Tolerance Test: Venous Plasma Glucose (mg/dL) Time Carpenter and Coustan NDDG Fasting 95 105 1 hr 180 190 2 hr 155 165 GDM diagnosed when any two values are met or elevated (GDM: gestational diabetes mellitus) Table 20.4: International association of diabetes and pregnancy study groups (IADPSG) (75 g oral glucose) (mg/dL). Time Values Fasting 92 1 hr 180 2 hr 153
- 122. FOGSI FOCUS: AdbhutMatrutva98 ciated with increased risk; younger age, nulliparous, and obese. Diabetic Nephropathy:49 Stages of development— Microalbuminuria: 30–300 mg/24 hr Macroalbuminuria: More than 300 mg/24 hr End stage disease. Nephropathy increases potential risk of fetal growth restriction, pre-eclampsia, preterm birth, chronic hyper tension and maternal morbidity. Diabetic Retinopathy (Flowchart 20.3): The first and the most common visible lesions are small microaneurysms. Nonproliferative stage managed by good glycemic control. But proliferative stage needs panretinal photocoagulation. Diabetic retinopathy is not a contraindication of vaginal delivery (NICE 2008). But in cases of untreated proliferative stage, labor causes increased intraocular pressure leading to intravitreal hemorrhage (rupture of fragile vessels); so caesarean section is done. Ophthalmic follow-up for at least 6 months after delivery is recommended in cases of preproliferative retinopathy. Diabetic Neuropathy: Uncommon but a form of peripheral symmetrical sensorimotor diabetic neuropathy called Diabetic Gastropathy, is associated with high risk of morbidity and poor perinatal outcomes. It causes nausea and vomiting, nutritional problems, poor glycemic control. Treatment with metoclopramide and H2 receptor antagonists, sometimes, helps. Diabetic Ketoacidosis: It may develop in hyperemesis gravidarum,diarrhealdisease,febrileillnesses,b-mimetics drugs given for tocolysis, corticosteroids given for inducing fetal lung maturity. Diabetic ketoacidosis (DKA) results from an insulin deficiency combined with excess in glucagon (counter regulatory hormone) resulting in gluconeogenesis and ketonebodyformation(b-hydroxybutyrateacetoacetate). Pregnant females develop ketoacidosis at lower glucose thresholds than nonpregnant females. Protocol recommended by the American College of Obstetrician and Gynecologists (2012) for management of diabetic ketoacidosis during pregnancy: Laboratory assessment: Arterial blood gas analysis at 1 or 2 hr interval to document degree of acidosis (measure glucose, ketones and electrolyte levels). Insulin: In low dose (intravenous) Loading dose: 0.2–0.4 U/kg Maintenance dose: 2–10 U/hr. Fluids: Isotonic sodium chloride Total replacement infirst 12 hr of 4–6 L One liter infirst hour; 500–1000 mL/hr for 2–4 hr 250 mL/hr until 80% replaced. Glucose: Begin 5% dextrose in normal saline when glucose plasma levels reaches 250 mg/dL (14 mmol/L). Potassium: If initially normal or reduced, an infusion rate up to 15–20 mEq/hr may be required. If elevated, wait until levels decrease into the normal range, then add to intravenous solution in a concentration of 20–30 mEq/L. Bicarbonate: Add 1 ampule (44 mEq) to 1 L of 0.45 normal saline, if pH is 7.1. Infections: Common are Candida vulvovaginitis, urinary and respiratory tract infections. During Labor Prolonged labor due to big baby Shoulder dystocia Perineal injuries Postpartum hemorrhage Increased incidence of caesarean section. Puerperium Puerperal sepsis Lactational failure. Fetal and Neonatal Effects50 Fetal Macrosomia51, 52 Birth weight greater than 4 kg (90th percentile). Macrosomic baby looks plethoric (due to polycythemia), with plumpy face, buried eyes and excessive buccal fat. Pedersen hypothesis has been discussed in Flowchart 20.4). Factors implicated in macrosomia: Insulin like growth factor (Luo and coworkers, 2012), C-peptide, epidermal growth factor, fibroblast growth factor, platelet-derived Flowchart 20.3: Pathophysiology in diabetic retinopathy.
- 123. Gestational Diabetes Mellitus99 growth factor, leptin and adiponectin (Grissa, 2011; Loukovaara,2004; Mazaki-Tovi, 2005). Fetal Anomalies Unlike in overt diabetes, rates of fetal anomalies do not appear to be substantially increased (Sheffield, 2002) Hydramnios Amniotic fluid index (AFI) greater than 24 cm (fetal hyperglycemia causes polyuria leading to hydramnios). Fetal Death Fasting hyperglycemia 105 mg/dL, increased risk of fetal death during the final 4–8 weeks [ADA(2003)] Other causes includes chronic hypoxia, placental villus edema impairing nutrient transfer. Chemical Imbalances Fetal hypoglycemia (due to maternal hypoglycemia) can cause sudden intrauterine fetal death. Neonatal hypocalcemia (due to delayed postnatal parathyroid hormone regulation) and hypomag nesemia (due to longstanding diabetic nephropathy in mother leading to loss of magnesium from maternal kidney and hence less availability of Mg2+ for the fetus) occur within 72 hr of birth. Neonatal hyperbilirubinemia with risk increased due to preterm delivery, and relative immaturity of hepatic bilirubin conjugation and excretion. Neonatal Hypoglycemia Neonatal hyperinsulinemia and removal of the exogenous glucose source (maternal) at the time of delivery may provoke hypoglycemia within minutes of birth. Cornblath and associates (2000) established threshold of 35 mg/dL in term neonates. Respiratory Distress Syndrome There is increased risk of respiratory distress syndrome due to surfactant deficiency, which is due to increased risk of preterm delivery in such mothers especially in uncontrolled blood sugar levels in the mother, and also due to late maturation of type 2 alveolar cells, and also fetal hyperinsulinaemia antagonize the action of cortisol causing blunted production of surfactant. Long Term Sequela Increased risk of obesity, type 2 diabetes, cardiovascular disease and impaired cognitive and motor function. MANAGEMENT53-62 Pharmacologicalmethodsareusuallyrecommendedifdiet modification does not consistently maintain the fasting plasma glucose levels 95 mg/dL or the 2 hr postprandial plasma glucose 120 mg/dL (ACOG 2013). The Fifth International Workshop Conference reco mmended that fasting glucose levels be kept 95 mg/dL (Metzger, 2007). Diabetic Diet The ADA recommends individualized nutritional coun seling based on height and weight (Bantle, 2008). On average, this includes a daily caloric intake of 30–35 kcal/ kg. ACOG 2013 suggests that carbohydrate intake be limited to 40% of total calories. The remaining calories are apportioned to give 20% as protein and 40% as fat. ADA 2003; obese women with body mass index (BMI) 30 kg/m2 should have 30% calorie restriction (approximately 25 kcal/kg/day). Monitoring done by weekly assessment of ketonuria, which have been linked with impaired psychomotor development in offspring (Rizzo,1995; Scholre,2012). Exercise Physical activity during pregnancy reduces the risk of gestational diabetes (Dempsy et al, 2004). Resistance exercise decreases the need for insulin therapy in overweight women with GDM (Brankston et al, 2004). ACOG 2013 recommends moderate exercise as part of treatment in women with GDM. Flowchart 20.4: Pedersen hypothesis.
- 124. FOGSI FOCUS: AdbhutMatrutva100 Glucose Monitoring ACOG 2013 recommends four times daily glucose monitoring per day, fasting and either 1 or 2 hour after each meal. Self-monitored capillary blood glucose goals have been described in Table 20.5. Insulin ACOG 2013 recommends that insulin be considered in females with persistently increased 1 hr postprandial glucose level of greater than 140 mg/dL or 2 hr one greater than 120 mg/dL and insulin is started with atypical dose of 0.7–1 unit/kg/day in divided doses. Action profile of commonly used insulins is shown in Table 20.6. Insulin management during labor and delivery: Usual dose of intermediate acting insulin is given at bedtime. Morning dose of insulin is withheld. Intravenous infusion of normal saline is begun. Once active labor begins or glucose levels decreases to 70 mg/dL, the infusion is changed from saline to 5% dextrose and delivered at a rate of 100–150 mL/ hr (2.5 mg/kg/min) to achieve a glucose level of approximately 100 mg/dL. Glucose levels are checked hourly using a bedside meter allowing for adjustment in the insulin or glucose infusion rate. Regular (short-acting) insulin is administered by intravenous infusion at a rate of 1.25 U/hr, if glucose levels exceed 100 mg/dL. Oral Hypoglycemic Agents Both Glyburide and Metformin are appropriate, as is insulin, for first line glycemic control in women with GDM (ACOG 2013). Obstetrical Management ACOG 2013 endorses fetal surveillance in women with GDM. Daily fetal movement recording (DFMR) is very important especially in the third trimester. Insulin treated females are admitted after 34 weeks and fetal heart rate monitoring is done three times each week. Women with gestational diabetes and adequate glycemic controls are managed conservatively. Delivery is planned for 38 weeks. Elective labor induction to prevent shoulder dystocia compared with spontaneous labor remains contro versial Caesarean delivery at or near term done if macrosomic baby,andinwomenwithadvanceddiabetes,especially those with vascular disease. Two IV lines must be secured during delivery. Postpartum Evaluation In GDM, the need for insulin after delivery reduces. It can be stopped if the glucose levels are within normal limits. Once the patient resumes full diet by third day after caesarean, a fasting and postprandial glucose level done for deciding subsequent therapy. Evaluation done at least every 3 years in women with a history of gestational diabetes but normal postpartum glucose screening (ADA 2011). ACOG 2013 recommends either fasting glucose or 75 g 2 hour OGTT for the diagnosis of overt diabetes. Prolonged antibiotics must be given especially in cases of complicated cesarean or instrumental delivery. GDM patients are also at risk for cardiovascular complications associated with dyslipidemia, hyper tension, and abdominal obesity; the metabolic syn drome. Akinci and Associates (2009) reported that fasting glucose levels ≥ 100 mg/dL in the index OGTT was an independent predictor of the metabolic syndrome. Table 20.5: Self-monitored capillary blood glucose goals. Specimen Level (mg/dL) Fasting ≤95 Premeal ≤100 1 hr postprandial ≤140 2 hr postprandial ≤120 Between 02:00 am to 06:00 am ≥60 Mean (average) 100 HbA1c ≤6% Table 20.6: Action profile of commonly used insulins. Insulin type Onset Peak (hour) Duration (hour) Short acting (SC) Lispro 15 min 0.5–1.5 3–4 Glulisine 15 min 0.5–1.5 3–4 Aspart 15 min 0.5–1.5 3–4 Regular 30–60 min 2–3 4–6 Long acting (LC) Detemir 1–4 hr minimal Up to 24 Glargine 1–4 hr minimal Up to 24 NPH 1–4 hr 6–10 10–16 (NPH: neutral protamine hagedorn)
- 125. Gestational Diabetes Mellitus101 Women with GDM have excessive cardiovascular disease by 10 years. Fifth International Workshop- Conference: Metabolic assessments recommended afterpregnancywithgestationaldiabetesaredescribed in Table 20.7. Recurrent Gestational Diabetes More common in obese females. So, loss of at least 2 BMI units was associated with a lower risk of gestational diabetes in women who were overweight or obese in the first pregnancy. Contraception Barrier methods are ideal Low dose hormonal contraceptives are safe in women with recent gestational diabetes Combined oral pills may be best avoided Intrauterine devices may predispose to infection but they are good alternatives in women with comorbid obesity, hypertension, or dyslipidemia Tubal ligation should be done with caution. Vasectomy should be preferred. REFERENCES 1. Committee opinion no. 504: Screening and diagnosis of gestational diabetes mellitus. Obstet Gynecol. 2011;118(3): 751-3. 2. Committee on Practice Bulletins—Obstetrics. Practice Bulletin 137: Gestational Diabetes Mellitus. 2013. Obstet Gynecol. 2013;122(1):406-16. 3. Seshiah V, Balaji V, Balaji MS, et al. Pregnancy and Diabetes Scenario around the World: India. Int J Gynaecol Obstet. 2009;104(Supp 1):S35-8. 4. Seshiah V, Balaji V, Madhuri S, et al. Prevalence of GDM in South India (Tamil Nadu): a Community based study. JAPI. 2008;56:329-33. 5. Zargar AH, Sheikh MI, Bashir MI, et al. Prevalence of gestational diabetes mellitus in Kashmiri women from the Indiansubcontinent.DiabetesResClinPract.2004;66(2):139- 45. 6. Grewal E, Kansra S, Khadgawat R, et al. Prevalence of GDM among women attending a Tertiary Care Hospital AIIMS Presented at DIPSI 2009 and 5th DIP Symposium, Sorrento, Italy, 2009. 7. Dorendra I, Devi B, Devi I, et al. Scientific Presentation Volume of the First National Conference of the DIPSI, Chennai, February 2006. 8. Yuvaraj MG. Data presented at the First National Conference of DIPSI: Chennai, February 2006. 9. Swami SR, Mehetre R, Shivane V, et al. Prevalence of carbohydrate intolerance of varying degrees in pregnant females in Western India (Maharashtra): a hospital-based Study. J Indian Med Assoc. 2008;106:712-4. 10. Divakar H, Tyagi S, Hosmani P, et al. Diagnostic criteria influence prevalence rates for gestational diabetes: implications for interventions in an Indian pregnant population. Perinatology. 2008:10(6);155-61. 11. Yogev Y, Ben-Haroush A, Hod M. Pathogenesis of gestational diabetes mellitus; Textbook of Diabetes and Pregnancy. 1st edition. London: Martin Dunitz, Taylor Francis Group plc; 2003. pp.46. 12. National Institutes of Health consensus development conference statement: diagnosing gestational diabetes mellitus. Obstet Gynecol. 2013;122(1):358-69. 13. Seshiah V, Balaji V, Madhuri S, et al. Gestational diabetes mellitus in India. J Assoc Physic of India. 2004;52:707-11. 14. Gabbe S, Gregory R, Power M, et al. Management of diabetes mellitus by obstericians-gynecologists. Obstet Gynecol. 2004;103:1229. 15. Moyer VA, U.S. Preventive Task Force. Screening for gestational diabetes mellitus: U.S. Preventive Services Task Forcedraft recommendation statement. Ann Intern Med. 2014;160(6):414-20. 16. de Aguiar LG, de Matos HJ, de Brito M. Could fasting plasma glucose be used for screening high-risk outpatients for GestationalDiabetesMellitus?DiabetesCare.2001;24(5):954-5. 17. Hayes L, Bilous R, Bilous M, et al. Universal screening to identify gestational diabetes: a multi-centre study in the North of England. Diabetes Res Clin Pract. 2013;100(3):74-7. 18. Graziano DC, Volpe L, Lencioni C, et al. Prevalence and risk factors for gestational diabetes assessed by universal screening. Diabetes Res Clin Pract. 2003;62(2):131-7. 19. Nahum GG, Wilson SB, Stanislaw H. Early-pregnancy glucose screening for gestational diabetes mellitus. J Reprod Med. 2002;47:656-62. Table 20.7: Fifth International Workshop-Conference: Metabolic assessments recommended after pregnancy with gestational diabetes. Time Test Purpose Post-delivery (1–3 days) Fasting or random plasma glucose Detect persistent, overt diabetes Early postpartum (6–12 weeks) 75 g, 2-hour OGTT Postpartum classification of glucose metabolism 1 year postpartum 75 g, 2-hour OGTT Assess glucose metabolism Annually Fasting plasma glucose Assess glucose metabolism Triannually 75 g, 2-hour OGTT Assess glucose metabolism Prepregnancy 75 g, 2-hour OGTT Classify glucose metabolism
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Availa ble at: www.cdph.ca.gov/progr. 41. Raiput R, Yadav Y, Raiput M, et al. Utility of HbA1c for diagnosis of gestational diabetes mellitus. Diabetes Res Clin Pract. 2012;98(1):104-7. 42. Lowe P, Metzger BE, Dyer AR, et al. Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study: Associations of maternal A1C and glucose with pregnancy outcomes. Diabetes Care. 2012;35(3):574-80. 43. Davies DM, Welborn TA. Glycosylated haemoglobin in pregnancy. Aust NZJ Obstet Gynaecol. 1980;20(3):147-50. 44. Pollak A, Widness JA, Schwartz R. Minor hemoglobins: an alternative approach for evaluating glucose control in pregnancy. Biol Neonate. 1979;36(3-4):185-92. 45. Widness JA, Schwartz HC, Kahn CB, et al. Glycohemoglobin in diabetic pregnancy: a sequential study. Am J Obstet Gynecol. 1980;136(8):1024-9. 46. McFarland KF, Catalano EW, Keil JE, et al. Glycosylated haemoglobin in diabetic and nondiabetic pregnancies. South Med J. 1981;74(4):410-2. 47. Rafat D, Ahmad J. HbA1c in pregnancy. Diabetes Metab Syndr. 2012;6(1):59-64. 48. Alberti K, Zimmett P. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med .1998;15(7):539-53. 49. Vidaeff AC, Yeomans ER, Ramin SM. Pregnancy in renal disease. 50. Merlob P, Hod M. Short-term Implications: the neonate. Textbook of Diabetes and Pregnancy. 1st edition. London: Martin Dunitz, Taylor Francis Group; 2003. pp.289-304. 51. Schwartz R, Gruppuso PA, Petzold K, et al. Hyperinsulinemia and macrosomia in the fetus of the diabetic mother. Diabetes Care. 1994;17(7):640-8. 52. Chattfield J. ACOG issues guidelines on fetal macrosomia. An FAM Physician. 2001;64(1):169-70. 53. Reiher H, Fuhramann K, Noack S, et al. Age-dependent insulin secretion of the endocrine pancreas in vitro from fetuses of diabetic and non-diabetic patients. Diabetes Care. 1983;6(5):446-51. 54. Paul VK, Deorari AK, Singh M. 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- 128. CHAPTER 21 Breastfeeding Kumkum Mehrotra,Awantika PROTECTING, PROMOTING, AND SUPPORTING BREASTFEEDING IN INDIA Only 42% mothers initiate breastfeeding within first hour of birth. Only 50% children are exclusively breastfed for the first 6 months. 20% of newborn deaths can be reduced by promoting and educating on a war basis. Such children are 11 times less likely to die from diarrhea and 15 times less likelytodiefrompneumonia.Breastfeedingsavesadditional 20,000 maternal deaths annually from breast cancer. India has achieved substantial gains in improving mortality rates:1 Under-five mortality rate at 43 per 10,000 Infant mortality rate (IMR) at 34 per 10,000 Neonatal mortality rate (NMR) at 25 per 10,000 Early NMR at 19 per 10,000 About68%ofIMRisconstitutedofNMRandmorethan 50% of IMR is due to early neonatal mortality highlighting the urgency for early preventive action. Breastfeeding Saves Lives and Protects Health and Contributes to Social and Economic Outcomes Protection against type 2 diabetes and obesity Higher cognitive functioning, improved academic performance, and increased productivity and earning as an adult Improves human capital investment and reduces health care expenditure It is the first inoculation against death and disease which is a missed opportunity. Why Early Initiation? Success in breastfeeding is not the sole responsibility of the parturient, but a collective societal responsibility.1 Breastfeeding is Exquisitely Personalized Medicine at a Critical Moment Evidence indicates that 22% of all newborn deaths can be averted, if initiation of breastfeeding within 1 hour of birth becomes a universal practice. What can Doctors and Healthcare Providers do? During antenatal care (ANC) visits counsel, encourage, and prepare pregnant mothers Regular training of staff from time to time Provideskilledsupportandcounselingtohelpmothers sustain breastfeeding even after cesarean delivery Create mother and baby friendly environment Inform mothers and their family members the hazards of improper use of infant milk substitutes (IMS), feeders, and infant foods Effective implementation of IMS Act.1 Collaborate with Indian Academy of Pediatrics (IAP), Indian Medical Association (IMA), and Indian AssociationofPreventiveandSocialMedicine(IAPSM) Disseminate information on Mamta TV. Adbhut Matrutva Sessions Role of Good Quality Antenatal Care Regarding Maternal Nutrition About 50% of pregnant women are anemic. About 42.2% of women enter pregnancy as underweight. And about 53%
- 129. Breastfeeding 105 of allwomen aged 15–49 years are anemic. About 22.9% of women are underweight. About 45% of adolescent girls are underweight. Adequate maternal nutrition emphasizes first 1,000 days,fromthetimeofconceptionto2yearsofage.Maternal malnutrition is the key contributor to low birth weight (LBW) or small for gestational age (SGA) or fetal growth restriction (FGR) babies. It could be due to mother’s own childhood malnutrition and short stature. Educate and emphasis on iron and folic acid (IFA) and Ca consumption.1 DEFINITION OF BREASTFEEDING Breastfeeding is defined as to enable mothers to establish and sustain exclusive breastfeeding for 6 months. World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) recommend initiation within first hour of birth. Exclusive breastfeeding is when the infant receives only breast milk without any additional food or drink not even water.1 ANATOMY OF BREAST (FIG. 21.1) Breast is a modified sweat gland. It consists of around 15 ductal systems. Each draining around 40 lobules. Each lobule consisting around 60 acini, which empty into small terminal ducts. Terminal ducts drain into larger collecting ductswhichopenintolactiferoussinusbeneaththenipple. Nipple has around six duct openings and each opening drains a separate lobular system. PHYSIOLOGY OF BREAST Terminal ducts and the acini are the most sensitive to ovarian hormones and prolactin (PRL). Breast epithelial cells proliferate in luteal phase of the menstrual cycle, and if there is no conception, they undergo programmed cell death at the end of luteal phase when estrogen, progesterone, and PRL decline. This is the reason of water retention in extracellular fluid (ECF), which causes premenstrual tenderness in breasts. PHYSIOLOGY OF MILK PRODUCTION Skin covering the nipple contains many nerve endings which get triggered and hormones are released. PRL acts on the glands while oxytocin helps release. The more let- down reflex is triggered the more is the production. A well- trained breast ensures more milk production. Even when the baby gets delatched breast goes on working. Whatever the baby drinks get automatically restored. Oxytocin reflex is stimulated by positive thoughts, baby’s sound, baby’s sight, and confidence. It is inhibited by stress, worry, pain. and doubt. Prolactin reflex is stimulated as early as the baby is put to breast. Also depends on as long as the baby suckles and how well is the skin-to-skin bonding. PRL reflex is inhibited by formula feeds, medications, and sore nipples. Breast milk changes throughout the feed. Early in the feed fat content is low. In midfeed, fat content increases. Finishing one breast is beneficial as the second breast has higher fat content now.2 Fig. 21.1: Anatomy of breast.
- 130. FOGSI FOCUS: AdbhutMatrutva106 HUMAN MILK COMPOSITION Mature human milk contains 3–5% fat, 8–9% protein, 6.9–7.2% carbohydrate calculated as lactose, and 0.2% minerals. Its energy content is 60–75 kcal/100 mL. Protein content is markedly higher and carbohydrate content lower in colostrums, than in mature milk. Race age parity or diets do not greatly affect milk composition. Principal milk proteins are casein homologous to bovine beta- casein, alpha-lactalbumin, lactoferrin, immunoglobulin A (IgA),lysozyme,andserumalbumin.Essentialaminoacids (AAs) closely resemble those required for the infant. The principal sugar is lactose but 30 or more oligosaccharides all containing terminal Gal (beta1–4)Glc and ranging from 3 to 14 saccharine units per molecule are also present. These may amount in aggregate to as much as 1 g/100 mL in mature milk and 2.5 g/100 mL in colostrums.2 Some of the AA may function to control intestinal flora because of their ability to promote growth of certain lactobacilli strains. Human milk fat has high contents of palmitic and oleic acids, which are heavily concentrated in the 2 position, and 1, 3 positions of triglycerides, respectively. Fatty acids correlate with diet. Phospholi- pids are phosphatidylethanolamine, phosphatidylcholine, serine, inositol, and sphingomyelin, amounting to total 75 mg/100 mL. Principal mineral contents are Na, K, Ca, Mg, P, and Cl. Calcium is 25–35 mg/100 mL. Phosphorus 13–16 mg/100 mL. Fe, Cu, and Zn vary. About 25% of total nitrogenofhumanmilkrepresentsnonproteincompounds including urea, uric acid, creatine, and a large number of AA including glutamic acid and taurine. All vitamins except vitamin K are found in significant concentrations.2 CAUSES OF LOW MILK PRODUCTION Anything that delays breastfeeding: Neonatal intensive care unit (NICU) admission Poor latching Tongue tie Sleepy baby Jaundice by birth Mastitis Scheduled or timed feeding instead of giving on demand Formula feeds (IMS) Pacifiers and dummies Smoking, drinking and addictions of mother Gestational diabetes Hypothyroidism Polycystic ovary syndrome (PCOS) Antihypertensive medications Combined oral contraceptive (COC) pills Infertility treated pregnancy3 How to increase production of milk: Ensure good diet Health supplements Plenty of room temperature water Herbal and pharmacological remedies (in pharmacological section). BREASTFEEDING BENEFITS Benefits for the Babies Contains all essential nutrients Satisfies thirst Helps in development of all body organs especially neural, liver, immune system, and blood Helps jaw development Helps resist infections, disease even later in life Reduces risk of obesity. Benefits for Mothers Reduces risk of hemorrhage Reduces risk of breast and ovarian Ca Convenient and cheap Can soothe the baby Creates bonding Lactational amenorrhea method (LAM) for contra ception.3 Getting Started Within first hour of birth. The first milk is colostrum, which is rich in proteins and antibodies. Mature milk replaces the colostrums in 48–72 hours. Lactating Sit upright, unwrap, and nose should be at the level of nipple. Bring baby to the breast and not the breast to the baby. Nipple should be aimed towards baby’s palate. Baby’s chin should be tucked into the breast. Nose should only be touching the breast skin. More of areola to be visible above the baby’s upper lip. There should be no clicking noise during sucking. How Often? 8–12 times a day in the first week of birth. Have at least five wetdisposablenappies.Have2–6runnybowelmovements till 6 weeks of life. Gaining weight and growing as expected. Baby is alert when awake and reasonably contented.
- 131. Breastfeeding 107 Sore Nipples Itis a very disgusting state. Emollients, cocoa butter, and lanolin cream is beneficial. PHARMACOLOGY Effects of Medications Once upon a time, breastfeeding was 100% up to 12 months. Baby’s daily milk requirement is 150 mL/kg/day. The pH of milk is 7.2 which is slightly acidic than maternal plasma 7.4, so it attracts oxycodone and caffeine. These drugs become ionized and get trapped in milk. Harmful effects are: Altered liver function tests (LFTs) Reduced platelet count Sudden infant death syndrome (SIDS) Deep pigmentation of teeth by tetracyclines. Commonly used drugs are mostly safe. There is a big difference between the placental barrier and breast barrier. Placenta lets the drug enter while breast acts as a barrier.4 Factors Affecting Passage of Drugs Passive diffusion Unbound drugs to proteins in plasma diffuse readily Molecule size Cross membrane in ionized form Lipid solubility Codeine, morphine causing central nervous system (CNS) effect.5 Factors Risking Adverse Effects Time of feeding just after medication Preterm babies having lower immunity Oral bioavailability Volume of breast milk Infant dose.5 Toxic Drugs Cytotoxic drugs: Cyclophosphamide, cyclosporine, methotrexate, and doxorubicin Cocaine, heroin, and marijuana Radioactive compounds: Copper and Iodine Antianxiety, antidepressants, and antipsychotics Metronidazole, metoclopramide, and chloramphe nicol Atenolol, acebutolol, bromocriptine, aspirin, ergota mine, lithium, phenindione, phenobarbitone, and primidone.4 Points to Remember Less than 1% medication appears in breast milk Most common ones are safe Drugs safe in pregnancy are all the safer in lactation period Those which are not absorbed orally, like heparin, insulin, lyapina (LA), and local creams are safe Estrogens suppress milk production so only progestin- only pills (POPs) can be prescribed and not COCs. Stimulants for Breast Milk Domperidone Metoclopramide Dopamine receptor blockers Remember antiemetic have some extrapyramidal symptoms such as hypotonicity and postpartum blues Natural: Fenugreek, herbal teas, coconut milk, and dry coconut Nonpharmacological methods: Support, positioning, and latching. Antibiotics and other Drugs which are Safe in Breast Abscess Amoxicillin plus and clavulanic acid Diclofenac Trypsin and chymotrypsin Bromelaine Serratiopeptidase. Differential Diagnosis of Postpartum Fever Lower urinary tract infection (UTI): Antibiotics, alkalizers, and urinary antispasmodics Malarial fevers: Chloroquine, primaquine, doxycycline, and clindamycin are safe, if given for short durations. Also diarrheas, viral, and fungal infections. Contraceptives Progestin-only pills (desogestrel) Depot medroxyprogesterone acetate (DMPA) Levonorgestrel-releasing intrauterine device (LNG- IUD) Lactational amenorrhea method.
- 132. FOGSI FOCUS: AdbhutMatrutva108 Postpartum Blues Can be treated with selective serotonin reuptake inhibitor (SSRI)/tricyclic antidepressants (TCAs)/valproic acid. Very small amounts in milk have been measured.5 SPECIAL CASES Following are safe: Antitubercular treatment (ATT) Epileptic treatment Anticoagulants Antihypertensive Antiasthmatics H2 receptor antagonists Antiretroviral (ARV) drugs Unsafe: Pyrazinamide Ethionamide Capreomycin Safe antiepileptics: Carbamazepine Infant monitoring is required with the following ŠŠ Valproic acid, phenytoin, phenobarbitone, and primidone Safer drugs (miscellaneous): Anticoagulants Dioxin Most Antihypertensive Angiotensin-converting enzyme (ACE) inhibitors Antiretroviral drugs Drugs for gastric disorders Antiallergics. Pathological alerts: Any serious or blood-tinged discharge alerts evaluation. Mostly (88%) are benign intraductal papillomas, fibroadenosis, prolactinemia, and infections. Drugs such as oral contraceptive pills (OCPs), TCA, dopamine antagonist, trauma, stress, pituitary adenomas, and tuberculosis. Rest 12% could be carcinomatous. Milky oozing is physiological while bloody, creamy, sticky, greenish, brownish or grey-colored, serous, and serosanguinous are other pathological types. Colostrum can last up to 2 years postpartum. Investigation modalities are sonography, mammo graphy, galactography, and magnetic resonance imaging (MRI). INDIA’S INFANT MILK SUBSTITUTES, FEEDING BOTTLES, AND INFANT FOODS (REGULATION OF PRODUCTION, SUPPLY, AND DISTRIBUTION) ACT In 1992, India adopted IMS Act and amended in 2003. Restrictions include: Advertising and promotion of IMS, feeding bottles or infant foods Unauthorized labeling of products, including complementary foods, such as use of images of mothersandchildrenorwordsthatimplysuperiority to breast milk Sponsorships,gifts,fellowships,andfinancialbenefits to healthcare providers and their associations Violations of the IMS Act should be referred to the District Civil Surgeon or District Magistrate.1 CONCLUSION Breastfeedingisassociatedwithnutritional,emotional, immunological, and social benefit. Select drug with relatively short half-life. Feed infant just before medication. Reassure that drug will return in bloodstream once plasma concentration falls. It is almost always possible for mothers to continue nursing. Drinking and smoking is absolutely contraindicated. Avoid addictions of cocaine, heroin, and lysergic acid diethylamide (LSD) dust. High consumption of tea/coffee causes disturbed sleep patterns. Coexisting mental health disorders need to be treated, but vigilance of the infant is must. REFERENCES 1. WHO/UNICEF (1989) In; Protecting, Promoting and Supporting breastfeeding; The special role of maternity service, Geneva Health Organization. 2. Farquharson J, Cockburn F, Patrick AW, et al (1992). Lancet 340, 810-3. 3. British Paediatric Association (1994) Standing Committee on Nutrition of the British Paediatric Association. Is Breastfeeding beneficial? Arch Dis Child71, 376-80. 4. Lawrence RA (1994), Drugs in Breast milk. Lawrence RA (Ed). Breastfeeding. A Guide for the Medical Profession. St. Louis;Mosby, pp. 668-769. 5. Dunlop W (1989). The Puerperium. Fetal Medical Review 1, 43-60.
- 133. CHAPTER 22 Postnatal Care ManpreetSharma, Neharika Malhotra Bora INTRODUCTION A post natal period begins immediately after birth of child. Puerperium is commonly known as first 6 weeks following child birth. Most maternal and newborn deaths occur during post natal period because of neglect. During the postnatal period either by normal or by cesarean. It is divided in two phases: 1. First phase: 6–12 hours of birth points to be looked for are as follows: i. Postpartum bleeding: To watch whether uterus has become globular and firm. Uterine massage is a big help for uterus to contract. ii. Episiotomy: Stiches to be looked for pain swelling redness and likewise treatment with good vaginal care and hygiene. ŠŠ Vitals: Pulse, BP, respiration. iii. Infant care: Immediately after birth, APGAR score is evaluated: ŠŠ Appearance ŠŠ Pulse ŠŠ Grimace ŠŠ Activity ŠŠ Respiration. Early skin to skin contact is initiated for baby and mother; and baby is put on mothers’ breasts like Kangaroo care. This practice gives warmth to baby and initiates feeding. 2. Second stage postpartum: It is for 2–6 weeks post birth. Women undergoing caesarean section, mobility to be increased so that chances of deep vein thrombosis and hypercoagulability reduces. Postpartum urinary incontinence is experienced by some women. Patient has to be taught perineal exercises to overcome this. Lochia: It is discharge from uterus after delivery which changes its color from bright red to brownish in 4–6 weeks’ time. Adult diaper and sanitary pads are to be used and changed frequently. Look for secondary postpartum hemorrhoids if color of lochia, becomes fresh. Hemorrhoids and constipation in this period is very common. Newborn needs frequent feeds for which help by relatives or health visitors is needed. PSYCHOLOGICAL PROBLEMS Postpartum depression It can affect both sex of parents. Early detection and early treatment is required. DELAYED POSTPARTUM PERIOD Lasts up to 6 months Muscles and connective tissue return more or less to normal prepregnancy levels Duringthisperiodbecauseofinfantregularsleeppattern mother also gets time to sleep and her general condition improves, and her normal sexual activity can start. DIET DURING POSTNATAL PERIOD Women needs to maintain balanced diet with iron, folic acid. Supplementations should also continue for 3 months after birth Should drink sufficient water Nutritional counselling Advise women to eat healthy food like meat, fish, seeds, oils, fruits cereals, beans, cheese and milk Mothers to be counselled that this food is nutritionally healthy and will not harm breast fed baby Taboos for food are to be talked over or avoid hard physical work. POSTPARTUM DANGER SIGNS FOR THE WOMEN Vaginal bleeding changed color to red Fits and convulsions Fast breathing
- 134. FOGSI FOCUS: AdbhutMatrutva110 Fever Weakness Severe headache, blurring of vision Calf pain redness and swelling Swollen red or tender breasts Problem in urination Infection or increased pain in perineum Infection in the area of wound Smelly discharge pervaginum Severe depression or suicidal tendency. GETTING BACK IN SHAPE: BY YOGA, WARM OIL MASSAGES, BY DIET AND NUTRITION Exercises Belly binding. POSTPARTUM CATCH UP VACCINATIONS 1. Hepatitis B: Getting back in shape 2. Influenza: Exercise, belly binding 3. Cervical cancer vaccine Any other: Warm massages Diet and nutrition. DANGER SIGNS FOR NEWBORN Difficulty in breathing Fits, convulsion Increased temperature Not feeding properly, rigors Yellow palms and soles Diarrhea excessive vomiting Ulcers or thrust within the mouth. DIET IN POSTPARTUM Daily requirement of postpartum female: High zinc: 11–12 mg/day Proteins: 75 gm/day Calcium: 1000 mg/day Vitamin C: 120 mg/day. Those all can be taken from: Liquids: Water 2–3 L/day Milk Fruit juices. Leafy green vegetables: Spinach, Broccoli, Indian gourd, Bottle gourd, Carrots, Dark leafy vegetables. Whole grain cereals: Almonds, fenugreek seeds, cumin seeds, sesame seeds. High protein: Milk, cheese, yogurt, meat, fish, egg, beans Take prenatal medicines or iron/calcium. Foods to be avoided: Limit junk food Alcohol Caffeine Swordfish, Shark, Tilefish.
- 135. CHAPTER 23 Contraceptions tobe Used After Child Birth Manpreet Sharma INTRODUCTION These are following methods which can be used after child birth: Breastfeeding Intrauterine device: Immediate postnatal After 6 weeks of birth Birth control implants Injections Hormonal methods Barrier methods Permanent methods: Vasectomy (Male) Tubal ligation (Female). BREASTFEEDING If one is giving exclusive breastfeeding and is having lactational amenorrhea, then this method works as a contraception but certain times it is not a sure-shot contraception and fertility may be resumed without ones knowledge. Following are method, which are safe during feeding. INTRAUTERINE DEVICE Intrauterine device (IUD) is a small T-shaped device that healthcare professional can insert in uterus cavity. Types of Intrauterine Device For immediate postpartum use: After normal delivery After LSCS. Hormone releasing IUDs: It releases small amount of hormones (progestin) into uterus and can be approved for 3.5 year of use. Copper-releasing IUDs: It releases small amount of copper into uterus and is approved for (according to make of IUDs). 3 years 5 years 10 years. Risks of IUDs Intrauterine device may come out of uterus its own if not applied properly. Irregular bleeding per vaginum—sometimes this occurs for first 3 months of application. This usually decrease as the time advances. Intermenstrual pains. Benefits of IUDs Intrauterine devices are safe with intercourse and day-to- day life. CONTRACEPTIVE SKIN IMPLANTS It is a small plastic rod which is: Inserted under the skin, inside of upper arm. It slowly releases hormone progesterone to stop ovulation. It is 99.95% effective. Side Effects May give rise to scanty bleeding Amenorrhea and unpredictable bleeding Mood swings, headache, acne Minor weight gain. VAGINAL RING It works same way as combined pill. It is not recommended, if one is exclusively breast feeding a child under 6 weeks. It can reduce supply of milk. Ring is inserted high in vagina for 3 weeks, and then is removed for 1 week to have regular periods. It is 99.7% effective, if used properly.
- 136. FOGSI FOCUS: AdbhutMatrutva112 BIRTH CONTROL INJECTIONS It contains depot medroxyprogesterone acetate, commonly known as depot medroxyprogesterone acetate (DMPA). It also prevents ovulation. It can be given every 3 months after vaginal or cesarean delivery. It is given intramuscular (IM), either in arm or buttock. Side Effects May give irregular bleeding per vaginum (PV) Amenorrhea Slight weight gain Headache. PROGESTIN ONLY PILLS These pills contain only progestin. It has to be taken everyday at same time. Advantages It does not interfere with sex and reduces bleeding. Side Effects Headaches Nausea Breast tenderness. Contraindications Breast cancer. BARRIER METHODS It includes: Spermicide Male and female condoms The diaphragm Cervical cap It should be started after 6 weeks of child birth. Benefits Barrier method usually protects sexually transmitted diseases. It has no effect on hormones Effectiveness of contraception methods. Note: The percentages indicate the number out of every 100 women who experienced an unintended pregnancy within the first year of typical use of each contraceptive method.
- 137. Contraceptions to beUsed After Child Birth 113 Side Effects Sometimes patient can feel itching in vagina, burning in vagina. Allergic to spermicides Can increase the risk of getting human immuno deficiency virus (HIV) from infected person. NATIVAL METHODS OF CONTRACEPTION These are fertility awareness methods Rhythm, cervical mucus observation and basal body temperature. High failure rates are associated with these methods. Permanent Methods (Sterilization) For Males: Vasectomy It takes about 2–4 months for semen to become totally devoid of sperms. So, for prevention of pregnancy, another method of birth control till sperms is not found in semen. For Females: Tubal Ligation Sterilization in females can be performed immediately after delivery. Interval ligation, whenever required. These procedures are permanent. If one wants to get reversal of these methods, it is possible but results are not guaranteed.
- 138. CHAPTER 24 Save Girl–EducateGirl–Empower Girl Nisha Sahu, Shashi Khare, Pushpa Pandey, BK Shubhada Neel I do not want to be remembered as the girl who was shot. I want to be remembered as the girl who stood up. —Malala Yousafzai INTRODUCTION Girl is always a blessing, an honor. They are the spirit of nation and pillars of society. With empowerment and the right support, girls can change the world. Many of them are already doing just that across the globe. They are standing up as never before and demanding to be free and contribute to the growth of our society. They are fighting against discrimination and gender inequality which is deeply rooted in our society. Gender discrimination is one of the main impediments to the progress of human race. Girls like Malala. Girls who have stood up at countless risk and who are requesting us to stand with them. Malala is far from alone in facing terrible danger because of her power as a girl. Any nation will not progress until both the genders are provided with equal opportunities and it is high time for us to recognize that girls are nobody’s property and nobody’s victims. Rather girls are the most powerful catalysts for a different world. BARRIERS TO GIRLS’EQUALITY Forasustainabledevelopmentofanynation,itisimperative to have gender equality. The main impediments toward gender equality faced by girls are: Education: Access to basic education is crucial for anyone to pursue their dreams and become independent. Yet the statistics reveals that across the World, there is a prejudice against girl child in terms of education. Globally, 62 million girls are out of school. Child marriage: More than 700 million women in the world today were married before their 18th birthday and one in three of those women was married before age 15. This boils down to the fact that at early age various household responsibilities are bestowed on girls keeping them away to pursue their dreams. Maternal mortality and reproductive health services: Maternal mortality is the second leading cause of death, after suicide, for teenage girls particularly aged 15–19 years. An estimated 70,000 adolescent girls die each year from complications during pregnancy or childbirth and every year 2.5 million girls under 16 give birth. Financial segregation and gender bias: With limited household income, societal norms in many places ensure that boys get the priority in terms of education, health and nutrition. Subsequently, more than 33% of young women in developing countries are jobless, i.e. out of the formal organized sector. Decision making: It is one of the main sources of empowerment for any gender. Girls are often marginalized at all the levels including cultural and institutional. Girls may be uncomfortable expressing themselves, and when they do, they often are not heard or valued. Traffickingandoppression:Girlsaredisproportionately affected, particularly by forced sexual exploitation. Due to lack of education and optimum source of income when girls try to search for better lives they may be deceived or pushed into forced labor or sexual mistreatment. INDIAN SCENARIO Post-economic liberalization of 1991, India achieved 6–7% average GDP growth annually and became the World’s fastest growing economy in the World. Yet gender inequality subsists in Indian Economy in all the sectors of life be it education, health, cultural, economic or political. Discrimination against the girl child is a very grave social problem prevailing in India. The societal and cultural thinking in India encourages preference for male child. Patriarchy is entrenched in the Indian society that even though one may try their hardest to uplift women to the level of men, patriarchy pulls them down.
- 139. Save Girl–Educate Girl–EmpowerGirl 115 The girl child’s discrimination begins before birth in the form of female feticide. The gender discrimination is reported to have claimed a whopping 50 million female lives. The practice of female feticide is widespread despite it being an illegal activity. Census of India (2011: provisional data) has revealed the worst child sex ratio (0–6 years) since India got independence. The sex ratio is defined as the ratio of males to females in a population, and is generally expressed per 100 females. In India, sex ratio is expressed as number of female per 1,000 male. Biologically normal child sex ratio ranges from 102 to 106 male per 100 female, converting the same in Indian terms it is 943–980 females per 1,000 males (World Health Organization, 2011). The current sex ratio as per the census figures as shown in Table 24.1 (provisional population totals, 2011). This gap is quite large between the anticipated biological child sex ratio and the prevalent sex ratio. This constant drop in child sex ratio is a disturbing figure even governmentandtheindependentbodiesaretakingactions in the form of laws, schemes and awareness campaigns (Fig. 24.1). No doubt India is putting its best efforts to be an technology superpower, tragically technologies which enable a series of prenatal investigative tools to categorize and cure any potential birth defects and associated abnormalities, are altered for selectively aborting female fetuses after such prenatal sex determination in spite of a legal regulation banning them. Techniques such as amniocentesis were introduced in 1975 to identify any genetic abnormalities which wretchedly became a tool for sex determination and a cause for death for the unborn female fetuses. Subse quently, and as a consequence, to both female feticide and infanticide there is a sharply declining sex ratio. The United Nations report says that about 750,000 girls are aborted every year in India. Abortion rates are increasing in almost 80% in Indian states, mainly Punjab and Haryana. These two states have the most number of abortions annually. This practice is more common among the weaker sections because of pecuniary scarcity and the education and marriage of a daughter is considered a financial problem on their parents. Female feticide and infanticide are not the only matters with a girl child in India. At every stage of life, she is discriminated and mistreated for education, nutrition, health facilities and living standard. She is pushed to get married before the legally prescribed age depriving her right to be literate and educated. Absence of education results in high fertility rate and aggravates the condition of females in India. According to the United Nations International Children’s Emergency Fund (UNICEF), in 1984 in Mumbai alone 7,999 out of the reported 8,000 abortions that took place were of girls. Girl children are killed shortly after being born when the family comes to know the sex of the child or killed slowly through neglect and rejection. In 1993 in Tamil Nadu, 196 girls died in suspicious circumstances. EVOLUTION OF THE LAWS AND POLICY It is said Indian government was one of the first few that took initiatives to the need of saving the girl child. Over the past few periods, the Government has introduced laws for deterrence of female feticide, it has announced special schemes that inspire families to have girl child and it has also undertaken various campaigns such as Save the Girl Child. Flowchart 24.1 summarizes the evolution of these initiatives taken by the Government of India and independent bodies for this novel cause. ROLE OF FOGSI The Federation of Obstetric and Gynaecological Societies of India (FOGSI) as a society has taken action and taking the lead in “Operation Beti Bachao”. FOGSI has Fig. 24.1: Sex ratio and child sex ratio, India 1990–2011. (Source: Census of India, 2011). Table 24.1: Sex ratio and child sex ratio. Year Sex ratio Child sex ratio 1991 927 945 2001 933 927 2011 940 914 (Source: Census of India, 2011).
- 140. FOGSI FOCUS: AdbhutMatrutva116 Flowchart 24.1: Evolution of the laws and policy—some initiatives taken by the Government of India and independent bodies. many volunteers, contributors and members for their involvement in education, steering general checkups, vaccination, adoption and fund-raising programs. Many branches of FOGSI are also participating in these activities. Empowerment of women starting from fetus in womb through holistic health education to every pregnant women (counseling, diet, physical, mental, social health care). Educational session for healthcare professional— anganwadi, supervisors, auxiliary nurse midwife (ANM) on their meeting, training by lecture, poster presentation. Girl’s schools of that area are empowered through holistic health education by lecture, poster presentation Involvement of religious, political and female organization of that area with gynecological, radiological association in every program Nukkad drama, rally, pledge for protection and safety of girl child Media involvement by articles on “save girl child”. FOGSI also have FOGSI—Mylan Smriti awards that are given for FOGSI society for special effort and activities addressing issue of saving the girl child. IMPORTANCE OF EDUCATING GIRLS In the current times, women are contending with men in all domains of life. Today, people not only understand the importance of quality education, but also send their daughters to school. A girls’ education can bring about a phenomenal change in the society and everyone is aware of this fact. However, things remain as it is in several rural parts of India, where people still do not send their daughters to schools due to cultural and pecuniary reasons. While some people think, due to sociocultural thinking, that girls should know nothing apart from household chores, others cannot afford to give their daughters proper education. Educated girls grow up to become educated women who can play an important role in the development of society be it political, cultural, economic or social sphere. Education not only empowers a grown up girl, but also makes her choose their dreams and become economically independent. This economic independence makes a woman feel self-assured about herself and gives her a sense of achievement. This is in-turn fight against the grave issue of gender inequality.
- 141. Save Girl–Educate Girl–EmpowerGirl 117 Aneducatedwomaniscapableofsharingtheburdenof men in the different spheres of life. In this age of economic crisis, it is hard for the middle class to make both ends meet. Educated and working women can add to the total income of their family and ensure that her children also learn and educate themselves. Educated girls can not only advance their own lives but can also enhance the future of the country by giving their children a good upbringing. Education leads to freedom of thought and broadens a woman’s outlook. This also makes her aware of her responsibilities and duties. EMPOWER THE GIRL CHILD It is very important to ensure that every girl child gets quality education. Working with top corporates, save the children has facilitated education across thousands of schools across the country by imparting training in extracurricular activities. The organization has mapped many out-of-school children and encouraged families to send their daughters to school. Many community events are also organized to sensitize families and communities about the relevance of girl child education. Empowerment of the girl child with the help of education will bring about a big change in the country. CONCLUSION As highlighted above, there is an imperative need to give impetus to the importance of raising public consciousness of the poor conditions some girls face. It is important to educate community members on their responsibilities for the betterment of our future. There is a need to sensitize the public to the difficulties of early and forced child marriages. Current trends of rapidly decreasing family average size, preference for male child remaining the same, the female population is showing a downward trend which definitely needs to improve with participation from society as well as government. Various initiatives are taken by Government, but it raised a question, whether it will be possible with current strategy to raise sex ratio in favor of girl child successfully or do we really need to internalize the process in favor of woman by taking some legislative measures? Just like these, there are many questions which are unanswerable, because the child ratio between 0 year and 6 years lessening day-by-day instead of growing. Empowerment of girls and gender equality is the need of the hour in every sphere whether it be education, social, political or economic in order to improve the overall status of our society and for a better future for all of us. BIBLIOGRAPHY 1. Annual Report of the Union Ministry of Women and Child Development, Government of India, New Delhi; 2015. 2. Day of the Girl Child-Gender Equality, UNICEF; 2014. 3. Hendriks SE, Bachan K. Because I Am a Girl: The Emergence of Girls in Development, Oxford: Oxford University Press; 2015. 4. Human Development, Economic Survey, Union Ministry of Finance, Government of India, New Delhi; 2016. 5. Resolution 66/170 adopted by the United Nations General Assembly. International Day of the Girl Child, United Nations, New York; 2011.
- 142. CHAPTER 25 Medicolegal Aspectof Maternity Care MC Patel INTRODUCTION Medical profession is the most noble, but dealing with the most complicated science of human life. Obstetrician and gynecologist deals with two patients at a time mother and fetus, so they are more prone to legal issues. Maternal mortality and infant mortality is matter of worry and great concern to obstetrician. As compared to neighbor countries, India is far behind the figure. Of course as compared to past, India has done well to check maternal mortality ratio (MMR) and infant mortality rate (IMR). Of course it is satisfactory, but long way to go yet. We can be quite hopeful to reach target with joint efforts of government, Federation of Obstetric and Gynaecological Societies of India (FOGSI), Indian Medical Association (IMA), social organizations working in field of education and health care, media and other organizations. Illiteracy and poverty is the main cause for the same. Either patient is poor and does not afford proper in time treatment or unaware of facilities available free near bye in government set up or any other organizations. To educate them for regular in time proper antenatal care to pick up high- risk pregnancy and to manage accordingly in time and to encourage them for institutional delivery. Thus, antenatal care becomes one of the most effective ways to check MMR and IMR. In some situations, it is very difficult to reach final diagnosis and etiology behind it. Many a times, patient is brought very late in critical condition, but in any given situation once patient is brought to the hospital, they consider doctor responsible for any outcome because they consider it physiological rather than pathological. Doctor is also under obligation to manage the patient with due reasonable care and skill. In spite of all these limitations, doctorworksinemergency24hoursadayandsevendaysa week. But expectations of patients and relatives are so high that, in spite of all efforts on part of a doctor, if anything goes wrong or expected result is not achieved it is all likely that doctor may have to face litigations. IGNORANCE OF LAW IS NO EXCUSE As soon as any act, any law, any ordinance passes in government gazette it is presumed by law that each citizen of India knows law and that is why ignorance of law is never an excuse. Doctor may have to face litigations either under Consumer Protection Act (CPA) 1986 (amendment 2003) or under civil suit or criminal case and sometimes simultaneously under both CPA and criminal or civil and criminal. One may has to face litigation in medical council also. PREVENTION IS ALWAYS BETTER THAN CURE There is no separate law for maternity care. General principles of law apply in any given situations or in any given case in managing any patient including antenatal patient. There are some situations which becomes potential for litigations. They are alarming situations; one should be vigilant enough not to end up in to litigation. Alarming Situations There are certain alarming situations in which one should be alert and vigilant. Missing important investigations to advice during antenatal visit, i.e. Forgot blood grouping—later found to be Rh- negative Forgot to do nuchal translucency/double/triple marker test and baby had Down’s syndrome Forgot to do gestational diabetes mellitus (GDM) screening and patient found to be having complications or intrauterine fetal death later Forgot to screen for thalassemia and baby delivered with thalassemia major Forgot to screen for thyroid profile and something goes wrong Forgot to ask for history of allergy
- 143. Medicolegal Aspect ofMaternity Care 119 Patient or relatives dissatisfaction Asking to take second opinion and one has refused Asking to shift the patient to another hospital and one has refused or delayed Complications or an unexpected result: Failure of procedure/operation Trauma/injury Hemorrhage Infections Complication of anesthesia Tremendous expense against not expected result Death of a young patient Request for medical record and one has refuse Failure of a patient to keep scheduled follow-up and ended into complications. So, if one is dealing with this situation, should be alert to face litigation. Prevention is always better than cure. Here are some tips to follow to avoid litigation: Proper antenatal care: Antenatal care is systemic supervision of woman during pregnancy It provides necessary therapeutic interventions and educating pregnant woman about planning of safe delivery, to pick up high-risk factors in time and planning accordingly, manage emergencies during pregnancy, and due intensive management accordingly Antenatal visits: ŠŠ Proper history with age, any symptom, detail menstrual [last menstrual period (LMP)] and detail obstetric history with past deliveries, abortions, mode of delivery, complications, etc. ŠŠ History of any systemic illness, surgery, hospitalization, etc. ŠŠ Proper counseling for antenatal visit monthly up to 32 weeks, biweekly after 32 weeks up to 36 weeks, and weekly up to delivery ŠŠ If any high-risk factor, then frequency of antenatal visit will be more ŠŠ Proper instructions during every visit Proper physical examination: ŠŠ Systemic examination ŠŠ Abdominal examinations including fetal heart auscultation when it becomes audible. Pelvic examination: ŠŠ Perspeculum and pervaginal examination as per case Investigations Blood: ŠŠ Grouping ABO Rh ŠŠ Complete blood count (CBC): Hemoglobin at initial visit and at least once in each trimester. If patient is under treatment for anemia frequency of test for hemoglobin will be more ŠŠ If anemia, treat meticulously and if any high-risk factor, then frequency of investigations will be more ŠŠ Venereal disease research laboratory (VDRL)/ hepatitis B surface antigen (HBsAg)/human immunodeficiency virus (HIV) ŠŠ Sugar: As per FOGSI guideline or Diabetes in Pregnancy Study Group in India (DIPSI) guideline, fasting blood sugar (FBS) at first visit and glucose challenge test (blood sugar after 1 hour of 50 g glucose irrespective of fasting status) between 24 weeks and 26 weeks ŠŠ Thyroid profile ŠŠ Test to rule out thalassemia trait ŠŠ Specific investigations as per condition Urine examination: ŠŠ Routine and microscopy with albumin and sugar Ultrasound examination: ŠŠ In early pregnancy to confirm intrauterine/ ectopic pregnancy ŠŠ During 11–13 weeks scan for NT and to rule out congenital malformation ŠŠ About at 22 weeks for four chamber view of heart, three vessels view and out flow tract, and to rule out other anomalies ŠŠ During 32–34 weeks for fetal growth parameters, liquor, and placental localization and to rule out accreta, increta or percreta Immunization: ŠŠ Twodoseoftetanustoxoidinjection0.5mL/dose deep intramuscular in upper arm at interval of 1 month after first trimester ŠŠ Second dose at least 1 month before delivery ŠŠ Prophylactic injection anti-D at 28 weeks in case of Rh-negative patient. Drugs: ŠŠ Tablets iron folic acid (100 mg elemental iron and 0.5 mg folic acid) daily till delivery and even in postpartum period also for some period as per case after first trimester ŠŠ Tablet calcium 1,000 mg daily after first trimester ŠŠ Otherdrugsaspercase,i.e.GDM,pre-eclampsia, etc. Diet and nutrition: ŠŠ Counseling for nutrition and proper diet
- 144. FOGSI FOCUS: AdbhutMatrutva120 Institutional delivery: Naturally institutional delivery under supervision of trained obstetrician will check MMR and IMR High-risk factors will be picked up at proper time and will be managed properly Emergencies will be taken care accordingly Identification of high-risk patients and management accordingly in higher centers: Will reduce morbidity and mortality so less litigations Take tender care with compassion of your patient during treatment/surgery: Because those who are open, pleasant, and communicative are much less to be sued, as patients are extremely forgiving of errors made by a friendly and concerned medical attendant Proper counseling about: Antenatal visits with follow-up visits Required investigations including HIV testing/ ultrasound examination/duel/triple/quadruple markers (as per case) Drugs Nutrition Rest Exercise Lifestyle considerations Period of pregnancy, probable complications, mode of delivery without come, and probable complications Postpartum period and probable complications Newborn care and contraception Available maternity care services Maternity benefits Government scheme related to maternity care Expert opinion whenever needed: Help taken from any expert or senior colleague in time always helps not only to the patient but to the treating person if he has to face any litigation. Because efforts to save life of patient are always considered by the court Take valid consent: Proper counseling and taking valid consent is also good defense, if one has to face any litigation Meticulous record/proper documentation: It reflects efforts taken by treating person to save life of patient. Naturally good record is good defense, poor record is poor defense, and no record is no defense. Thing done, if not recorded means thing not done. Meticulous record is always at your rescue when facing litigation Importantbillofpurchaseofdrugs,oxygencylinder, and emergency instruments, i.e. Ambu bag, ventilator, etc. should be preserved. Bill of refilling of oxygen cylinder is also important document. Printed protocols: Pregnancy profile to be handed over at first visit. It should be in local language. Signature of patient should be taken. If patient does not follow the instruction, it becomes contributory negligence which one more good defense in favor of treating person Ensure that you will not miss any high-risk factor Emergency box: Should be available round the clock Please check at regular interval about expiry date and update it in time accordingly If you are providing ultrasound services, please get your center registered under Pre-Conception and Pre- Natal Diagnostic Techniques (PCPNDT) Act and strict compliance with the provisions of the Act Please do not issue any certificate in absence of patient or in back date In event of death, if you are not sure of cause of death, please do not issue death certificate. Advise postmortem examination Inform police, if required Comply with the provisions of law Security alert Closed-circuit television (CCTV) coverage at every strategic point Formation of local level rush team/medicolegal cell to have surgical assistance in emergency and assistance in event of sudden death on table, mob violence, and other odd situations and medicolegal consequences Collective responsibility in unusual circumstances. Do not blame each other when treating persons are more than one Proper communication with relative about mishap (special attention) Take medicolegal advice from point one, if required Identify yourself well in the court: Tender loving care with compassion is secret of success in any case. Take care of any patient as if she was your family member. Majority of litigations or any legal issues will not occur and if at all occur, will be solved with proper approach. —Have a litigation free practice.
- 145. CHAPTER 26 Preventing CervicalCancer and STDs Bhagyalaxmi Nayak, BK Shubhada Neel INTRODUCTION Cervical cancer is a great public health challenge accounting for 20% of the world’s incidence and mortality. It is second only to breast cancer in Indian women, cancer breast becoming the most common in the last few years (GLOBOCAN 2018). New cases detected in our country each year are 96,922 and mortality due to cervical cancer is 60,078—which is a slight decline from the previous years but remains a dismal high as compared to developed countries. One-fourth of the world’s cervical cancer patients are in India. India has a large population of 432.20 million women aged more than 15 years.1 This group is at an increased risk of developing cervical cancer though the incidence of cervical intraepithelial neoplasia (CIN) in adolescence has seen an increase in the recent past. Though the factors leading to high prevalence of cervical cancer in India are many, they are all known to us and need attention and execution. The high mortality is unfortunately not prevented yet. It is due to mainly lack of awareness about the disease in common men and women and partly due to absence of not so feasible organized screening programs. Here comes the role of human papillomavirus (HPV) vaccination. It is good to know that 58 countries have already included HPV vaccine in their national immunization schedule so that the prevalence of cervical cancer can be brought down. Simultaneously, there is a large unmet need for an organized screening program throughout the country, which cannot be ignored. Cervical cancer is a huge health problem in spite of it being an absolutely preventable disease and is an indicator of general health status of females. Though there has been an appreciable decline in the number of new cases and number of deaths due to cervical cancer in India (GLOBOCAN 2018) still there is a long way to go. Mothers are not dying because of diseases we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving (Mahmoud F Fathalla). It is so true for cervical cancer. So let us all stand up together to prevent the preventable disease and make it a story of the past. Persistent infection with high-risk HPV has been now proved beyond doubt to be a necessary cause for cervical cancer. HPV vaccines are virus-like particle (VLP) vaccines that protect against infection with HPV. Hence it looks promising to be able to eradicate cervical cancer with the advent of cervical cancer vaccine and making it a part of the universal immunization programme, as has been the case with polio. But implementing HPV vaccination has not been very feasible due to many reasons. Preventing cervicalcancerisagreatchallengetomoderndaymedicine not because of its nature but for the taboo attached to it and that it being asymptomatic in its precancerous and early invasive stages. Convincing women to take a preventive healthcare checkup in a country like India is a Herculean task. Women education and empowerment are the answer to cervical cancer prevention when they come forward to ask for screening. And that is when we know the sun will rise in the horizon of new India. Being optimistic is the way forward. There has been slow but steady progress in women education, empowerment, and healthcare accessibility and affordability. Cervical cancer has almost become synonymous to low socioeconomic status and resource poor situations. The problem is not only the high prevalence but also the high mortality due to this disease because majority present late. Every 7 minutes, an Indian woman dies of cervical cancer (WHO, 2010). Survival rate is poor and less than 50% women diagnosed with cervical cancer are able to survive for more than 5 years, because there are no symptoms in the early stages. The reason for such a high mortality due to cervical cancer is late diagnosis. Despite the considerable burden of cervical cancer in India, there are only few meager organized cervical cancer screening programs in the country. Majority of these are done by NGOs and philanthropic organizations. The majority of womenarediagnosedonlyaftertheybecomesymptomatic or at advanced stages of disease, with poor prognosis.
- 146. FOGSI FOCUS: AdbhutMatrutva122 Screening of asymptomatic women is practically absent, (2.3%). It is estimated that less than 1.5 million smears are opportunisticallytakenannually.Thequalityofthesmears, the technical expertise to report on the smears, follow- up of the abnormal reports and their treatment is a huge challenge. In recent years, HPV DNA testing is increasingly being used in the private sector, though it is likely that less than 50,000 HPV tests are carried out annually as it is not very economically available. Women in India have very low awareness about cervical cancer and in fact any other sexually transmitted disease (STD) in that matter and its prevention. In a study, nearly half of Indian women (45%) showed that they were worried more about obesity than developing cervical cancer (24%). Similarly a study in Chennai showed that majority of women (69.6%) were not aware of cervical cancer and very few (16.4%) were aware of screening tests available. A recent report by WHO states that low- and middle-income countries, where more than 85% of cervical cancer deaths occur, can particularly benefit from HPV vaccine. HPV vaccine has one of the highest per-person impacts on mortality of all vaccines. In the longer-term, high HPV vaccine coverage will reduce the economic and human costs of cervical cancer treatment. Moreover, in Indian settings, where women have less access to cervical cancer screening the vaccine would be particularly beneficial, though on the long run. Regular cervical cytology examination (Pap smear) for all women who have initiated sexual activity can prevent the occurrence of cervical cancer. The primary aim should be to offer once a lifetime screening for all women around the age of 40 years. It is the coverage of screening that is important to bring about a change in incidence. Political willtodoitisthemostexpectantwayforward.Government and private healthcare providers can join in this effort and offer these services. Though cytological examination has been the mainstay for early detection of cervical cancer, its widespread use has not been possible in our country due to paucity of resources, other emerging health issues and lack of manpower and other facilities. Looking at alternative strategies such as naked eye visual inspection of cervix (down staging), visual inspection with acetic acid (VIA), magnified VIA (VIAM), visual inspection with Lugol’s iodine (VILI), cervicography, and HPV DNA testing in detecting cervical cancer and its precursors have to be adopted depending on the socioeconomic settings in which we are working. Regular screening through VIA along with treatment in the same sitting would be the most optimistic way looking at the problem and our resources. However, further referral for treatment may be needed in many cases for which we need to be equipped. Screening without treatment of the lesions fails the purpose of screening. As the age affected by cervical cancer is decreasing thus a study has suggested that screening should be initiated at 25 years of age. Screening approaches in India and other developing countries can reduce the lifetime risk of cancer by approximately 25–36%. A national HPV vaccination program appears to be practically possible as compared to screening program in India. The infrastructure and trained personnel for vaccinationarealreadyinplaceatalllevelsofhealthservice delivery. Policy makers should realize the importance of this vaccine and should seriously consider including HPV vaccine in National Immunization Schedule. The vaccine is creating a buzz in the private sector. Efforts should be made to increase the awareness about this disease so that the unfelt need of the society can be converted into felt need. A vaccine program cannot be successful without the support and approval of the general public so media should be very responsible. Role of press should be supportive and adverse effects following immunization (AEFI) should not be misreported and blown out of proportion. At present, cervical cancer prevention depends on various segments—primary prevention and secondary prevention. Primary prevention includes vaccination and screening for detection of precancerous lesions of the cervix and treating them. Vaccination: The vaccines approved by FDA and now available are the quadrivalent vaccine by Merck called Gardasil, the bivalent vaccine by GSK called Cervarix and the more recently launched nonavalent vaccine Gardasil 9. Gardasil 9 is not available in India right now. Vaccination of children and adolescents today will prevent 90% cervical cancer but the results will show after may be two decades. HPV vaccination, when used judiciously, has the potential to reduce cervical cancer incidence globally by around roughly 90%.2 As of now, we have enough evidence to show that protection against the vaccine related HPV types has been found to last for 10 years with Gardasil,2 9 years with Cervarix,3 and 6 years with Gardasil 9.4 More than that, the vaccines may also cut down on the costs for screening and subsequent medical care, biopsies, and invasive procedures associated with follow-up from abnormal cervical screening and thus help to reduce healthcare costs and anxieties related to follow-up procedures.5 HPV vaccine if administered before the diagnosis of pregnancy, termination of pregnancy is not deemed necessary. However, further doses of vaccine need to be withheld. Vaccination can be safely continued after child birth during lactation. The Centers for Disease Control and Prevention (CDC) developed recommendations regarding all vaccination,
- 147. Preventing Cervical Cancerand STDs 123 including HPV vaccination. The current CDC recommen dations for vaccination are as follows:6 All children aged 11 or 12 years should get two HPV vaccine shots 6 to 12 months apart. If the two shots are given less than 5 months apart, a third shot will be needed. There could be future changes in recommendations on dosing. HPV vaccine is recommended for young women up to age 26, and young men up to age 21. Adolescents who get their first dose at age 15 or older need three doses of vaccine given over 6 months. (0, 1, 6 or 0, 2, 6 as the vaccine schedule may be) Persons who have completed a valid series with any HPV vaccine do not need any additional doses. To curb the menace today screening and treatment of precancerous lesions is the only answer. SCREENING FOR CERVICAL CANCER Methods Available Cervical cytology has been the oldest method of screening and well-organized cytology programs have been very successful to bring down the cervical cancer rates in many countries, the glaring example being British Columbia and Canada. It could be conventional cytology, liquid base cytology (LBC), or more advanced automated Pap smear testing methods (AutoPap and AutoCyte Screen). Nonetheless it is difficult to sustain effective cervical cytology programs in developing countries like ours. Visual inspection methods: Visual inspection of the cervix with naked eye [after application of acetic acid (VIA) or Lugol’s iodine (VILI)]. The test characteristics have been evaluated in many field studies and sensitivity ranges from 67% to 79% and specificity 49– 86%.7 HPV-based screening tests: With the discovery of HPV as a necessary cause of cervical cancer by noble laureate Harald zur Hausen, testing for the presence of HPV as a marker for cervical cancer has emerged as an important screening modality. TherearevariousmethodsoftestingforHPV:CareHPV, Cervista, Hybrid Capture 2, E6/E7 mRNA, etc. They rely on molecular technologies to detect HPV DNA in cervical or vaginal fluids. Detection rates of high-grade lesions by this method are far better than visual methods and cytology. They can however, complement each other which further improves the pickup rates. Though very sensitive, the specificity of these tests lacks specificity. Hybrid Capture 2 is the most commonly used method of HPV testing. With the availability of simple, affordable, and accurate HPV tests, it can be used as a primary screening approach in low-resource settings for women who are at least 30 years of age.8 Transient HPV infections are picked up as HPV positive in women where no cytological changes have occurred. Managing such women can be challenging. FOGSI GCPR is an extremely useful guiding tool to decide on screening modalities to be followed and also to manage the screen positives according to the resource settings in which we are working. There is, in fact, everything that can be done in every situation. But looking at the diverse demographic characteristics of Indian population and the large unmet needs of screening, visual methods of cervical screening have emerged successful candidates in resource poor settings. Of these, visual inspection after application of 3–5% acetic acid and visual inspection with Lugol’s iodine are the simplest and easily available and affordable. More than that, these can be done by healthcare workers and paramedics.Hence,alargepopulationcanbescreenedand a single visit “screen and treat” will be the most effective method of bringing down the rates of cervical cancer. Awareness program about the preventable nature of the disease and the preventive measures that are available is again a crucial step that does not get due importance. Then coming to secondary prevention, this includes early detection which may be in symptomatic or asymptomatic women. This is again a large segment which is missed out because per speculum examination is falling out of practice. Neither the patient nor the healthcare professional appreciate the great importance of doing a perspeculum examination, the great secrets that it reveals which no Hi-Tech Investigation will. Please do not lose the opportunity of doing a perspeculum examination for all women attending any healthcare facility for any problem. Screen Positive Women This is a supplement to the screening program that cannot be ignored. Hence developing a support system to convince patients for treatment as close to their homes is a trick that will do it. Hence screen and treat would be good alternative and wisest option in India and accepting the rates of overtreatment is the fine we pay for that. FOGSI RECOMMENDATIONS Human papillomavirus vaccines are licensed for use in females aged 9–45 years; however, the preferred target age group is 9–14 years (Level A). Vaccination in sexually active females may be less effective, but may provide some benefit as exposure to all vaccine types previously is unlikely (Level B).
- 148. FOGSI FOCUS: AdbhutMatrutva124 Females aged 15–25 years should be considered for catch-up vaccination program only if resources are available (Level B). Girls aged 9–14 years of age should receive two doses of HPV vaccine at least 6 months apart, although the interval between two doses can be extended to 12–15 months in circumstances where the second dose is not repeated within 6 months (Level A). Catch-up vaccination can be offered to females more than 15 years till 26 years. They should receive three doses, however, the second dose should be given after 1 or 2 months (depending on the vaccine that is used) and third dose after 6 months of the first dose (Level A). Older girls/women who have been sexually active should be counseled regarding reduced efficacy of HPV vaccine and the importance of screening from the age of 25 years. (Level A). Screening of HIV-positive women should start in the first year of diagnosis irrespective of age (Level A). In order to enhance the coverage, ART services should be integrated with cervical screening program (Level B). In good-resource settings screening should be continued as per age recommendation every 3 years up to 65 years (Level A). In limited resource settings, VIA should be done every 3 years up to 50 years (Level B). Vaccination in males is not recommended at present in the Indian setting (Level C). HIV-positive girls should be advised to start HPV vaccination from 9 years to 14 years and should be prescribedthreedoseschedule(0,1,6months)(LevelB). For women aged 25–45 years, the first priority should be given to cervical cancer screening. Cervical cancer screening and HPV vaccination are not mutually exclusive (Level A). More recently, research is focusing to find innovative and novel systems to produce and deliver newer HPV vaccines and to help overcome shortcomings that have partly restricted the potential benefit of the vaccines in use today.9 Requests from various agencies working on cervical cancer to the Government of India to include HPV vaccination in the Universal Immunization Program is under consideration. In few states, it has been taken up at Government level to vaccinate girls: UP, Delhi, and Chandigarh. FOGSI as a huge scientific body started its program of “Screen the mother: Immunize the daughter” (Akshay Jeevan) in Varanasi. The FOGSI GCPR guidelines about HPV vaccination laid down in January 2018 by Dr Neerja Bhatla, the then chairperson of Oncology Committee, FOGSI is uploaded in FOGSI website for everyone’s perusal. Screening and vaccination have to go hand-in- hand to prevent the menace of cervical cancer. As proud members of FOGSI, it is our onus to spread awareness of cervical cancer and responsibility to screen at least five women per day. Minimum coverage of 70% of the target population by screening at least once in a lifetime along with effective treatment of the precancerous lesions is the only way to bring down the rates of cervical cancer and cervical cancer mortality.10 Trials in low-resource settings have demonstrated the need for dedicated staff for cancer screening to make any program successful.11 PREVENTING SEXUALLY TRANSMITTED DISEASES The common STDs are syphilis, acquired immunodefi ciency syndrome, Chlamydia, gonorrhea, trichomoniasis, HPV infections, hepatitis B, herpes simplex, etc. Parents should be encouraged to discuss sexuality and contraception that is consistent with the family’s values, attitude, belief, and circumstances. It should start early in life starting to differentiate a good touch from a bad touch. Comprehensive sexual education about STDs in school curriculum does not increase promiscuity. Adolescence is the most vulnerable period and the most effective time to startwithtailoredcounseling.InIndiathereare243million adolescents constituting 21% of the total population. Must be specific, culturally sensitive, and nonjudgmental. Counseling and vaccination against hepatitis B and HPV is an important step. Safe and responsible sexual practices should be taught to children by parents. It is always better that they learn from parents than fulfill curiosities from internet or peer group. However, not having sex is the only sure way to prevent STDs. Specific adolescent clinics need to evolve to address the needs of today’s adolescents, tomorrow’s future. Abstinence should be encouraged and in fact channelizing the energy of youth into positive activity in the form of outdoor activities, yoga, and meditation need to be encouraged. Youth empowerment is the key to build the nation. Drug abuse and peer pressure are aggravating factors and need to be discussed. Accept adolescents as they are. They need more care, love, and appreciation. Youth friendly services need more attention that sports lot of confidentiality. Supportive components of STD control: Leadership and advocacy to ensure an environment supporting STD control and prevention is the need of the day. Programs for STD surveillance and track burden of disease are important. Partners of STD patients need to be traced and screened and treated. Key population such as sex workers, men having sex with men, mentally challenged people, drug addicts, sharing syringes, etc. should be taken into
- 149. Preventing Cervical Cancerand STDs 125 confidence and given thorough counseling about the do’s and don’ts. Encouraging correct and consistent use of condom by male and female should be encouraged and screening asymptomatic persons at risk is the crux. Monogamous relationships should be encouraged. FOGSI “Adbhut Matrutva Programme” the flagship programme of FOGSI President Dr Jaideep Malhotra has been a great program and with its thrust on overall physical and mental wellbeing of women of India, improvement of nutritional status, improvement of maternal intelligence to handle pregnancy and children safely will go a long way to prevent cervical cancer and STDs in the coming future. REFERENCES 1. Rathi A, Garg S, Meena GS. Human papilloma virus vaccine in Indian settings: Need of the hour. J Vaccines Vaccin. 2016;7:346. 2. Kjaer SK, Nygård M, Dillner J, et al. A 12-year follow-up on the long-term effectiveness of the quadrivalent human papillomavirus vaccine in 4 Nordic countries. Clin Infect Dis. 2018;66(3):339-45. 3. Huh WK, Joura EA, Giuliano AR, et al. Final efficacy, immunogenicity, and safety analyses of a nine-valent human papillomavirus vaccine in women aged 16-26 years: a randomised, double-blind trial. Lancet. 2017;390(10108): 2143-59. 4. Naud PS, Roteli-Martins CM, De Carvalho NS, et al. Sustained efficacy, immunogenicity, and safety of the HPV- 16/18 AS04-adjuvanted vaccine: Final analysis of a long- term follow-up study up to 9.4 years post-vaccination. Hum Vaccin Immunother. 2014;10(8):2147-62. 5. Steinbrook R. The potential of human papillomavirus vaccines. N Engl J Med. 2006;354(11):1109-12. 6. National Cancer Institute (2018). Human papillomavirus (HPV) vaccines. [online] Available from https://www.cancer. gov/about-cancer/causes-prevention/risk/infectious- agents/hpv-vaccine-fact-sheet [Accessed December 2018]. 7. Sankaranarayanan R, Gaffikin L, Jacob M, et al. A critical assessment of screening methods for cervical neoplasia. Int J Gynaecol Obstet. 2005;89:S4-12 8. Sankarnarayanan R, Nene BM, Shastri SS, et al. Concurrent evaluation of visual, cytological, and HPV testing as screening methods for the early detection of cervical cancer in Mumbai, India. Bull World Health Organ. 2005;83: 186-94. 9. Barra F, Maggiore ULB, Bogani G, et al. New prophylactic human papilloma virus (HPV) vaccines against cervical cancer. J Obstet Gynaecol. 2018;27:1-10. 10. Gravitt PE, Belinson JL, Salmeron J, et al. Looking ahead: a case for human papilloma virus testing of self-sampled vaginal specimens as cervical cancer screening strategy. Int J Cancer. 2011;129:517-27. 11. Dinshaw K, Mishra G, Shastri S, et al. Determinants of complianceinaclusterrandomizedcontroltrialonscreening of breast and cervical cancer in Mumbai, India. Compliance to Screening. Oncology. 2007;73:145-53.
- 150. CHAPTER 27 Pradhan MantriSurakshit Matritva Abhiyan Nisha Sahu, Pushpa Pandey ABOUT PRADHAN MANTRI SURAKSHIT MATRITVA ABHIYAN The Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) has been launched by the Ministry of Health and Family Welfare (MoHFW), Government of India. The program aims to provide assured, comprehensive, and quality antenatal care (ANC), free of cost, universally to all pregnant women on the 9th of every month. The PMSMA guarantees a minimum package of ANC services to women in their second or third trimesters of pregnancy at designated government health facilities. The program follows a systematic approach for engagement with private sector, which includes motivating private practitioners to volunteer for the campaign developing strategies for generating awareness and appealing to the private sector to participate in the Abhiyan at government health facilities. RATIONALE FOR PRADHAN MANTRI SURAKSHIT MATRITVA ABHIYAN Data indicates that maternal mortality ratio (MMR) in India was very high in the year 1990 with 556 women dying during childbirth per hundred thousand live births as compared to the global MMR of 385/lakh live births. AspertheRegistrarGeneralofIndia–sampleregistration system (RGI–SRS) (2011–2013), MMR of India has now declined to 167/lakh live births against a global MMR of 216/lakh live births (2015). India has registered an overall decline in MMR of 70% between 1990 and 2015 in comparison to a global decline of 44%. While India has made considerable progress in the reduction of maternal and infant mortality, every year approximately 44,000 women still die due to pregnancy-related causes and approximately 6.6 lakhs infants die within the first 28 days of life. Many of these deaths are preventable and many lives can be saved, if quality care is provided to pregnant women during their antenatal period and high-risk factors such as severe anemia, pregnancy-induced hypertension, etc. are detected on time and managed well. GOAL OF THE PRADHAN MANTRI SURAKSHIT MATRITVA ABHIYAN Pradhan Mantri Surakshit Matritva Abhiyan envisages to improve the quality and coverage of ANC including diagnostics and counseling services as part of the Pradhan Mantri Surakshit Matritva Abhiyan— package of services.
- 151. Pradhan Mantri SurakshitMatritva Abhiyan 127 reproductive maternal neonatal child and adolescent health (RMNCH+A) strategy. Objectives of Pradhan Mantri Surakshit Matritva Abhiyan Ensure at least one antenatal checkup for all pregnant womenintheirsecondorthirdtrimesterbyaphysician or specialist. Improve the quality of care during antenatal visits. This includes ensuring provision of the following services: All applicable diagnostic services Screening for the applicable clinical conditions Appropriate management of any existing clinical condition such as anemia, pregnancy-induced hypertension, gestational diabetes, etc. Appropriate counseling services and proper documentation of services rendered Additional service opportunity to pregnant women who have missed antenatal visits. Identification and line listing of high-risk pregnancies based on obstetric or medical history and existing clinical conditions. Appropriate birth planning and complication readiness for each pregnant woman especially those identified with any risk factor or comorbid condition. Special emphasis on early diagnosis, adequate, and appropriatemanagementofwomenwithmalnutrition. Special focus on adolescent and early pregnancies as these pregnancies need extra and specialized care. KEY FEATURES OF PRADHAN MANTRI SURAKSHIT MATRITVA ABHIYAN The PMSMA is based on the premise that if every pregnant woman in India is examined by a physician and appropriately investigated at least once during the PMSMA, and then appropriately followed-up— the process can result in reduction in the number of maternal and neonatal deaths in our country. Antenatal checkup services would be provided by obstetrician-gynecologist (OB/GYN) specialists or radiologist or physicians with support from private sector doctors to supplement the efforts of the government sector. A minimum package of ANC services (including investigations and drugs) would be provided to the beneficiariesonthe9thdayofeverymonthatidentified public health facilities like Primary Health Centers (PHCs) or Community Health Centers (CHCs), District Hospitals (DHs) or urban health facilities, etc. in both urban and rural areas in addition to the routine ANC at the health facility or outreach. Using the principles of a single window system, it is envisaged that a minimum package of investigations (including one ultrasound during the second trimester of pregnancy) and medicines such as iron folic acid (IFA) supplements, calcium supplements, etc. would be provided to all pregnant women attending the PMSMA clinics. While the target would reach out to all pregnant women, special efforts would be made to reach out to women who have not registered for ANC (left out or missed ANC) and also those who have registered but not availed ANC services (dropout) as well as high-risk pregnant women. The OB/GYN specialists or radiologist or physicians from private sector would be encouraged to provide voluntary services at public health facilities where government sector practitioners are not available or inadequate. Pregnant women would be given mother and child protection(MCP)cardsandsafemotherhoodbooklets. One of the critical components of the Abhiyan is identification and follows-up of high-risk pregnancies. A sticker indicating the condition and risk factor of the pregnant women would be added onto MCP card for each visit (Table 27.1). A National Portal for PMSMA and a Mobile application have been developed to facilitate the engagement of private or voluntary sector. “IPledgeFor9” Achievers Awards have been devised to celebrate individual and team achievements and acknowledge voluntary contributions for PMSMA in states and districts across India. ROLE OF FOGSI IN PRADHAN MANTRI SURAKSHIT MATRITVA ABHIYAN Private FOGSI (Federation of Obstetric and Gynecological Societies of India) members support the government doctors to provide ANC services would be provided to pregnant women in their second or third trimesters of at government health facilities. Dr Jaideep Malhotra, FOGSI President, launched “Adbhut Matrutva Initiative”, on 19th January 2018, at Bhubaneswar in AICOG 61. Adbhut Matrutva Table27.1:Indicatorofconditionandriskfactorofthepregnantwomen. Indicator of high risk Sticker color Condition Green Sticker Women with no risk forctor detected Red sticker Women with high risk pregnancy
- 152. FOGSI FOCUS: AdbhutMatrutva128 concept based on value of preconception counseling, recommended number of antenatal visits, promote institutional deliveries, and top it up with early initiation of breastfeeding and postpartum contraception. Adbhut Matrutva means “incredible motherhood”, this noble concept helps to deliver a divine baby from divine mother, to create a beautiful and harmonious world and to make a healthy and happy future generation. The FOGSI in association with Brahma Kumaris organized many sessions of grand training of trainers in different parts of country. Dr Malhotra appeals to FOGSI members to provide voluntary services at government health facilities in their district sand conduct the spiritual part of the program along with PMSMA on the 9th of every month to supplement the efforts of the government doctors. In many districts, FOGSI societies are doing this program regularly along with PMSMA. The FOGSI members who are volunteering for the Abhiyanwouldbeexpectedtovisitdesignatedgovernment health facilities in their districts and provide free ANC checkups to pregnant women on 9th of every month. Joining the Campaign If you are ready to volunteer there are three simple steps for joining the campaign. 1. Step 1: Registering your intent to volunteer On portal www.pmsma.nhp.gov.in. By dialing toll free number 18001801104, or By sending and SMS—“PMSMA Name” to 5616115. However, in the interim period, all those who are willing to provide voluntary services on 9th of every month at neighboring government health facilities are requested to share the following information on the email id—[email protected]: first name, last name, mobile number, email address, state, and district where you would be volunteering for PMSMA (You can access the States and Districts by visiting FOGSI website, www.fogsi.org). 2. Step 2: Deciding the health facility where you would like to volunteer. 3. Step 3: Provide feedback or check your contribution. Recognition for Volunteers by FOGSI Societies FOGSI values, the contribution of volunteers and will be awarding them. Some of these awards are: For volunteers who have served maximum number of patients, Forvolunteerswhohaveconsistentlyprovidedservices on all PMSMA days, and For volunteers who have served in remote or inaccessible areas. It is planned that volunteers would be felicitated by Member of Parliament or District Magistrate (DM) at District level and by the Health Minister or State Health Secretary at State level. It is also envisaged that doctors providing exemplary services would be nominated for National level recognitions. Utilization of social media such as Facebook and Twitter, for recognizing the work of volunteers is a core strategy of the initiative. A virtual “Hall of Fame” is created forrecognitionofdoctorswhohaveconsistentlyperformed and achieved the desired benchmarks. AWARDS AND RECOGNITION BY GOVERNMENT OF INDIA The PMSMA “IPledgeFor9” Achievers Awards celebrate individual and team achievements under the PMSMA across India. Objectives of the PMSMA‘IPledgeFor 9’ Achievers Awards The objectives of the awards are two-fold: 1. Objective 1: Identify and recognize excellence in PMSMA performance at various levels. 2. Objective 2: Identify and recognize exemplary public, private, and voluntary sector contribution to PMSMA. Public and Social Recognition Team, individual, and organizational contribution are publicly recognized through awards’ ceremonies as well as across virtual platforms, the “Halls of Fame”, in national and state health portals and social media. Certificates for good performance are awarded in public functions at various levels (District, State, and National) awarded by Ministers or Elected Members of the Parliament, Legislative Assembly in the presence of State or District Authorities and Panchayati Raj Institutions with full media coverage of events. Press release by authorities in the local or State or National media and feature in Radio and TV channels that provides wide public recognition. Photographs of best performing teams, individuals, and organizations are also showcased through the PMSMA portal and social media. Categories of Awards There are three broad categories of awards: 1. Team Awards, 2. Individual Awards, and 3. Special Awards. Team Awards:Teamawardsarefocusedonfacilities providing full complement of services and facilities
- 153. Pradhan Mantri SurakshitMatritva Abhiyan 129 Table27.2:Districtlevelawards. Sr. no. Sub- categoryAwardeeCriteria Numberof awardsVerificationcriteriaPeriodicityTypeofawardsAwardedby 1.TeamGovernment teamsfromhealth- carefacilities Facilitiesprovidingfull complementofservices everymonth1 Allfacilities whofitthe eligibility criteria VerificationbyDistrict QualityAssurance Committees(DQACs) 12months; Firstsetof awardswillbe inApril2017 ŠŠCertificatesina publicfunction ŠŠPressreleaseby DistrictAuthorities inthelocalmedia MP/MLA withDistrict Collector/ District Magistrate PRImembers inpresence oflocal media 2.TeamGovernment teamsfromhealth- carefacilities Proportionofhigh-risk pregnanciesidentified Allfacilities whofitthe eligibility criteria ŠŠIdentificationof 15–25%high-risk pregnancies ŠŠDatasource:Monitoring reportssubmittedby facilitiestoDistricts aspermonitoring format2 inthefirstyear. Subsequentlydata availableontheRCH portalwouldbeutilized 3.IndividualPrivate practitioners Privatepractitioners volunteeringservicesfor all12months Allpractitioners whofitthe eligibility criteria Datasource:PMSMAportal 4.IndividualPrivate practitioners PrivatePractitioner providingservicesto maximumnumberof pregnantwomen Top3Datasource:PMSMAportal 5.SpecialOrganizations: Professional Associations-IMA FOGSI,Radiologist Association, Rotary,Lionsclubs, NGOs,CBOs,FBOs, etc. Providingexemplary supportforPMSMA3 Allorgani zationswhich fittheeligibility criteria TobedecidedbyDistrict PMSMACommittee 6.SpecialAnyindividual servinginhardto reach/tribalareas requiringspecial recognition Providingexemplary supportforPMSMA(as decidedbytheDistrict PMSMACommittee) Allindividuals whichfitthe eligibility criteria TobedecidedbyDistrict PMSMACommittee 1 Fullcomplementofservicesincludingdrugs,diagnosticservicesandnecessaryequipment’sforthesameasperannexure3operationalframework(onsitemonitoringformat) 2 District/StatePMSMAcommitteestoensuredatavaliditybasedonsamplechecksbyDistrictQualityAssuranceCommittees 3 ProvidingmaximumnumberofvolunteersforPMSMA/providinganyothersupportforPMSMAsuchastransport/logistic/foodforpregnantwomen,etc. (FBO:faith-basedorganizations;CBO:community-basedorganization;MLA:MemberofLegislativeAssembly;MP:MemberofParliament;NGO:nongovernmentalorganization; PMSMA:PradhanMantriSurakshitMatritvaAbhiyan) (Source:https://pmsma.nhp.gov.in).
- 154. FOGSI FOCUS: AdbhutMatrutva130 Table27.3:Statelevelawards. Sr. no. Sub- categoryAwardeeCriteria Numberof awardsVerificationcriteriaPeriodicityTypeofawards Awarded by 1.TeamDistrictsDistrictswithmaximumnumberof facilitiesprovidingfullcomplement ofserviceseverymonth:1 ŠŠOverall ŠŠHPDs 1–3Districts depending uponsizeof State Basedonperverification ofDQACs 12months; Firstsetof awardswill beAprilin 2017 ŠŠCertificatesina publicfunction ŠŠPressrelease ŠŠFeatureinFMradio ŠŠLunch/Dinner hostedbyHealth Minister Honorable Health Ministerin presence ofState media2.TeamDistrictsDistrictswithmaximumpropor- tionofpregnantwomenreached.2 ŠŠOverall ŠŠHPDs 1–3Districts depending uponsizeof State Basedoninformation availableinPMSMAPortal 3.TeamDistrictsProportionofHighRisk PregnanciesIdentified 1–3Districts depending uponsizeof State ŠŠIdentificationof 15–25%high-risk pregnancies ŠŠDatasource:PMSMA Portal3 inthefirstyear. Subsequentlydata availableontheRCH portalwouldbeutilized 4.IndividualPrivate practitioners Privatepractitionerproviding servicestothemaximumnumber ofpregnantwomen: ŠŠOverall–AtDistrictHospitals/ MedicalColleges ŠŠOverall–AtSDHsandbelow ŠŠHPDs–AtDistrictHospitals/ MedicalColleges ŠŠHPDs–AtSDHsandbelow Top3from eachcategory Source:PMSMAportal 5.IndividualPrivate practitioners Privatepractitionersvolunteering services: ŠŠForall12months ŠŠForatleast8monthsinHPDs Allpractitioners whofitthe eligibility criteria Source:PMSMAportal 6.SpecialOrganizations: Professional Associationssuch asIMAFOGSI, RadiologistsAsso ciationsRotary, Lionsclubs,NGOs, CBOs,FBOs,etc. Providingexemplarysupportfor PMSMA4 All organizations/ individuals whichfitthe eligibility criteria AsdecidedbytheState PMSMACommittee(Data availableinPMSMAportal onnumberofvolunteers byeachorganizationmay alsobyused) 1 Fullcomplementofservicesincludingdrugs,diagnosticservicesandnecessaryequipment’sforthesameasperannexure3ofoperationalframework(onsitemonitoringformat) 2 TotalnumberofpregnantwomenprovidedPMSMAservices(once)outoftotalestimatedpregnancies(basedoninformationavailableinportal) 3 District/StatePMSMAcommitteestoensuredatavaliditybasedonsamplechecksbyDistrictQualityAssuranceCommittees 4 ProvidingmaximumnumberofvolunteersforPMSMA/providinganyothersupportforPMSMAsuchastransport/logistic/foodforpregnantwomen,etc. (FBO:faith-basedorganizations;CBO:community-basedorganization;DQAC:DistrictQualityAssuranceCommittee;FOGSI:FederationofObstetricandGynecologicalSocieties ofIndia;HPD:healthproductdeclaration;IMA:IndianMedicalAssociation;NGO:nongovernmentalorganization;PMSMA:PradhanMantriSurakshitMatritvaAbhiyan) (Source:https://pmsma.nhp.gov.in).
- 155. Pradhan Mantri SurakshitMatritva Abhiyan 131 Table27.4:Nationallevelawards. Sr. no. Sub- categoryAwardeeCriteriaNumberofawardsVerificationcriteriaPeriodicityTypeofawards Awarded by 1.TeamStatesStateswheremaximum proportionofpregnant womenreached1 ŠŠOverall ŠŠHPDs Total12awards: 6Awards–Overall; 6Awards–HPDs including: ŠŠTop2largehigh focusStates ŠŠTop2non-high focusStates ŠŠTop1amongNE States ŠŠTop1amongUTs DataSource: PMSMAPortal 12months; Firstsetof awardswill beinApril 2017 ŠŠCertificatesina publicfunction ŠŠPressreleaseat nationallevel ŠŠFeatureinFM radio/TV ŠŠLunch/Dinner hostedby HealthMinister Union Health Ministerin presence ofNational media 2.TeamStatesProportionofhigh-risk pregnanciesidentified 6Awardsincluding: ŠŠTop2largehigh focusStates ŠŠTop2non-high focusStates ŠŠTop1amongNE States ŠŠTop1amongUTs Identificationof 15–25%high- riskpregnancies Datasource: PMSMAportal supplementedby datavalidatedby theStateinthefirst year.Subsequently dataavailableon theRCHportal wouldbeutilized 3.IndividualPrivatepractitionersPrivatePractitionerproviding servicestothemaximum numberofpregnantwomen ŠŠOverall—AtDistrict Hospital/MedicalColleges ŠŠOverall–AtSDHsand below ŠŠHPDs–AtDistrict Hospitals/MedicalColleges ŠŠHPDs–AtSDHsandbelow Total12awards: ŠŠTop3individuals ineachcategory acrossIndia (3*4=12) Datasource: PMSMAportal Contd...
- 156. FOGSI FOCUS: AdbhutMatrutva132 Sr. no. Sub- categoryAwardeeCriteriaNumberofawardsVerificationcriteriaPeriodicityTypeofawards Awarded by 4.IndividualPrivatepractitionersPrivatepractitionersproviding exemplaryservicesunder PMSMA2 1perState/UTEachStateto nominateone practitionerforthe NationalAward 5.SpecialOrganizations: Professional Associationssuchas IMAFOGSI,Rotary, Lionsclubs,NGOs, CBOs,FBOs,etc. Providingexemplarysupport forPMSMA Allorganizations whichfittheeligibility criteria Asdecidedbythe NationalPMSMA Committee(Data availableinPMSMA portalmayalsobe used) 1 TotalnumberofpregnantwomenprovidedPMSMAservices(once)outoftotalestimatedpregnancies(basedoninformationavailableinportal) 2 ProvidingmaximumnumberofvolunteersforPMSMA/providinganyothersupportforPMSMAsuchastransport/logistic/foodforpregnantwomen,etc. (FBO:faith-basedorganizations;CBO:community-basedorganization;DQAC:DistrictQualityAssuranceCommittee;FOGSI:FederationofObstetricandGynecologicalSocieties ofIndia;HPD:healthproductdeclaration;IMA:IndianMedicalAssociation;NGO:nongovernmentalorganization;PMSMA:PradhanMantriSurakshitMatritvaAbhiyan) (Source:https://pmsma.nhp.gov.in). Contd...
- 157. Pradhan Mantri SurakshitMatritva Abhiyan 133 Table27.5:Virtualawards. Sr. no. Who willbe featuredCriteriaWhoareeligible Detailsofvirtual recognition Display period Periodicity ofchange Startdateof thevirtual recognition Typeof awardsAwardedby 1.IndividualsPrivate practitioner volunteering forPMSMA whoprovide servicesto maximum numberof pregnant women (Basedon volunteer creditin PMSMA Portal) ŠŠTop3individualsineach categoryattheNationallevel (3*4=12): −−Overall–AtDistrictHospitals/ MedicalColleges −−Overall–AtSDHsandbelow −−InHPDs–AtDistrictHospitals/ MedicalColleges −−InHPDs–AtSDHsandbelow ŠŠTop3individualsineach categoryatStatelevel(3*4=12) −−Overall–AtDistrictHospitals/ MedicalColleges −−Overall–AtSDHsandbelow −−InHPDs–AtDistrictHospitals/ MedicalColleges −−InHPDs–AtSDHsandbelow Volunteerdetails willbefeaturedin theNationaland StateHallsofFame: ŠŠName ŠŠPhotograph ŠŠDetailsof contribution MonthlyMonthlyFirstmonth ofPMSMA E-Certificates for contribution Ministry ofHealth andfamily Welfare, Government ofIndia 2.IndividualsPrivate practitioners volunteering services continuously forallmonths in3,6,9,12 months AllVolunteerdetails willbefeaturedin theNationaland StateHallsofFame: ŠŠName ŠŠPhotograph ŠŠDetailsof contribution QuarterlyQuarterlyEndof quarter-1of PMSMA E-Certificates for contribution Ministry ofHealth andFamily Welfare, Government ofIndia 3.IndividualsPrivate practitioners providing exemplary servicesin hardtoreach areas 3perState/UT(asnominatedbythe State/UT) Volunteerdetails willbefeaturedin theNationaland StateHallsofFame: ŠŠName ŠŠPhotograph QuarterlyQuarterlyEndof quarter-1of PMSMA E-Certificates for contribution Ministry ofHealth andFamily Welfare, Government ofIndia 4.Allphysical awards achievers Asper physical awards criteria Alleligibleindividuals,teams, organizations Achievers’details intheNationaland StateHallsofFame: ŠŠNames ŠŠPhotographs ŠŠDetailsof contribution Scheduledas perphysical awards’ timeframes Scheduled asper physical awards’ timeframes Scheduledas perphysical awards’ timeframes E-Certificates for contribution Ministry ofHealth andFamily Welfare, Government ofIndia (HPD:healthproductdeclaration;UT:unionterritory).
- 158. FOGSI FOCUS: AdbhutMatrutva134 reaching the maximum proportion of beneficiaries and are aimed for state or district or facility level teams from the Government sector. Team awards for identification of high-risk pregnancies are also included. Individual Awards: Individual awards recognize consistent contribution overtime as well as significant contribution in terms of maximum beneficiaries reached. These awards have been designed to recognize the contributions of the volunteers from the private sector. Special Awards: Special awards recognize signifi cant and consistent involvement in special regions including High Priority Districts, hard to reach areas, and tribal areas. Outstanding organizational contributions of professional associations or NGOs or private sector organizations, etc. to PMSMA are also recognized, including thematic contribution for technical support and operations support. Levels of Award, Frequency, and Timeframe The awards are proposed at three levels: 1. District level (Table 27.2) 2. State level (Table 27.3) 3. National level (Table 27.4) Virtual Awards In all, 37 “Halls of Fame” (one National and 36 State Halls of Fame) are available in the National PMSMA portal to feature best performance virtually. Every month, the photographs of all doctors registering to provide voluntary service are displayed for 24 hours in the PMSMA Portal, after which it is available in the weekly or monthly archive. Every month, top three individuals providing service to the maximum number of beneficiaries, across the country and every State are featured. Top three performances in the High Priority Districts are also featured at the National and State “Halls of Fame”. In addition, the top performers are recognized by the Ministry in Tweets. All recipients of physical awards are also featured in the virtual “Halls of Fame” Awards (Table 27.5). Award for Reduction in MMR under PMSMA “IPLEDGEFOR9”Achievers On June 30, 2018, Award function was organized by MoHFW, Bill and Melinda Foundation, United Nations Children’s Fund (UNICEF) and United States Agency for International Development (USAID) in New Delhi to honor the achievers. Awards were given by Shri JP Nadda, Union Minister for Health and Family Welfare. Kerala, Maharashtra, and Tamil Nadu are the states, which received the awards for achieving sustainable development goal for MMR. Dr Jaideep Malhotra, President, FOGSI, said that FOGSI is committed to support “PMSMA”. “Private partnership with the Government of India under the vision of Honorable Prime Minister Mr. Narendra Modi achieved a phenomenal results in reducing MMR”, she said. MMR is defined as the proportion of maternal deaths per 100,000 live births. India has registered a significant decline in MMR recording a 22% reduction in such deaths since 2013, according to the SRS. PMSMA guarantees a minimum package of ANC services to women in their second and third trimesters of pregnancy at designated Government health facilities. CONCLUSION Initialresultsofthisprogramaremotivatingandsuccessful. If Government works with same willpower, these steps will prove to be milestones in improving maternal health in India.
- 159. CHAPTER 28 Adbhut MatrutvaApp Dayanath Mishra, Rashid Rizvi INTRODUCTION The basic objective of the Adbhut Matrutva App is to make pregnancy a pleasurable experience. All these facilities are available to the patient and doctor on the Adbhut Matrutva mobile/web App to provide complete holistic experience to pregnant women: Clinical care trimester-wise Relevant investigations Yoga and meditation Nutritional guidance Music and aroma therapy Motivational lectures Motivational stories Videos Pregnancy diary Immunization guide Supplementation and medication. SALIENT FEATURES Health Seeker Ease and convenience in doctor interaction Safe, accessible, and comprehensive medical records Medical record-based interpretation of medical condition Proactive health management Easy and transparent access to health services providers. Doctors/Medical Establishment Tools for providing better healthcare Statutory compliance Medical reference resources Build relationship with patients and service providers. Health Service Providers Closer coordination with doctors. Special Services—Unique to Adbhut Matrutva App Prescription ‘truly’ digitized Investigative reports ‘truly’ digitized Reproduce high quality investigative images in device Important hospitalization record digitized User basic general/medical data self-entered. Medical Records Easily Retrieval in Various Options Time-wise Treatment-wise Others Graphs/chartsacrossdatabaseforselectedparameters Progress of treatment for particular condition Electronic health record (EHR) summary for doctor before he starts consultation Doctor/clinic/hospital compliance for record keeping. Electronically Entered Prescription Electronic page view same as doctor’s prescription with logo, etc. Electronic page with sections standard in prescriptions Some data will be generated by the App if populated Doctor’s assistant can fill some permitted data from own device Doctor can chose template in sections or use blank space While writing medicines – the app prompts doctor in case of Duplicate medication, under/over dosage Allergy and drug interactions Brand and generic output Prescription instructions in local language Can forward to user’s pharmacy/test centers from doctor’s App.
- 160. FOGSI FOCUS: AdbhutMatrutva136 Strengthening Doctor-Patient Bond Reminder for next appointment Reminder to take critical medicines Reminder for tests and upload report Explaining side effects, safety, efficiency of medicine Conditions not to worry Conditions to contact doctor Periodically checking patient’s condition Encourage user for lifestyle change Diet and exercise Motivational articles Links to simple articles related to condition Informing prompted relatives on current medical conditions Wishing user of quick recovery Text platform to share worry with the doctor Multilocation users for online consultation Algorithm for emergency conditions User button for hospitalization from home Resident Medical Officer (RMO) button for doctor contact from hospital Emergency text from diagnostic lab to doctor Emergency text from doctor to patient to contact as soon as possible Doctors-Patient List—active and passive Doctor—prescription—pharmacy—diagnostics loop Doctor—‘referred from’ and ‘referred to’ captured Doctor—compliance to statutory rules Reminder Helpline and news Doctor—upcoming events/conference/latest medical news Doctor’s resources Exhaustive medical references Legal/statutory/accreditation helplines.
- 161. Adbhut Matrutva App137 Medical Resources Calculators Protocols Diseases and control articles Drug monographs Procedures Protocol standards. Small Features with Big Impact Doctor’s list of active and passive patients; segment- wise Doctor connected to patient–pharmacy–diagnostic lab loop Report on ‘referred from” and “referred to” for closure of treatment Upcoming events/conferences/latest medical news/ notifications/statutory changes Medicine and tests prescribed report. It is well said that “God cannot be everywhere and therefore God created mother”. Mother is an embodiment of love and care, through this love and care she makes her baby healthy and happy. Let’s join hands together to fulfill the dream of the Almighty to create children who have the personality of purity and divinity to create a healthy World, health E India and a healthy family by joining the Adbhut Matrutva initiative, the brainchild of FOGSI President 2018. Dr Jaideep Malhotra