Pregnancy and Delivery

PRE-PREGNANCY EXAMINATION

The first few weeks of the pregnancy are the most important period for development of the baby. However, numerous women are even unaware of their pregnancy during this period. Therefore, every woman who contemplates pregnancy must absolutely have herself checked by a gynecologist and obstetrician before quitting protection. The purpose of this check is to detect any potential abnormalities and risk factors to arise during the pregnancy, delivery, or after the delivery. 
The chronic diseases (such as hypertension, anemia, diabetes, epilepsy, thyroid), gynecologic diseases (such as myoma, ovarian cyst, infections), and the conditions related to previous pregnancies (miscarriage, birth with anomaly, ectopic pregnancy, stillbirth-premature birth), which may change the pregnancy follow-up and affect the pregnancy negatively are queried in this examination. The dose adjustment of the regularly taken medicines as per the pregnancy is also handled in this check. Information is given on the changes required to be made in the dietary habits, smoking and drinking alcohol, work life, sleep and rest habits, and exercising habits. If not conducted within the last one year, the cervical cancer screening (smear) test is conducted. The blood tests deemed appropriate by your doctor are done. 

HOW IS THE OVULATION PERIOD CALCULATED?

Although the menstrual period is between 28 and 32 days for most of the women, some women have shorter and still some other have longer menstrual periods. A menstrual period between 21 and 35 days is deemed normal.
For the women whose menstrual cycles are regular, the ovulation time is calculated by going 14 days back from the first day of the next menstrual cycle.
For most of the women, the ovulation day is between the days 11 and 21 starting from the first day of the menstrual cycle, and having sexual intercourse within this period increases the chance of pregnancy.
If the menstrual cycles are not regular, we can find the ovulation time by monitoring the follicle with ultrasonography.

WHAT ARE SYMPTOMS OF PREGNANCY?

• Delayed Menstruation
• Implantation Bleeding: While the emerging embryo settles in the uterus, you may have some stain-like or a bit more bleeding 6-12 days after the intercourse. In some women, cramps may accompany the bleeding.
• Fullness and tenderness of the breasts
• Weakness, fatigue
• Nausea, vomiting
• Frequent urinating
• Cracks and stains on the skin

WHAT ARE THE TESTS REQUIRED TO BE CONDUCTED IN PREGNANCY?

The pregnancy period is composed of 3 trimesters each of which lasts about 3 months. The 1st trimester includes the first 13 weeks (months 1, 2, and 3); the 2nd trimester includes the period from the end of the first one to week 26 (months 4, 5, and 6); and the 3rd trimester includes the rest of pregnancy until delivery (months 7, 8, and 9). 
• Complete blood count
• Full urine test
• Infection screening tests (the Ig M and Ig G antibodies for toxoplasma, rubella, and CMV, VDRL for syphilis, hepatitis, and HIV tests are conducted) 
• Kidney and Liver function tests (urea, creatinine, AST, ALT)
• Fasting blood glucose
• Thyroid function tests (TSH, T4)
• Blood type
• DOUBLE SCREENING TEST: It is the test conducted between the weeks 11 and 14 to search for Down Syndrome (trisomy 21) and trisomy 18. The baby's neck thickness and nasal bone are checked in the ultrasonographic evaluation. The maternal age, the values of beta hCG and PAPP-A in blood are determined and combined with the ultrasonography findings. In consequence of the test, the private risk rate is determined. 
• TRIPLE SCREENING TEST: It is the test conducted between the weeks 16 and 18 to search for Down Syndrome (trisomy 21), trisomy 18, and neural tube defect (the gap in the baby's spinal cord region). The evaluation is made against the maternal age, the baby's head diameter (BPD measurement) in ultrasonography, and the beta hCG, estriol (E3), and AFP values in the blood analysis. 
• DETAILED (2nd LEVEL COLORED) ULTRASONOGRAPHY: This is the ultrasonography carried out in the weeks 20-22 by the perinatology (risky pregnancy) department to have a detailed organ screening of the baby. 
• ORAL GLUCOSE TOLERANCE TEST (OGTT): The test conducted between the weeks 24 and 28 by giving blood after drinking glucose on empty stomach. It detects the gestational diabetes in the expectant mother. 
• INDIRECT COOMBS: If the mother is Rh(-) and father is Rh(+), their bloods are incompatible, and the Anti-D immunoglobulin injection can be applied on the basis of the result of the indirect coombs test conducted in the week 28. The Anti-D immunoglobulin injection must definitely be repeated after the birth.

NAUSEA-VOMITING IN PREGNANCY

It is seen in 70-85% of the pregnant women. It starts usually around the week 6 and ends around the week 12. Although it is seen mostly in the mornings, it can happen any time of the day. 
The pregnant women who complain about nausea must eat less but frequently, avoid the fluid intake between half an hour before and half an hour after the meal, sip instead of drinking at once, and avoid fatty and spicy foods that increase nausea and vomiting. Salty crackers, lemon and ginger may do good. In case of nausea that does not clear up with these measures and causes vomiting, your doctor may start medication.
If vomiting is severe and oral feeding is not possible, if the pregnant woman vomits more than 3-4 times a day and has lost more than 5% weight during pregnancy, and if her blood table shows deterioration, it may be necessary to hospitalize her. 

URINARY TRACT INFECTION IN PREGNANCY

It is the most frequently observed infection in pregnancy. Since the uterus will prevent complete emptying of the urinary bladder because of the pressure it applies on the bladder as it expands during the pregnancy, the infection risk increases. It may have symptoms such as frequent urinating, urinary burning, malodorous urine, nausea, inguinal pain, back pain, and flank pain, or it may have no symptoms at all and be detected during the urine analysis. The antiseptic medicines that clean the urine and antibiotics can be used in its treatment. If the pregnant patients with this complaint are not treated, the infection may progress and affect the kidneys. Besides, it may affect the pregnancy process and cause premature delivery or that the babies have low birth weights.

CERVICAL INSUFFICIENCY

The cervix is the exit from the uterus and remains rigid and closed until the birth begins. In the pregnant women whose cervices are weak, the cervix begins to shrink and open early, and then, there is the premature birth risk. The cervical insufficiency is monitored by checking the cervical length on the ultrasound. 
In order to prevent premature delivery, it is aimed to postpone the delivery beyond the week 37 by stitching the cervix with a method called cerclage in the suitable pregnant women. The 3rd month of the pregnancy, i.e. the weeks 12-14, is the optimum time for cervical stitch. However, if the cervical shrinkage is detected in an earlier or later period, emergency cervical cerclage may be applied. Before applying the cerclage, its benefits and complications must be evaluated rather well. In case of spasms and cramps like labor pain, vaginal bleeding, breaking of water, high fever or shivering, vomiting, malodorous vaginal discharge after cervical cerclage, it is necessary to consult a doctor. The cervical stitch is left there until the week 37. However, if the labor pains are regular in the previous period and delivery action begins, it is removed. Its removal is not difficult.

PLACENTA PREVIA (CLOSURE OF THE CERVIX BY THE PLACENTA)

Placenta previa is the condition when the placenta settles near or in such a manner as to cover the cervix completely. When the cervix begins to expand before delivery or the placenta detaches from the uterus during delivery, hemorrhage occurs. It is observed more frequently among those who have undergone uterine surgery and those who have had cesarean section delivery previously. Its most frequent symptom is painless bleeding. These patients must avoid sexual intercourse and manual vaginal examination. The pregnant women who have been diagnosed to have placenta previa cannot have normal vaginal delivery; they are made to have cesarean section delivery before beginning of the labor pains if possible.

PLACENTAL DETACHMENT (EARLY DETACHMENT OF THE PLACENTA)

It is detachment of the placenta from the uterine wall. It is observed more frequently among smokers, pregnant women older than 35 years of age, pregnant women diagnosed to have hypertension and preeclampsia (toxemia of pregnancy), and those who were hit in the abdominal region. Its symptoms are vaginal bleeding, tender uterus, and frequent uterine spasm that does not go away. If the placenta detaches from the uterine wall, the blood flow to the baby stops, and thus the food and oxygen transfer to the baby also stops. In that case, emergency cesarean section delivery is necessary.

GESTATIONAL DIABETES

It is the diabetes diagnosed during pregnancy. Although insulin secretion increases in pregnancy, the hormones secreted by the placenta starting from the 6th month resist the insulin. This resistance causes the blood glucose in the women who are under diabetes risk to rise. The blood glucose that rises without control causes that the glucose in the baby also rises, and the problems that can even cause the death of the fetus. Therefore, the gestational diabetes is a disease that must be diagnosed absolutely and monitored correctly. 
The risk is particularly higher for the pregnant women who are older than 35 years of age, are overweight, have delivered baby heavier than 4,000 grams previously, put on excessive weight during pregnancy, have diabetes history in the family, have excessive water, and whose babies are big according to their current weeks according to the ultrasound image. 
The oral glucose tolerance test is suggested for all pregnant women to detect gestational diabetes. The OGTT (Oral Glucose Tolerance Test) is conducted between the weeks 24 and 28. If the pregnant woman is in the high risk group, the test can be conducted in the earlier weeks as well. Generally, 75 g challenge test is applied at a single stage. The fasting blood glucose is checked in the morning hours after fasting for 8-12 hours. Then, the person is made drink a solution that includes 75 g of sugar. The fasting blood glucose ≥92 mg/dl, 1st hour postprandial blood glucose ≥180 mg/dl, 2nd hour postprandial blood glucose ≥153 mg/dl; if one of the values is high, the gestational diabetes diagnosis is established.
For the women diagnosed to have gestational diabetes, their diets must be adjusted, and insulin therapy must be commenced if necessary. The diet varies by the patient's weight, height, additional diseases, and physical activities. The dietary list prepared for every pregnant woman is different, and the diet is special to person. The weight gain must be followed at each check.

PREECLAMPSIA (TOXEMIA OF PREGNANCY)

It is a condition that starts generally after the week 20 of pregnancy and in which the tension exceeds 140/90 mm/hg. If it is ignored, it may cause serious problems that go up to growth retardation in the baby, premature birth, stillbirth, or even maternal death. The protein leakage and edema may accompany urine. 
The blood pressure (tension) of every pregnant woman diagnosed to have preeclampsia must be monitored regularly. The urine test, full blood analysis, bleeding profile tests must be made, and the baby's umbilical cord blood flow must be measured with Doppler ultrasonography.
The treatment varies by the week of pregnancy. Salt consumption must be limited; fluid intake must be increased; and excessive physical activity and stress must be avoided. In order to keep the tension under control, the antihypertensive drugs that can be used in pregnancy can be preferred. If the pregnancy is in its final phases, the pregnant woman is made deliver the baby as early as possible, because delivery is the definite treatment of preeclampsia. 

REASONS FOR CESAREAN SECTION BIRTH

• Previous uterine surgery (c-section, myoma removal)
• Baby in a position inconvenient for delivery (breech, transverse arrest)
• Baby with an estimated birth weight over 4000 g and head circumference over 100 mm
• No increase in opening of the cervix despite sufficient labor pains (non-progressive delivery)
• Sagging of the baby's cord into the vagina
• Placental detachment (detachment of the placenta)
• Fetal Distress (irregularity in the baby's heartbeats)
• Placenta previa (closure of the cervix by the placenta)
• Multiple pregnancies
• Unsuitability of the pregnant woman's pelvic structure for vaginal delivery
• The conditions that make vaginal delivery risky for the pregnant woman (heart disease, herniated disc, congenital hip dislocation, respiratory tract diseases, etc.)
• Delivery fear
• Mother's request