Pregnancy Management Timeline

This timeline is a guide to Dr Howland’s management of your pregnancy and can be flexible.

FIRST VISIT

High-risk pregnancy: 6-7 weeks
Scan: Viability and early dating scan
Test: Blood group, others if indicated

Routine pregnancy: 8-11 weeks.
Scan: Dating, growth, very early structure
Tests: all routine blood tests, pap if due, full examination, NIPT(chromosomal test) if indicated, requested or recommended

If your first visit is after 13 weeks, the opportunity to predict increased risk for poor placental function or developing high blood pressure is missed. If found, these risks can be reduced by prophylactic drugs.

ANTENATAL VISITS

If you at any point have any pressing concerns you are welcome to book in and see Dr John if you think there may be a problem. Visits are intended to pick up problems before they become serious and which may not be apparent to the patient. Some conditions or problems may require more frequent visits.

Routine antenatal visits are usually following the timeline below:

  • 10 or 11 weeks
  • 15-16 weeks
  • 20 weeks to 28 weeks: every 4 weeks
  • 28 to 34 weeks: every 2 weeks
  • 34 weeks untill delivery: weekly

At each visit, weight, urine and blood pressure checked, uterus size, screening scan and audible heartbeat.

After 24 weeks, we encourage sleeping on either side during the night. This is to ensure that there is no reduction in blood flow in the inferior vena cava and blood flow to the placenta.

 After 34 weeks, John will do a scan to measure the blood flow in the baby’s brain (by measuring the middle cerebral artery flow) to ensure the placenta is working properly towards the end of the pregnancy. We hope that this will reduce the risk of your baby unexpectedly dying late in pregnancy.

6 WEEK POST-NATAL VISIT

6 weeks after the birth, we ask you to come back for a post-natal check with Dr Howland. In this appointment, he checks your stomach to make sure your organs have moved back to where they belong, your vagina to ensure it has healed and intercourse will not be a problem as well as how you are going with breastfeeding  or formula feeding . You can also discuss contraception, like the insertion of a Mirena.

ULTRASOUND SCANS

Dating Scan:

6-8 weeks: viability (is there a heartbeat? How many babies?)
8-11 weeks: Dating, growth, very early structure

Nuchal and early morphology scan (13-week scan):

12-13.6 (best 13-13.6): Early morphology (is structure normal?), Down syndrome and other chromosomal risk assessment, risk of pre-eclampsia and with PAPP-A blood test of poor placental function developing later in the pregnancy.
Best done at 13-13.6 weeks, crown-rump length 60-84mm
This scan aims to detect any abnormalities which formerly were only seen at 18-22 weeks

Morphology scan (20 weeks):

19-21.6 weeks (best 21-21.6): Main morphology scan, growth rate, 98% sex predication accuracy if seen, placental position and risk of premature labour.
It looks for abnormalities in your baby’s structural development and growth. It also checks the position of the placenta. It is not a screening test for chromosomal anomalies.

Placental function and fetal growth scan:

27 weeks: a better time to examine some structures eg. Heart, face, brain if not seen well at 20-22 week scan, placental position if low, cervix length if previously shor.t
30+ weeks: may be needed to monitor progress and risk including ensuring the placenta is working adequately.

34+ weeks: part of routine visit scan will be to look for signs of abnormal placental function which is affecting the baby. We hope that this will reduce the chance of stillbirth.

BLOOD TESTS

Routine tests performed early in pregnancy:

  • Blood group
  • Blood group antibodies (do you need an anti-d injection)
  • Full blood cell examination including anaemia and platelet problems
  • Electrolytes, renal and kidney function
  • Rubella immune status
  • Syphilis test
  • Hepatitis B antigen test
  • Hepatitis C antibody test
  • Toxoplasmosis antibodies
  • Thyroid function
  • HIV
  • Parvovirus antibodies
  • Cytomegalovirus antibodies
  • Varicella zoster antibodies (if no history of chickenpox)
  • PAPP-A

NIPT Generation Test A blood test through QML for chromosomal abnormalities including Down Syndrome. Dr Howland will discuss this with you in your initial visit. It is not compulsory; it is used to identify chromosomal abnormalities if requested or at risk.

Glucose Tolerance Test (GTT): performed before 28 weeks to test for gestational diabetes. This test looks at how your body processes glucose over 2 hours. You will need to book in this blood test at QML or SNP.

PROPHYLACTIC DRUGS

    • Folate or folic acid. Best started at least 2 months before conception. It gives most value for preventing malformations before your pregnancy test is positive. Best taken in a pregnancy multivitamin tablet.
    • Pre-natal or pregnancy multivitamin. Started early, it ensures all of you essential vitamin and mineral needs are met.
    • Iron tablets if you have been iron deficient a or have had heavy periods.
    • Calcium tablets although enough calcium can be found in dairy products.

If you have a high risk of placental dysfunction or preeclampsia later in the pregnancy, a small dose (150mg) of aspirin taken at night significantly reduces the risk. It is usually started after 10 weeks and should be started by 16 weeks. It appears to have very little risk to you or your baby. It is continued until delivery. You still cannot take aspirin in painkilling doses (usually 600mg) at this can harm the baby.

If you are Rh-negative and have not formed any anti-Rh antibodies, you will receive an injection of “Anti-D” at 28 and 34 weeks and then after birth if baby is Rh positive. This aims to reduce the chance of the present baby and especially future babies being affected by serious Rh blood problems.

If you have been found to have Streptococcus Group B in your vagina during the pregnancy, you will be offered intravenous antibiotic during your labour. This crosses the placenta and helps to protect the baby from developing a serious infection after delivery. An antibiotic injection is routinely given through the IV drip during caesarean delivery to reduce the chance of postoperative infection in the mother.

Dr Howland and team are very pro-vaccination, so we will recommend immunisations for mum, dad, family and baby when they are born.

Mum: influenza, whooping cough (given @ 23-34 weeks in evey pregnancy for free at your GP), Hep B and Rubella (if required, after birth)

Dad & close family: influenza & Boostrix (includes whooping cough, diphtheria and tetanus. Lasts 10 years)

Baby at birth: Vitamin K and Hep B

If you have a high risk of premature labour (history or short cervix at 20+ weeks), you will be offered progesterone pessaries to insert in your vagina. You may also need a suture to hold your cervix closed.

If you seem very likely to delivery by any route before 34 weeks, you will be offered steroid injections before delivery to improve your baby’s lung function to a safe level. This is 2 doses of betamethasone day apart.

If you have an elective caesarean delivery before 38 weeks + 4 days, the paediatricians request that you have a steroid injection before the delivery. This appears to reduce the chance of breathing problems in the baby from about 1:6 to 1:30.

Babies born by caesarean operation may miss out on receiving “good” bacteria from their mother’s vagina at delivery. This is thought to increase the risk of allergies and toxic bowel problems in young babies. A probiotic with a mix of bacteria can be given to the baby after birth to give the baby best protection. These are available at pharmacies. Dry capsules are better the refrigerated liquid preparations.

Postnatally after a caesarean delivery or if antibiotics are given, probiotics for the mother reduce the incidence of mastitis and other infections.