Pregnancy follow up

Проследяване на бременност

With the arrival of one of the most important periods in a woman’s life, the adequate women’s care becomes a priority, in order to ensure a smooth pregnancy. During the follow-up of the pregnancy we conduct various examinations and tests, which are tailored to the physical condition and the health of the woman, her age and the progress of the pregnancy.

Learn more about the Women’s Care packages that we offer, which are at a special price and include all the necessary examinations, highly specialized tests and screenings for pregnant women.

Pregnancy is divided into 40 weeks of gestation (wog), with the beginning of the first week coinciding with the start date of the last regular menstruation. In addition to monthly routine visits to an obstetrician-gynecologist, pregnancy follow-up also includes specialized examinations at 11-14 wog, 19-23 wog and 36 wog, which I discuss in more detail in my articles.

We start with the first visit to gynecologist (2 to 4 weeks from the delay of the menses)

The first visit to gynecologist should not be too early, nor too late. What do I mean? If you go two days late on your period, nothing significant will be found during the examination, because an amniotic sac may not be visualized. If you visit your doctor 3-4 months into your pregnancy, you will miss important tests, and you may not even have taken folic acid at 800 micrograms per day, which is used to prevent neural tube defects in the fetus and anemia in the mother. My advice is to see your gynecologist within 2 to 4 weeks from the delay of your period.

During the visit to the doctor, you will talk about your current pregnancy, previous pregnancies, illnesses, surgeries, etc. It’s important to be open and to share all the information you have, because even the smallest details can be significant.

The gynecological examination is very important for us in order to establish various pathological conditions that cannot be detected by ultrasound alone. For example, a polyp on the cervix can cause a lot of problems if it is not detected, because it can start bleeding and you will be prescribed medication that is of no use and you will continue to bleed. If a genital infection is left without examination and microbiological test, it cannot be diagnosed and treated, and it can cause premature birth. The gynecological examination allows us to study your anatomical and physiological features – the state of the external genitalia, vagina, cervix, uterus, ovaries, pelvis, etc. You should know that this examination is not dangerous neither for you nor for the pregnancy – it brings only benefits. During the gynecological examination, it is important to evaluate the cervix, uterus, and adnexa, thus determining whether the pregnancy is uterine or ectopic.

Then echography is done, which provides additional information about the presence or absence of pregnancy, its location and duration. The woman’s reproductive system, as well as the lesser pelvis, are examined. The ultrasound test can be a very informative method when performed by a well-trained specialist. Here I want to add that both in Bulgaria and all over the world there are many courses for ultrasound training. But only in the UK, USA, Canada and Australia there are several subspecialty centers in Fetal Medicine, where the experts in this field are trained. In Great Britain, this training is 2 years and is conducted under the supervision of Prof. Kypros Nicolaides at King’s Collage Hospital in London, University Collage Hospital in London, The Fetal Medicine Foundation in London. You can find information about all doctors trained there at the following site:

In addition, in some cases, a beta-hCG (human chorionic gonadotropin) test may be required to confirm or rule out the presence of pregnancy and to monitor how it is developing. If an ectopic pregnancy is suspected, it may be necessary to monitor this index every other day. I would advise you to do the test always in the same laboratory, if it needs to be monitored, as this will minimize the variation in results between different laboratories.

Early in your pregnancy, your gynecologist will want you to have routine blood and urine tests, unless you have any medical conditions that require follow-up and additional tests.

The blood tests include:

  • Blood type and Rh factor of the partners – there is a condition in which if the mother is Rh negative and the father is positive in a next pregnancy, there is a risk of complications for the fetus, if prophylaxis with anti-D gamma globulin was not done during the first pregnancy
  • CBC (complete blood count) – generally speaking, it shows the presence or absence of anemia and infection
  • Glucose or blood sugar – increases if there is diabetes
  • AST and ALT – liver enzymes that show if there is liver damage
  • Bilirubin – there are two types, it is indicative for liver function and for hemolytic anemias
  • Urea and creatinine – show the kidney function
  • Toxoplasmosis IgM and IgG – a parasitic disease that damages the fetus, it is transmitted by animals – cats and dogs most often, so avoid contact with animals during pregnancy, especially at the beginning;
  • CMV IgM and IgG – a virus that can cause severe damage to the fetus
  • Hepatitis B and hepatitis C – infectious diseases that can lead to severe liver disorders
  • AIDS – an infectious syndrome in which the immune system is suppressed and the body has reduced its resistance against infections and neoplasms in the body
  • Syphilis – an infectious disease, leading to severe damage to the nervous system of the patient, if not treated, and to severe damage to the entire organism of the fetus. All these diseases are largely transmitted to the fetus in the womb or during birth.

Urine is also tested for sugar, protein, sediment, increased bilirubin products, bacteria, etc.

The most important screening is the first-trimester screening (11 to 14 wog)

Goals of Prenatal Studies

During this period of pregnancy, all organs and systems of the fetus are formed, from here onwards they follow their maturation. Until this period of pregnancy the risk of miscarriage was 15%, after 12 wog is now only 2-3%. This should be a moment of relief for you, future mothers. Of course, you may still have morning sickness and vomiting, but if you do not have more than four to five episodes a day, not connected with eating, take enough liquids and manage to eat, though less, you need to be calm. Soon and morning nausea and vomiting will pass. For those who have vaginal bleeding and morning sickness, do not worry, the fact that these are two separate symptoms does not increase the risk of miscarriage, but just the opposite – it reduces it. It is unclear why bleeding and sickness are associated with lower risk of abortion, but most textbooks and guidelines say so.    

After the brief introduction, I begin with the reasons for performing ultrasound examination in 11-14 wog. Before the examination, each doctor takes a detailed history by questioning the patient. If you have not had another examination to date, which I doubt, but in the UK this is mostly the first examination, now is the time to determine the place and the number of fetuses, i.e. whether the pregnancy is singleton, bigeminal, triple, etc. In humans, the most common spontaneous pregnancy is singleton, rarely there is bigeminal, and extremely rarely multifetal pregnancy. With in-vitro fertilization and embryo transfer of more than one embryo, the number of multifetal pregnancies increases. When multiple pregnancies occur, one should determine whether they share one placenta or have separate placentas. In case of multiple pregnancy with one placenta, the risk of complications is much greater and requires frequent follow-up. The next step is to check the heart activity of each fetus. Every parent is excited to hear the beating of their child’s heart.

After determining the number of fetuses and heart activity, the placental location, a subjective assessment of the amniotic fluid should be determined. During this period of pregnancy, it is found to be the most accurate time to date the pregnancy and to tell you the term. This is done by measuring the fetus and according to its size, we will determine how far your pregnancy is. For this purpose, the fetus should be within a range between 45 mm and 84 mm. Once we give you the new term until the end of your pregnancy, it will be our reference point and will not change for any reason! Defining the term on the last menstrual period is not so accurate method, because even if you have a very regular period, few women know exactly when ovulation has occurred. Even if you are aware of the date of ovulation and the date of the sexual intercourse, it is also important to specify that the sperm life is between 24-48-72h, and the ovum 24-48h., i.e. the actual fertilization can be done with a difference of 2 to 3 days. And this is important in tracking pregnancy and fetal growth. The most accurate method for dating pregnancy is in in vitro fertilization and fresh transfer. Then we know the exact moment of fertilization and the date of the term has to be determined by the clinic in which the in vitro procedure was performed. Therefore, in patients with such pregnancy, we do not change the term and do not date.

Among the main objectives of the examination in the first trimester between 11-14 wog is screening for the most common chromosomal abnormalities – Down, Patau and Edwards syndrome. Combined screening test is performed and the risk for each of these anomalies is calculated by the age of the woman, biochemical parameters from the blood test, and ultrasound markers and parameters.

And here comes the question why we need to check if your child can have a Down syndrome!? The analysis, especially the combined screening test, and cff DNA, are non-invasive procedures related only to taking venous blood from the pregnant woman. These methods do not pose a risk either to you or your baby. With these two methods, screening is also done for Patau and Edwards syndromes. Detecting some of these syndromes would be extremely helpful for both you as a prospective parent and for us, the medics. It is important for the parents because they will be able to make the right decision for them – whether to continue the pregnancy or to discontinue it. In other words, the presence of any of these or other anomalies in no way obliges you to commit an abortion! This decision is only yours! We will support you in your choices with understanding, with more information and the follow-up medical activities dictated by you. If you do not want to have a child with some of these syndromes, the end of the first trimester is the most appropriate and poses the least hazards for you and your childbearing ability. If you decide to continue your pregnancy, you will become more aware of this condition, look for more information, and you will be far more prepared to take care of your child and what you will experience after birth. For us, doctors, it is important to be able to track pregnancy more closely, to look for anomalies in detail, to plan birth, and not least to give you advice on next pregnancies, to direct you to genetic counseling if necessary, to determine the risk of recurrence of this syndrome in the next pregnancy.

Another important objective of the examination in 11-14 wog is monitoring of the anatomy of the fetus in the early stages of pregnancy and detection of abnormalities. Yes, even in this early period, it is possible to detect multiple abnormalities.

For several years now, it has been possible to determine which women are at risk of developing Preeclampsia – a complication in the second half of the pregnancy with increase in blood pressure, affecting organs and systems in the pregnant woman’s body, which is a leading cause of maternal and newborn mortality and morbidity. Determining the women who are at risk, we can take preventive measures and increase our attention to them, to reduce the danger to the pregnant woman and the fetus. All this starts in the 12th week of gestation!

That is why the first trimester screening is so important!

Fetal morphology (between 19 и 22 week of gestation)

The aim of fetal morphology is to trace the normal anatomical and physiological development of the fetus for this period, to make biometric measurements, respectively to detect pathological changes, if any, to conclude and determine the follow-up. It is a highly specialized analysis done with a high-resolution ultrasound scan.

If we detect deviations during this period of pregnancy, we should ask ourselves the following questions: What is this anomaly? Is it related to other deviations? What are the consequences of this/these anomalies? Is this condition compatible with life? What is the severity of the anomaly? What can be the reasons? How can these reasons be detected? What can we do? What alternatives do we have? Once we answer all these questions together, we come to a decision on the follow-up and alternatives. In some severe anomalies, the possibility of interruption of pregnancy may be considered.

Fetal morphology is done until the 22nd WOG as long as there are serious anomalies within this time, there is a time up to 24 WOG until an abortion can be made on medical evidence. After this period, a medical abortion can only be performed in conditions that endanger the mother’s life.

Monitoring the growth of the fetus (after 28 wog)

The aim is to trace the dynamics of how the fetus grows, the sequence of the growth of the individual indicators, the relationship between them and the sequence as a whole. We look at the placenta again for position, structure and maturity. We measure the presence of amniotic fluid, maternal blood flow to the placenta, placenta to the fetus and blood flow of the fetus. We observe breathing movements, body movements and the limbs of your baby. All this shows us the viability of the fetus, the discovery of early signs of suffering of the fetus of different nature and the possibility of drawing up a follow-up plan.

Of course, within this period, we are doing biometric measurements of the fetus to track its growth. Deviations from the norm may be in one direction or another and signal a different pathology. It is important to trace not only whether it is in the norm but also the systemacity of growth, i.e. whether it follows one growth line or there are deviations from that line. A complete idea of growth needs to be built up to draw conclusions. If there are any deviations, the reasons are sought with further studies and more frequent tracing of the fetus with ultrasound.

Author: Dr. Boris Stoilov


Center for Fetal Medicine

Get informed about the world of Fetal Medicine with Dr. Boris Stoilov.

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