16 to 20 weeks. Visits to your obstetrician

Q  I am now 16 weeks pregnant. what should I expect at my obstetrician?

Your baby will be fully formed, much larger and fingers and toes can be seen. The sex of the baby can be determined. He may want to do a blood test (triple test) for down's syndrome if the oscar test was not done earlier in the pregnancy.

Q  What is a triple test?

This is a blood test to determine your risk of down's syndrome and other chromosome defects, detect spina bifida or other neural tube defects. The test measures 3 hormones and together with the mother's age and weeks of gestation, a risk factor is determined. A factor more than 1:250 would be positive. There are however false positives and negatives in this screen and it is not infallible. A positive test would indicate a need for an amniocentesis.

Q  I have been told that I need an amniocentesis. How is this procedure done and what are the risks?

Approximately 15 mls of the babies waterbag fluid is extracted under local anaesthesia. This is usually done under ultrasound scan guidance. The fluid will contain the foetal cells from shed skin. These cells are harvested and examined . The procedure is relatively painless and takes about 20 minutes. The cell culture takes about 2 weeks and therefor the test should be done well before 20 weeks. It is a safe procedure with a less than 1% risk of complications. The main risk is that of miscarriage.

Q  My obstetrician advised me to have an amniocentesis at 16 weeks rather than a chorionic villus biopsy at 9 weeks. Why is this so?

Chorionic villus biopsy is a procedure in which a biopsy is taken from the placenta under ultrasound guidance. The material is then undergoes DNA analysis to determine gene disorders. The risk of miscarriage is higher than amniocentesis, the results often inconsistent and a UK study has shown increased foetal abnormalities resulting from the procedure.

Q  Both my husband and I are thalassaemia carriers. What tests should I do to determine if my baby is normal?

If both your husband and you are carriers, then you have a 1:4 chance of having a thalassaemia major child. This is fatal in childhood. This can be excluded by means of foetal blood sampling. the foetal cord is identified under ultrasound scan and a needle inserted to aspirate a small amount of cord blood and the blood then undergoes DNA analysis.

Q What is a foetal-DNA test and when should it be done?

This test may be done as early as 9 weeks. It tests the baby's DNA that passes into the mother's bloodstream. It is a very accurate test almost 99% and looks to replacing amniocentesis as the test of choice. It is non invasive and therefore does not carry the risks that are associated with an amniocentesis. This test is referred to as the Harmony test or Panorama test.

Common Problems You May Encounter 16 - 20 Weeks

Q   I am now 16 weeks pregnant and have low back pain. Is this common and what can I do to prevent this? 

Although backache is more common in the last trimester, it may occur at any time in the pregnancy. The physiological changes in pregnancy result in a relaxation of the ligaments and muscles that support the joints. The increasing weight of the pregnancy means that there is extra strain on these ligaments. Avoid using high heels, and always keep an upright posture. Your centre of gravity when standing should be slightly behind. This way your back muscles will not need to work so hard to hold up the extra weight in front.

Q  I am 16 weeks pregnant and feel persistently breathless. Why is this so?

Breathlessness is common and by 16 weeks 25% of women will feel so. This is due to the effect of the pregnancy hormone progesterone on the breathing muscles. You should of course have yourself checked for lung or heart problems such as asthma, bronchitis, valve prolapse of the heart etc all of which may cause you to be breathless.

Q  I have been having frequent headaches. Is this normal and what can I take?

Headaches in pregnancy are common. It is often due to the increased circulation in the brain. Tension headaches and migraine are also more common. Should the headache be mild, simple painkillers may suffice. However should the headaches be persistent or severe, then brain blood vessel malformations and hypertension needs to be ruled out by your doctor.

Q  I was standing at the bus stop when I suddenly felt feint. Is this normal and what can I do to prevent this?

Feeling giddy and feint is very common and is due to the haemodynamic changes of the body during the early stages of pregnancy. There is a fall in the normal blood pressure of pregnant women which only returns to its normal level at about 28 weeks. Avoid standing in a queue for too long, getting up too fast from a sitting or sleeping position. Should you encounter this problem, raise your arms above your head and the blood from the arms will go to your head. When you feel better sit down and slowly put your head between your legs. You will feel less of this problem when you are in your third trimester.

Q  I am 16 weeks pregnant and have noticed that my ankles are swelling. Is it normal to swell so early in pregnancy?

In the early pregnancy swelling is due to the increased hormone oestrogen. This causes the blood vessels to be more permeable and water seeps out through them to surrounding tissues especially the ankles due to gravity. It affects about 1:3 pregnancies. It is considered as normal. However watch your salt intake as this may also cause more water retention and eventually high blood pressure. Swollen ankles early in pregnancy may also indicate impending pre-eclampsia, a condition that occurs in first pregnancies. have your blood pressure monitored regularly that it is not increasing. Avoid standing for long periods and raise your legs at night when sleeping.

Q  I have been having frequent leg cramps. How can I avoid these?

Leg cramps may be due to several factors. It may be due to a deficiency of certain minerals such as calcium, magnesium, or sodium. The more common reason is due to pooling of blood in the legs as a result of too much standing during the day and poor circulation. Your doctor may want to do your blood mineral levels and replace them with supplements. To reduce poor circulation, you may want to have your husband massage your calfs before sleeping and also sleep with your legs raised on two pillows.

Q  I have been having frequent palpitations. Is this normal and what needs to be done?

A fast heartbeat that lasts one or two hours is considered normal in pregnancy. It is related to the changes in the circulation of blood. However if it persists and lasts longer and more frequent than that, you should check with your doctor to exclude any problem with the heart. Irregular and fast heartbeats require urgent assessment by your doctor and perhaps a referral to a cardiologist to exclude certain conduction defects of the heart.

Q  I am always leaking urine when I cough, sneeze or run after a bus. Is this normal?

About 60% of pregnant women will develop stress incontinence, a condition in which the normal structures of the bladder outlet which prevents leakage are altered due to the hormonal changes taking place. You should be rest assured that it is normal and will improve after delivery. However, if your delivery is difficult or assisted with either a forceps or vacuum, there is a chance that these tissues will be weakened and the stress incontinence may persist after pregnancy. Kegel excercises during the pregnancy and after may help. This problem does not usually arise in those having caesarean section delivery.

Q  Why can't I get a good sleep at night?

It is common in pregnancy to have poor and broken sleep. You do not need to worry that it will affect your baby if you have insufficient sleep. However do try to rest more during the day if the sleep at night is broken. You may have a problem with having to get up due to more frequent urination, cramps, backache, an uncomfortable large uterus, or due to anxiety. Dreams seem to be more common in pregnancy perhaps due to the hormonal changes. It is not advisable to take sleeping tablets. Instead try taking a leisurely walk in the evening followed by a hot cup of milo or any beverage. Avoid all caffeine after 3 o'clock, spicy food for dinner, television, and bright lights in your bedroom.

Q  I have a pain in the outer portion of my thigh when I walk but gets better when lying down. Is this normal?

During pregnancy the swollen ligaments of the groin may press on a nerve called the lateral cutaneous nerve which supplies the outer portion of the thigh and skin. There will be pain and numbness. Rest assured that this is temporary and will disappear after delivery.

Q  I have numbness and pain in my fingers when I wake up in the morning. What is this due to and how can I relieve this?

The numbness and pain is due swelling and compression of the nerve known as the median nerve which runs under the ligament of the wrist. There may be tingling , numbness or pain in one or both hands. It is known as carpal tunnel syndrome. This is usually a temporary problem in pregnancy and will resolve after delivery. It may be mild in which case no treatment is required. If it is distressing medication to reduce water retention may be prescribed. Surgery is not usually required for this condition in pregnancy.

16 to 20 weeks of pregnancy - visits to your obstetrician and prentatal tests

Q I am now 16 weeks pregnant. What should I expect at my obstetricians?

He may want to do an ultrasound scan. You will see that the baby is now much larger, starting to move its arms and legs. Fingers and toes will be visible and in some instances may be seen to be sucking its fingers and toes!. the sex of the baby can be determined with accuracy at this stage. A triple blood test may be done if the oscar test was missed earlier.

Q What is a triple test and why do I need to have this?

This is done to determine if you are high risk of developing a Down's Syndrome baby ( baby with an extra chromosome resulting in mental retardation). It will also tell us the risk of defects of the spine. It is usually performed if the Oscar test has been missed. It measures 3 hormones present in the mother's blood and correlating this with her age and stage of pregnancy, a risk factor can be determined. This screen is not however as accurate as the Oscar test and like most tests will have false positives and negatives. A positive test would indicate the need for an amniocentesis ( tapping the fluid in the baby's water bag). A positive test for spinal defects can be correlated with a detailed foetal abnormality scan at 20 weeks.

Q I have been told that I need an amniocentesis. How is this procedure carried out and is it risky?

Approximately 15 mls of the baby's water bag is aspirated under ultrasound scan guidance. The ultrasound scan will determine the best site to insert the needle. The needle is inserted with or without local anaesthetic and the needle is watched on the ultrasound scan so that the chance of hurting the baby and its cord are minimised. It is a relatively  painless procedure. The fluid contains the baby's skin cells shed from the baby. The cells are grown in the laboratory and the cells examined. It takes about 2 weeks for the karyotyping, but for an extra cost a PCR may be done and results obtained in 3 days. However it is still advisable to have a full karyotype.

The procedure carries a risk of less than 1%. The main risks are of miscarriage following leakage of the baby's water bag, injury to the baby. The majority will have no complications.

Q My obstetrician advised me to undergo amniocentesis at 16 weeks rather than a chorionic villus biopsy at 9 weeks. Why is this so?

Chorionic villus biopsy (CVB) is a procedure in which a biopsy is taken from the foetal placenta at about 9 weeks gestation.The specimen undergoes a DNA analysis to determine certain genetic disorders. The procedure carries a higher risk of miscarriage than amniocentesis. There are also inconsistencies in the results and maternal contamination of villus samples have led to to errors in gene analysis. More importantly, studies in the UK have shown abnormalities in foetuses born to women who have had this procedure performed.

Q  Both my husband and I are thalassaemia carriers. What tests should I do to determine if my baby is normal?

If both you and your husband are carriers, you have a 1 in 4 chance of having a baby with thalassaemia major, a condition which is almost always fatal in childhood. This can be diagnosed by foetal cord blood sampling at 16 weeks. The foetal cord is identified under ultrasound scan and a needle inserted to aspirate a small amount of blood which undergoes DNA analysis.

Q  I have been told that I should have a detailed scan of my baby at 20 weeks. Why is this necessary?

The aim of every obstetrician is to have as low a perinatal mortality and morbidity rate as possible ie low death rate and low foetal complication. About 20% of perinatal mortality is due to congenital abnormalities. One of the important tools to diagnose congenital abnormalities is the ultrasound scan. The majority of abnormalities are best seen at about 20 weeks. Some abnormalities detected may be so severe as to warrant a decision to have an abortion. Other less severe abnormalities detected can prepare the patient, paediatrician for further treatment at the time of birth.

Q  How accurate is an ultrasound scan in excluding foetal abnormalities? Can I assume that my baby is normal since my ultrasound scan did not show up any abnormalities?

There are 3 levels of ultrasound scanning. The first is a general scan. This scan determines the number of foetus, position of the foetus and placenta, amount of fluid, measurement of the gestational age and growth of the foetus, a general look at the structure of the foetus. The second level would look at a more detailed structure and form of the foetus while the third level includes blood flow studies to exclude cardiac abnormalities. Most obstetricians with sufficient experience would do level 2 scans. The level of accuracy will depend on the experience of the obstetrician performing. An experienced obstetrician should obtain an accuracy of about 80%.

Q  What structural abnormalities may not be picked up by ultrasound scanning?

Small abnormalities are difficult to pick up. Very pften the fingers of the hand are clenched making it difficult to view all of them. Small holes in the heart, the way the major vessels enter and leave the heart are difficult to view, positional deformities of the legs and feet. The accuracy will depend greatly on the position of the baby at the time of scanning, the amount of abdominal fat in the mother, the position of the placenta and amount of fluid.

Q Is a 3 D and 4 D scan of value?

3D and 4D (3D in motion) scans have become almost standard in todays context. With advances in ultrasound machine technology, not only  2D but 3D clarity have improved tremendously. A 3D and 4D scan will complement the 2D scan. It shows the baby in a form more readily identifiable to most patients. If abnormalities are detected at 2D, the 3D and 4D will help confirm or refute the diagnosis. Another great advantage of the 4D is mother/ father and baby bonding which can start now before the baby is born!

Ultrasound scanning and common problems

Q  Why does my obstetrician perform an ultrasound scan through the vagina? Is this different from a scan over my abdomen?

A scan through the vagina is usually performed in the early pregnancy and particularly when the uterus is deep in the pelvis as with a retroverted uterus. It is purely technical to obtain a better image. If done through the abdomen, the bladder will ahve to be full and the view not as clear. The contents of the uterus, foetus, placenta are more easily seen. The cervix can be viewed and measured. This is important if cervical incompetence is suspected.

Q  What is cervical incompetence and how is it diagnosed? How can this be treated?

Cervical incompetence is a condition where the cervix cannot hold the pregnancy. The cervix is the neck of the womb and if it is damaged eg by previous abortions or surgical procedures such as a cone biopsy, then it may slowly open during the pregnancy without much in the way of symptoms and a premature delivery results. This may also happen with multiple pregnancies. To diagnose the condition, a vaginal ultrasound scan is done at 12 , 16, 20 and 24 weeks. The normal length of the cervix is 3-5cms. If the cervix is <2.5cms, a premature delivery is likely. The diagnosis is best made as early as possible and preferably around 12 weeks. The treatment is the insertion of a stitch around the cervix. This will usually help hold the pregnancy until 38 weeks when it can be taken out and the delivery allowed to proceed.

Q  I am 12 weeks pregnant and have noticed an increase in the amount of vaginal discharge. Is this normal?

When you are pregnant, the physiological changes that take place cause swelling in the neck of the womb and an increase in clear watery discharge. This discharge coagulates as it passes down the vagina and turns into a white and sometimes powdery discharge called leucorrhoea. However, if the discharge is yellow, green, bloody or there is a smell or itch, you may have a fungal or bacterial infection and this will need treatment.

Q  I am 12 weeks pregnant and have a thick, white, pasty discharge. It is causing a great deal of itch. What is this and do I need treatment?

You probably have moniliasis, a fungal infection that is very common in pregnancy. It occurs in about 20% pregnant women as is due to the excess moisture and alkalinity of the vagina. It may also occur after a course of antibiotics as the fungus is controlled by 'good' bacteria in the body. The antibiotics kills the 'good' bacteria and allows the fungus to multiply. Treatment is with vaginal pessaries or oral anti-fungals. If it is resistant to treatment or recurs, a blood test to exclude diabetes should be done.

Q  I am 12 weeks pregnant and have noticed a greenish yellow discharge. What is this and what treatment should I receive?

Your obstetrician will want to examine you and perhaps take a swab from the vagina to be examined. If he sees small protozoa under the microscope then you have an infection called trichomoniasis. Treatment is with a 10 day course of metronidazole. Your husband should be treated as well as this is sexually transmitted. If there is a suspicion of having contracted a sexual disorder, your obstetrician can do a blood test to exclude other sexually transmitted disorders as trichomoniasis very often coexists with them.

Q I am 12 weeks pregnant and have been having this foul smelling discharge mixed with blood for the last one month. What is this due to?

The most common cause is a polyp on the neck of the womb. These fleshy growths grow from the inner portion of the neck of the womb. They are related to hormonal changes that take place during the pregnancy, and can sometimes be very large. They can be removed with a forceps without danger to the baby.

Q I am 12 weeks pregnant and get these sudden pains in the back of my thigh and buttocks. What is this due to and what can be done?

The pain is known as sciatic pain and is due to pressure on the nerve roots that supply the back of the thigh and buttocks. It is common in pregnancy due to the changes that take place in the intervertebral spaces during pregnancy and will usually disappear later. Your obstetrician may want to give you something to reduce the spasm that is associated with it and also vitamin B 12 which appears to help. Avoid using high heels and ensure that you maintain an erect posture.

Q I am 12 weeks pregnant.Is it safe to have sexual intercourse?

If your pregnancy is uncomplicated by bleeding pr premature rupture of membranes, low-lying placenta, it should be safe to resume sexual intercourse. Intercourse may continue until such time that it becomes uncomfortable which is usually in the last 2 months.There is no evidence that sexual intercourse is harmful to the baby.

Q  What should my diet be at 12 weeks?

Your baby is now fully formed and is growing rapidly in size. You will want to increase your protein intake as these are the building blocks of the baby. You should take the equivalent of one steak per day. Your calorie intake will have to be increased by about 300 calories. You should ensure that you have sufficient calcium, iron and folic acid.

Q  Are there any foods that I should avoid now that I am in my second trimestor?

To avoid putting on too much weight you should avoid eating too much fried and oily foods, fast foods and foods with 'empty' calories such as cakes , cookies, chocolates etc. Semi-ccoked and raw foods are not advisable as food poisoning can be harmful to your baby.

Q  Is it true that I should avoid eating any shellfish and prawns during pregnancy?

There is no reason for you not to eat shellfish and prawns but make sure they are well cooked. Cockles that are not properly cooked can resullt in hepatitis A infection which can be harmful to your baby.

Q  What excercises can I do in my 12th week and what excercises should I avoid?

The best form of excercise would be cardiovascular eg swimmong and walking. This would build up your stamina without putting too much strain on your joints. You should do some form of stretching and flexilbility excercises. Yoga would be the ideal as it will improve flexibilty, stamina, and tone the muscles. You should avoid straineous excercises such as jogging that would also put a greater starin on your joints. Ball games such as tennis, and golf should be avoided. Do an hour of walking a day or 20 minutes of swimming to build your stamina.

12 to 16 weeks. Visits to your obstetrician

Q  I am 12 weeks pregnant. What can I expect at my visit to my obstetrician?

He may want to do an ultrasound scan. Your baby is now fully formed and is about 10 cms long. This is an important scan as he will probably want to determine if there is visible structural abnormalities, presence or abscence of nasal bone, nuchal fold thickness, and whether there is more than one foetus. Both height and weight, blood pressure and urine tested for sugar, blood and protein.

Q  What is nuchal fold thickness (NT) and why is it done?

Between 11 and 14 weeks the foetus will show fluid behind the nape of the neck. This is from the developing lymphatic system. The measurement is taken with the foetus lying on its back. It has been found that a thick fold may indicate a chromosomal abnormality and the greater the NT the greater the likelihood of an abnormality such as Down's Syndrome. Generally a NT of >2.5 cms would be taken as being abnormal.

Q  Why is it necessary to determine the presence of the nasal bone?

The nasal bone is absent in Down's Syndrome and many other chromosome abnormalities. A nasal bone measurement can be taken between 14 and 20 weeks. A measurement greater than 4.6mm would be considered as normal, while a measurement of less than 3.5mm would likely be a Down's. The ratio of the diameter of the head (BPD) to the nasal bone should by less than 8 and if > 10 is suggestive of Down's Syndrome.

Q  What is the Oscar Test?

This is a prenatal screen for Down's syndrome and other chromosome abnormalities. It measures the risk of having a Down's baby. It it is a combination of the nuchal fold thickness, and 2 blood parameters, free beta HCG and PAPP-A. The accuracy of the test is over 90%, however with any screen there are both false positives and negatives.The test is done from 11 to 14 weeks. If the test is positive, your obstetrician will advise you to have an amniocentesis (tapping of the baby's water bag to obstain foetal cells for culture and examination)

Q  What is the triple test and how does it differ from the oscar test?

The triple test is done at 15 weeks and above. It is also a prenatal screen for Down's syndrome and measures the 3 factors in the blood, alpha feto protein, free beta HCG and unconjugated estriol. The accuracy is over 80% and like the oscar test has both false positives and negatives. As with the oscar test, if positive, your obstetrician will advise an amniocentesis.

Other concerns in early pregnancy

Q  What are stretch marks and are they preventable?

Stretch marks are caused by the undue stretching of the collagen fibres in the skin that has been altered by the pregnancy hormones. They may occur on the abdomen, thighs, breasts. Alot depends on your skin type which is genetically determined. Some have more stretchable skin and do not get stretch marks while others may even get severe stretch marks all over. To avoid them, try not to put on too much weight, and avoid rapid weight gain. The bigger the baby the more likely you are to get stretch marks. They are generally unavoidable otherwise, and applying stretch mark creams are unhelpful. Stretch marks will lighten and turn to a silvery colour after birth.

Q  I have developed brown patches on my face during this pregnancy, and a dark line down the middle of my abdomen. Is this normal?

The brown patches are known as melasma, and the line, linear nigra. They are the result of an increase in the pigment hormone melanin. Generally they will lighten and disappear several months after delivery. There are medications such as triluma to apply to remove them, but are not advisable to use during pregnancy.

Q  I have been told that I have a retroverted or tilted womb. I am now 8 weeks pregnant. Will this in any way have  an effect on my pregnancy?

About 10% of women are born with a tilted womb. Although there are some reports of a higher risk of miscarriage it does not appear to affect the outcome of the pregnancy. The uterus will usually correct itself and assume the normal anteverted position at about 16 weeks. A retroverted womb may cause some backache, constipation and difficulty in passing urine. If severe, can result in urinary retention and the need for catheterisation. The neck of the bladder may be stretched by the enlarging womb that eventually it is so narrow that urinary retention results. If persistent, admission to hospital may be necessary and an indwelling tube in the bladder inserted.

Q  I am in my 10th week of pregnancy and have found that I am having difficulty in passing urine. What is this due to?

If your obstetrician has told you that you have a tilted womb at your earlier examination, then that ios the cause of the difficulty in passing urine. The stretching and narrowing of the bladder outlet that is positioned over the uterus results in retention of urine. In the beginning there may be difficulty in passing urine and this may eventually lead to complete urinary retention. The treatment is admission to hospital and insertion of an indwelling catheter. The problem usually improves as the pregnancy advance s towards 16 weeks and the uterus rises out of the pelvis.

Excercises in early pregnancy

Q  What excercises can I do in the early pregnancy?

If you have been doing some form of aerobic excercise before pregnancy it is alright to carry on, however do not overstrain and do it in moderation. Do not start vigorous excercise for the first time otherwise. Jogging and ball games should be avoided. Your joints and ligaments are more susceptible to damage during pregnancy. Jogging will divert precious oxygen and blood from the growing baby. Always start slow with warming up excercises and stretch well after your excercise. Swimming, cycling on a stationary cycle and walking are the ideal forms of aerobic excercises.

Q  Can I do yoga?

Yes but with limitation. Taking it as a form of stretching and toning excercise would be best. The muscles to tone would be the back, abdominal and calf muscles as these are the ones that would be worked most during your pregnancy. When lying on your back do not do this for long periods ie more than 5 minutes as this may cause a drop in your blood pressure and also reduce the blood flow to the baby.  When getting up from the flow do so slowly as there may be a sudden fall in blood pressure.