History

Fact Explanation
Missed periods Menstruation is sloughing off of the uterine endometrial lining epithelium as a response to declining pituitary sex hormones (estrogen and progesterone) in the absence of pregnancy, and happens in cycles. [1] Commonly, the first observed feature of pregnancy is the absence of menstrual bleeding. However using last menstrual period is not very useful in determining the gestational age. [13]
Vaginal bleeding following a period of amenorrhea It's common for pregnant females to bleed on and off during the first trimester[12] and this could be misinterpreted as menstrual bleeding, but bleeding could be due to a spontaneous abortion, ectopic pregnancy, or gestational trophoblastic disease. Therefore it's important to know whether the last menstrual periods were similar to previous ones, and whether she was on any hormonal contraceptive method before coming to conclusion.
Gastrointestinal disturbances (e.g. Nausea, vomiting) and malaise (morning sickness) It's a very common presentation, and affects about 70%-80% pregnant females.[2] During pregnancy, the blood levels of progesterone is constantly high, and that is suggested to be an adaptation to keep the uterine smooth muscles relaxed until the fetus is mature enough to be delivered. [3] It is also a way to keep the mother away from ingesting potentially harmful substances for the fetus. [6] But as an adverse outcome of this adaptation, relaxation of smooth muscle tissue in the body's other parts give undesirable symptoms. It is also described that human chorionic gonadoptropin and estrogens also play a major role in nausea and vomiting during pregnancy. Overall, the susceptibility for gastrointestinal disturbances are mediated by vestibular, gastrointestinal, olfactory, and behavioral pathways. [4] [5] Hyperemesis gravidarum should always be taken into consideration.
Lower abdominal pain It could be the first presentation of pregnancy, a benign implantation bleed but could be a warning sign of subchorionic hemorrhage, spontaneous abortion, ectopic pregnancy, heterotopic pregnancy, anembryonic pregnancy, gestational trophoblastic disease, and round ligament syndrome. [7] [8] Apart from the commoner aspects, rarer cases of lower abdominal pain have been reported and cannot be considered lightly. [9] [10]
As an incidental finding during medical checkup. Especially in women who have irregular menstrual cycles, or been on a selection of contraception, or more commonly who are uneducated about conception. [11]
References
  1. JABBOUR, H.N, KELLY, R.W, FRASER, H.M and CRITCHLEY, H.O. Endocrine regulation of menstruation. Endocr Rev. [online] 2006 Feb;27(1):17-46. [viewed April 16, 2014] DOI: http://dx.doi.org/10.1210/er.2004-0021
  2. LEE, N.M and SAHA, S. Nausea and vomiting of pregnancy. Gastroenterol Clin North Am [online] 2011 Jun;40(2):309-34. [viewed April 16, 2014] Available at http://www.ncbi.nlm.nih.gov/pubmed/21601782.
  3. SHERMAN, P.W. and FLAXMAN, S.M. Nausea and vomiting of pregnancy in an evolutionary perspective. Am J Obstet Gynecol [online] 2002 May;186(5 Suppl Understanding):S190-7. [viewed April 16, 2014] Available at http://www.colorado.edu/eeb/facultysites/flaxman/Publication_List_files/ShermanFlaxman02NVP.pdf.
  4. GOODWIN, T.M. Nausea and vomiting of pregnancy: an obstetric syndrome. Am J Obstet Gynecol. [online] 2002 May;186(5 Suppl Understanding):S184-9. [viewed April 16, 2014] Available at http://www.utilis.net/Morning%20Topics/Obstetrics/N&V.PDF
  5. LACASSE A. , REY E. , FERREIRA E. , MORIN C. and BÉRARD A. Epidemiology of nausea and vomiting of pregnancy: prevalence, severity, determinants, and the importance of race/ethnicity. BMC Pregnancy and Childbirth [online] 2009, 9:26 doi:10.1186/1471-2393-9-26 [viewed April 16, 2014]
  6. FLAXMAN, S.M. and SHERMAN, P.W. Morning sickness: a mechanism for protecting mother and embryo. Q Rev Biol. [online] 2000 Jun;75(2):113-48. [viewed April 16, 2014] Available at http://www.colorado.edu/eeb/facultysites/flaxman/Publication_List_files/FlaxmanSherman00.pdf.
  7. OSTGAARD, H.C. , ANDERSSON, G.B.J. and KARLSSON, K. Prevalence of Back Pain in Pregnancy. Spine [online] 1991 May;16(5): p. 549-552. [viewed April 16,2014] Available at http://journals.lww.com/spinejournal/Abstract/1991/05000/Prevalence_of_Back_Pain_in_Pregnancy.11.aspx.
  8. HUANCAHUARI, N. Emergencies in early pregnancy. Emerg Med Clin North Am. [online] 2012 Nov;30(4):837-47. [viewed April 17, 2014] doi: 10.1016/j.emc.2012.08.005.
  9. DINCGEZ, Burcu, Murat BOZKURT, Banu ÖNDES, Ayşe Ender YUMRU and Cengiz YUMRU. Adnexal torsion in the first trimester of a spontaneous pregnancy: detorsion and oophoropexy. Proceedings in Obstetrics and Gynecology[online] 2013;3(3):4. [viewed April 17, 2014] Available at http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1231&context=pog.
  10. VIAL, Y. , P. PETIGNAT and P. HOHLFELD. Pregnancy in a Cesarean scar. Ultrasound in Obstetrics & Gynecology [online] 2000 Nov; 16(6): p 592–593. [viewed April 17, 2014] Available at DOI: 10.1046/j.1469-0705.2000.00300-2.x
  11. BOCHICCHIO, G.V, NAPOLITANO, L.M, HAAN, J, CHAMPION, H and SCALEA, T. Incidental pregnancy in trauma patients. J Am Coll Surg. [online] 2001 May;192(5):566-9. [viewed April 17, 2014] DOI: http://dx.doi.org/10.1016/S1072-7515(01)00818-3.
  12. HARVILLE, E.W, WILCOX, A.J, BAIRD, D.D and WEINBERG, C.R. Vaginal bleeding in very early pregnancy. Hum Reprod. [online] 2003 Sep;18(9):1944-7. [viewed April 17, 2014]. doi: 10.1093/humrep/deg379.
  13. SAVITZ, D.A, TERRY, J.W JR, DOLE, N, THORP, J.M JR, SIEGA-RIZ, A,M and HERRING, A.H. Comparison of pregnancy dating by last menstrual period, ultrasound scanning, and their combination. Am J Obstet Gynecol. [online] 2002 Dec;187(6):1660-6. [viewed April 17, 2014] doi:10.1067/mob.2002.127601

Examination

Fact Explanation
Enlarged uterus in bimanual examination An enlarged uterus can be felt by bimanual palpation even in the first trimester. [1] [3] The gestational age can be assessed through the size of uterus but it is not as accurate as ultrasonography and may lead to unnecessary interventions. [1] [2]
Breast changes. Increase in size and glandularity is a constant change during pregnancy. It could manifest in early weeks, though the changes are more visible later on. [1] [2]
Hegar's sign Softening and enlargement of the cervix. Which can be observed at around 6 weeks. [1] [2] [5] [6]
Chadwick sign Bluish discoloration of the cervix from venous congestion. This can be observed by 8-10 weeks [1] [2]
Palpable uterus low in the abdomen. Usually later in pregnancy, at least after 12-13 weeks. [1] [2]
Wight, height and body mass index (BMI) Extremes of pre-pregnancy or first trimester BMI has been associated with adverse fetal outcomes, mainly preterm births. [7] [8] [9]
References
  1. PAUL, M, SCHAFF, E and NICHOLS, M. The roles of clinical assessment, human chorionic gonadotropin assays, and ultrasonography in medical abortion practice. Am J Obstet Gynecol. [online] 2000 Aug;183(2 Suppl):S34-43. [viewed April 17, 2014] Available at doi:10.1067/mob.2000.108230
  2. WIERINGA-DE WAARD, M, BONSEL, G.J, ANKUM, W.M, VOS, J and BINDELS, P.J. Threatened miscarriage in general practice: diagnostic value of history taking and physical examination. Br J Gen Pract. [online] 2002 Oct;52(483):825-9. [viewed April 17, 2014] Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1316086/pdf/12392123.pdf.
  3. EVANS, M.F. Diagnosing pregnancy. What is the best way? Can Fam Physician. [online] Feb 1998; 44: 287–289. [viewed April 17, 2014] Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2277596/pdf/canfamphys00048-0081.pdf
  4. SAVITZ, D.A, TERRY, J.W JR, DOLE, N, THORP, J.M JR, SIEGA-RIZ, A,M and HERRING, A.H. Comparison of pregnancy dating by last menstrual period, ultrasound scanning, and their combination. Am J Obstet Gynecol. [online] 2002 Dec;187(6):1660-6. [viewed April 17, 2014] Available at doi:10.1067/mob.2002.127601
  5. SPECK, G. Correct use of Hegar's sign. Am J Obstet Gynecol. [online] 1986 Mar;154(3):691-2. [viewed April 17, 2014] Available at doi:10.1016/0002-9378(86)90634-4.
  6. WINKLER, M. and W. RATH. Changes in the cervical extracellular matrix during pregnancy and parturition. Journal of Perinatal Medicine. [online] 1999 Mar;27(1) p 45–61 [viewed April 17, 2014] Available at DOI: 10.1515/JPM.1999.006
  7. GUENDELMAN, S, PEARL, M, KOSA, J.L, GRAHAM, S, ABRAMS, B. and KHARRAZI, M. Association between preterm delivery and pre-pregnancy body mass (BMI), exercise and sleep during pregnancy among working women in Southern California. Matern Child Health J. [online] 2013 May;17(4):723-31. [viewed April 17, 2014] Available at doi: 10.1007/s10995-012-1052-5.
  8. KOSA, J.L, GUENDELMAN, S, PEARL, M, GRAHAM, S, ABRAMS, B and KHARRAZI, M. The association between pre-pregnancy BMI and preterm delivery in a diverse southern California population of working women. Matern Child Health J. [online] 2011 Aug;15(6):772-81. [viewed April 17, 2014] Available at doi: 10.1007/s10995-010-0633-4.
  9. LYNCH, A.M, HART, J.E, AGWU, O.C, FISHER, B.M, WEST, N.A and GIBBS, R.S. Association of extremes of prepregnancy BMI with the clinical presentations of preterm birth. Am J Obstet Gynecol. [online] 2013 Dec 7. pii: S0002-9378(13)02181-9. [viewed April 17, 2014] Available at doi: 10.1016/j.ajog.2013.12.011.

Differential Diagnoses

Fact Explanation
First trimester miscarriage. When vaginal bleeding is the presentation, needs to exclude a miscarriage. Researches have shown that heavy bleeding in the first trimester, particularly when accompanied by pain, is associated with higher risk of miscarriage. Spotting and light episodes are not, especially if lasting only 1-2 days. [1]
Ectopic pregnancy. Most present with missed periods, a lower abdominal pain, and probably vaginal bleeding. Ultrasonography is the gold standard to exclude an ectopic. [2] [3].
HCG secreting pelvic tumors. Mainly germ cell tumors. Even though not much of a differential diagnosis, it's worthy to consider in atypical presentations because they can mimic some symptoms of pregnancy due to high HCG level, and also can yield false positive results in urine HCG tests. [4] Lower abdominal pain can mimic a ruptured ectopic pregnancy. [6]
Pregnancy luteoma. It's rare and a benign neoplasm of the ovary which is thought to be caused by the hormonal effects of pregnancy. Usually asymptomatic and an incidental finding at the ultrasonography. [5] This is a benign tumor but other tumors which are not so worthy of ignorance can manifest as a luteoma. [8]
Choriocarcinoma It can always appear as a soft tissue mass in pregnant females, and sometimes with exaggerated pregnancy features. The females who pose a risk for gestational trophoblastic disease should always be screened for. [7]
References
  1. HASAN, R, BAIRD, D.D, HERRING, A.H, OLSHAN, A.F, JONSSON-FUNK, M.L. and HARTMANN, K.E. Association between first-trimester vaginal bleeding and miscarriage. Obstet Gynecol. [online] 2009 Oct;114(4):860-7. [viewed April 17, 2014] Available at doi: 10.1097/AOG.0b013e3181b79796.
  2. DOUBILET, P.M, BENSON, C.B, FRATES, M.C and GINSBURG, E. Sonographically guided minimally invasive treatment of unusual ectopic pregnancies. J Ultrasound Med. [online] 2004 Mar;23(3):359-70. [viewed April 17, 2014] Available at http://www.jultrasoundmed.org/content/23/3/359.full
  3. LIN, E.P, BHATT, S and DOGRA, V.S. Diagnostic clues to ectopic pregnancy. Radiographics. [online] 2008 Oct;28(6):1661-71. [viewed April 17, 2014] Available at DOI: http://dx.doi.org/10.1148/rg.286085506.
  4. ULBRIGHT, T.M. Germ cell tumors of the gonads: a selective review emphasizing problems in differential diagnosis, newly appreciated, and controversial issues. Mod Pathol. [online] 2005 Feb;18 Suppl 2:S61-79. [viewed April 17, 2014] Available at doi:10.1038/modpathol.3800310.
  5. MASARIE, K, KATZ, V. and BALDERSTON, K. Pregnancy luteomas: clinical presentations and management strategies. Obstet Gynecol Surv. [online] 2010 Sep;65(9):575-82. [viewed April 17, 2014] Available at doi: 10.1097/OGX.0b013e3181f8c41d.
  6. SHEELAA W.G. and Jayasree MANIVASAKAN. Hemoperitoneum: a diagnostic dilemma. A solid ovarian tumour mimicking ruptured ectopic pregnancy. Int J Reprod Contracept Obstet Gynecol. [online] 2013; 2(2): 254-256 [viewed April 17, 2014] Available at doi: 10.5455/2320-1770.ijrcog20130635.
  7. ABABNEH, K. and AL-KHATEEB, T. Aggressive pregnancy tumor mimicking a malignant neoplasm: a case report. J Contemp Dent Pract. [online] 2009 Nov 1;10(6):E072-8. [viewed April 17, 2014] Available at http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=2044&Type=FREE&TYP=TOP&IN=_eJournals/images/JPLOGO.gif&IID=172&isPDF=YES
  8. OZDEGIRMENCI, O, KAYIKCIOGLU, F, HABERAL, A. and OZFUTTU, A. Krukenberg tumor mimicking pregnancy luteoma. Acta Cytol. [online] 2009 Mar-Apr;53(2):195-7. [viewed April 17, 2014] Available at doi:10.1080/09513590701532401.

Investigations - for Diagnosis

Fact Explanation
Obstetric ultrasonography Currently the best and diagnostic investigation, [1] [12] not only for confirmation but to assess the pregnancy in terms of singleton/multiple, site [4] [5], dating [3], and later on follow up with fetal growth monitoring. It is also an important tool in assessing fetal malformations. [2] Excluding an ectopic pregnancy is very essential in suspected individuals. [9]
Urine HCG. (Human Chorionic Gonadotrophin) It is a glycoprotein synthesized by the syncytiotrophoblast to continue the pregnancy. Detectable in urine in dipstick test two weeks following conception and in blood, even before that. [6] [7] The sensitivity of urine testing is satisfactory. [8] Even with using an extremely sensitive assay for hCG, 10% of clinical pregnancies were undetectable on the first day of missed menses. [11] Negative urine pregnancy testing with the presence of amenorrhea can imply a pathological condition. [10]
References
  1. WIERINGA-DE WAARD, M, BONSEL, G.J, ANKUM, W.M, VOS, J and BINDELS, P.J. Threatened miscarriage in general practice: diagnostic value of history taking and physical examination. Br J Gen Pract. [online] 2002 Oct;52(483):825-9. [viewed April 17, 2014] Available at http://www.ncbi.nlm.nih.gov/pubmed/12392123.
  2. RASIAH, S.V, PUBLICOVER, M, EWER, A.K, KHAN, K.S, KILBY, M.D and ZAMORA, J. A systematic review of the accuracy of first-trimester ultrasound examination for detecting major congenital heart disease. Ultrasound Obstet Gynecol. [online] 2006 Jul;28(1):110-6. [viewed April 17, 2014] Available at DOI: 10.1002/uog.2803
  3. SEYMOUR A, ABEBE H, PAVLIK D and SACCHETTI A. Pelvic examination is unnecessary in pregnant patients with a normal bedside ultrasound. Am J Emerg Med. [online] 2010 Feb;28(2):213-6. [viewed April 17, 2014] doi: 10.1016/j.ajem.2008.10.018.
  4. DOUBILET, P.M, BENSON, C.B, FRATES, M.C and GINSBURG, E. Sonographically guided minimally invasive treatment of unusual ectopic pregnancies. J Ultrasound Med. [online] 2004 Mar;23(3):359-70. [viewed April 17, 2014] Available at http://www.jultrasoundmed.org/content/23/3/359.long.
  5. LIN, E.P, BHATT, S and DOGRA, V.S. Diagnostic clues to ectopic pregnancy. Radiographics. [online] 2008 Oct;28(6):1661-71. [viewed April 17, 2014] Available at DOI: http://dx.doi.org/10.1148/rg.286085506.
  6. COLE, L.A. Human chorionic gonadotropin tests. Expert Rev Mol Diagn. [online] 2009 Oct;9(7):721-47. [viewed April 17, 2014] Available at doi: 10.1586/erm.09.51.
  7. COLE, L.A. The hCG assay or pregnancy test. Clin Chem Lab Med. [online] 2012 Apr;50(4):617-30. [viewed April 17, 2014] Available at doi: 10.1515/CCLM.2011.808.
  8. SUTTON, J.M. Charge variants in serum and urine hCG. Clin Chim Acta. [online] 2004 Mar;341(1-2):199-203. [viewed April 17, 2014] Available at http://dx.doi.org/10.1016/j.cccn.2003.12.006.
  9. ALKATOUT I, HONEMEYER U, STRAUSS A, TINELLI A, MALVASI A, JONAT W, METTLER L, and SCHOLLMEYER T. Clinical diagnosis and treatment of ectopic pregnancy. Obstet Gynecol Surv. [online] 2013 Aug;68(8):571-81. [viewed April 17, 2014] Available at doi: 10.1097/OGX.0b013e31829cdbeb.
  10. WIWANITKIT, V. Implication of negative urine pregnancy testing in subjects with unknown last menstrual period. Clin Exp Obstet Gynecol. 2006;33(1):26-7. Available at http://www.ncbi.nlm.nih.gov/pubmed/16761534.
  11. WILCOX, A.J, BAIRD, D.D, DUNSON, D, MCCHESNEY, R .and WEINBERG CR. Natural limits of pregnancy testing in relation to the expected menstrual period. JAMA. [online] 2001 Oct 10;286(14):1759-61.[viewed April 17, 2014] Available at doi:10.1001/jama.286.14.1759.
  12. SAVITZ, D.A, TERRY, J.W JR, DOLE, N, THORP, J.M JR, SIEGA-RIZ, A,M and HERRING, A.H. Comparison of pregnancy dating by last menstrual period, ultrasound scanning, and their combination. Am J Obstet Gynecol. [online] 2002 Dec;187(6):1660-6. [viewed April 17, 2014] Available at doi:10.1067/mob.2002.127601

Investigations - Fitness for Management

Fact Explanation
VDRL test. ( Venereal Disease Research Laboratory) It is a serological screening test to assess whether the patient has been infected with syphilis, though there are many false positives and negatives [3], and with the current higher use of antibiotics the prevalence being low [1], the importance of checking it is that if one person has been infected with one sexually transmitted infection, then she has a higher chance of being infected with other infections as well. So this serves a dual purpose in treating the pregnant females for syphilis [4], and also identifying the risky population, especially for HIV. [1] [2] [5]
Hemoglobin level Pregnancy is a demanding period of life, because the mother has to nurture another growing human being inside her, with storing nutrition for upcoming nursing period as well as managing her own daily nutrition requirement. Anemia in pregnancy has been associated with fetal adverse outcomes [9] with spontaneous abortions, preterm deliveries and postnatal complications. [6] Anemia has quite a high prevalence in the pregnant females of developing countries. [10] The commonest cause is iron deficiency. [7] But there are other less common but important causes such as malaria. [8] Reasonable analysis and treating as required improves the outcome of pregnancy. [6]
Fasting blood glucose Fasting blood sugar describes the ability to handle glucose level in between meals, that is to say, the basal insulin action. This can be used as a tool to screen pre-existing diabetes mellitus [11] [12] or impaired fasting glucose which pose a threat to the mother and the fetus both [13]. Early in pregnancy the blood glucose levels tend to fall slightly as a normal physiological reaction. [14] So it is important to use cut-off limits for gestational age of pregnancy. [15]
Oral glucose tolerance test (OGTT) The estimates insulin sensitivity taken from OGTT is significantly useful than that of fasting glucose level. [16] During pregnancy the anti-insulin hormones ( human placental lactogen, glucagon and cortisol mainly) are grossly elevated, even though insulin level is also doubled, the total effect is relative glucose intolerance. This steadily and progressively increases with gestational age. [17]
Blood group Screening for Rhesus negative females during first trimester makes it more efficient and cost-effective in using antenatal prophylaxis against Rh incompatibility of the fetus. [18] Prior diagnosing the ABO blood group is important in maternal emergencies.
Urine proteins Proteinuria/albuminuria is a hallmark feature of pre-eclampsia, and it also screens for pre-existing renal disorders. In females with normal blood pressure, this is to establish a reference level for later uses. [19]
HIV screening This is not done as a routine investigations but when the female is volunteering to get herself screened, it is a must to do so, and by that prevents fetal adverse outcomes and also vertical transmission of HIV. [20]
References
  1. WOLFF, T. , SHELTON, E. , SESSIONS, C. , and MILLER, T. Screening for Syphilis Infection in Pregnant Women: Evidence for the U.S. Preventive Services Task Force Reaffirmation Recommendation Statement. Ann Intern Med. [online] 2009;150:710-716 [viewed April 17, 2014] Available at http://www.sfcityclinic.org/providers/CongenitalSyphilisUSPTFAnnals2009.pdf.
  2. GEUSAU, A. , KITTLER, H. , HEIN, U., DANGL-ERLACH, E., STINGL, G. and TSCHACHLER, E. Biological false-positive tests comprise a high proportion of Venereal Disease Research Laboratory reactions in an analysis of 300,000 sera. Int J STD AIDS. [online] 2005 Nov;16(11):722-6. [viewed April 17, 2014] Available at doi: 10.1258/095646205774763207.
  3. SMIKLE, M.F, JAMES, O.B and PRABHAKAR, P. Biological false positive serological tests for syphilis in the Jamaican population. Genitourin Med. [online] 1990 Apr;66(2):76-8. [viewed April 17, 2014] Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1194464/pdf/genitmed00044-0028.pdf.
  4. GENÇ, M and LEDGER, W.J. Syphilis in pregnancy. Sex Transm Infect [online] 2000;76:73-79. [viewed April 17, 2014] Available at doi:10.1136/sti.76.2.73.
  5. NAYAK, S. and ACHARIYA, B. VDRL Test and its Interpretation. Indian J Dermatol. [online] 2012 Jan-Feb; 57(1): 3–8. [viewed April 17, 2014] Available at doi: 10.4103/0019-5154.92666.
  6. HOROWITZ, K.M, INGARDIA, C.J. and BORGIDA, A.F. Anemia in pregnancy. BMJ. [online] 2013 Jun 21;346:f3443. [viewed April 17, 2014] Available at doi: 10.1016/j.cll.2013.03.016.
  7. HAIDER B.A. et al. Anaemia, prenatal iron use, and risk of adverse pregnancy outcomes: systematic review and meta-analysis. BMJ. [online] 2013 Jun 21;346:f3443. [viewed April 17, 2014] Available at doi: 10.1136/bmj.f3443.
  8. VERHOEFF, F.H, BRABIN, B.J, CHIMSUKU, L, KAZEMBE, P. and BROADHEAD, R.L. An analysis of the determinants of anaemia in pregnant women in rural Malawi--a basis for action. Ann Trop Med Parasitol. [online] 1999 Mar;93(2):119-33. [viewed April 17, 2014] Available at http://dx.doi.org/10.1080/00034989958609.
  9. MARCHANT, T, SCHELLENBERG, J.A, NATHAN, R, ABDULLA, S, MUKASA, O, MSHINDA, H. and LENGELER, C. Anaemia in pregnancy and infant mortality in Tanzania. Trop Med Int Health. [online] 2004 Feb;9(2):262-6. [viewed April 17, 2014] Available at DOI: 10.1046/j.1365-3156.2003.01178.x.
  10. ADAM, I. , KHAMIS, A.H. and ELBASHIR, M.I. Prevalence and risk factors for anaemia in pregnant women of eastern Sudan. Trans R Soc Trop Med Hyg [online] (2005) 99 (10): 739-743. [viewed April 17, 2014] doi: 10.1016/j.trstmh.2005.02.008
  11. HAWKINS, J.S. Glucose Monitoring During Pregnancy. Curr Diab Rep. Jun 2010; 10(3): 229-234. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856850
  12. BOUHSAIN, S, EL KOCHRI, S, BABAHABIB, M.A, HAFIDI, M.H, BOUAITI, E. and MOUSSAOUI, M.D. [Comparing two screening policies of gestational diabetes mellitus: The Mohammed V Training Military Hospital of Rabat (Morocco).] Gynecol Obstet Fertil. [online] 2014 Jan 7. pii: S1297-9589(13)00270-1. [viewed April 17, 2014] Available at doi: 10.1016/j.gyobfe.2013.09.006.
  13. WENDER-OZEGOWSKA, E, WRÓBLEWSKA, K, ZAWIEJSKA, A, PIETRYGA, M, SZCZAPA, J and BICZYSKO, R. Threshold values of maternal blood glucose in early diabetic pregnancy--prediction of fetal malformations. Acta Obstet Gynecol Scand. [online] 2005 Jan;84(1):17-25. [viewed April 17, 2014] Available at DOI: 10.1111/j.0001-6349.2005.00606.x.
  14. RISKIN-MASHIAH, S, DAMTI, A, YOUNES, G. and AUSLANDER, R. Normal fasting plasma glucose levels during pregnancy: a hospital-based study. J Perinat Med. [online] 2011 Mar;39(2):209-11. [viewed April 17, 2014] Available at doi: 10.1515/JPM.2010.142.
  15. RAJAB, K.E, SKERMAN, J.H. and ISSA, A.A. Screening for gestational diabetes by measuring fasting plasma glucose levels. J Sci Res Med Sci. Aug 2003; 5(1-2): 5-8. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3174726.
  16. KIRWAN, J.P, HUSTON-PRESLEY, L, KALHAN, S.C. and CATALANO, P.M. Clinically useful estimates of insulin sensitivity during pregnancy: validation studies in women with normal glucose tolerance and gestational diabetes mellitus. Diabetes Care. [online] 2001 Sep;24(9):1602-7. [viewed April 17, 2014] Available at doi: 10.2337/diacare.24.9.1602
  17. LAIN, K.Y. and CATALANO, P.M. Metabolic Changes in Pregnancy. Clin Obstet Gynecol. [online] 2007 Dec;50(4):938-48.[viewed April 17, 2014] Available at doi: 10.1097/GRF.0b013e31815a5494
  18. CACCIATORE A et al. Obstetric management in Rh alloimmunizated pregnancy. J Prenat Med. [online] 2009 Apr-Jun; 3(2): 25–27. [viewed April 17, 2014] Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279102/
  19. WILKINSON C, LAPPIN D, VELLINGA A, HENEGHAN HM, O'HARA R and MONAGHAN J. Spot urinary protein analysis for excluding significant proteinuria in pregnancy. J Obstet Gynaecol. [online] 2013 Jan;33(1):24-7. [viewed April 17, 2014] Available at doi: 10.3109/01443615.2012.711388.
  20. FITZ HARRIS, L.F. , TAYLOR, A.W. , ZHANG, F. , BORKOWF, C.B. , ARTHUR, B.C. , JACQUES-CARROLL, L. , WANG, S.A. and NESHEIM, S.R. Factors associated with human immunodeficiency virus screening of women during pregnancy, labor and delivery, United States, 2005-2006. Matern Child Health J. [online] 2014 Apr;18(3):648-56. [viewed April 17, 2014] Available at doi: 10.1007/s10995-013-1289-7.

Investigations - Followup

Fact Explanation
Obstetric ultrasonography. The modified biophysical profile has been found to be an excellent means of fetal surveillance and identifing patients who are at increased risk for adverse perinatal outcome and small-for-gestational-age infants. [1] The frequency depends on the stage of pregnancy and the obstetrician's wishes. Biophysical profile is more accurate in the identification of the hypoxic fetus than any other single method.
References
  1. NAGEOTTE, M.P, TOWERS, C.V, ASRAT, T. and FREEMAN, R.K. Perinatal outcome with the modified biophysical profile. Am J Obstet Gynecol. 1994 Jun;170(6):1672-6. Available at http://www.ncbi.nlm.nih.gov/pubmed/8203424.