Antenatal Care and Common Gynaecological Presentations

Obstetrics and Gynaecology — Antenatal Care and Gynaecology, NMC MBBS licence examination syllabus (Nepal Medical Council).

Antenatal care and common gynaecological presentations

Most antenatal visits find nothing. That is the point of them.

Antenatal care is often described as "checking the baby is fine", which misdescribes it badly. It is a screening programme, and like every screening programme in the epidemiology chapter, its value lies in the small number of women in whom it detects something before it declares itself.

Blood pressure taken at every visit is not a formality — it is how pre-eclampsia is caught while it is still silent. Haemoglobin, blood group, and infection screening each exist because there is an effective action to take. And the single most valuable thing a woman leaves a clinic with is not a reassurance but a list of danger signs and the confidence to return.

🩺 Where this lives: In Nepal, maternal outcomes correlate strongly with whether a woman reaches a facility in time, and the delay is frequently in recognising that something is wrong rather than in transport. So the counselling element of antenatal care — explaining exactly which symptoms mean come back now, to the woman and to whoever makes decisions in her household — is not an optional extra at the end of the consultation. In many settings it does more good than any test performed during the visit.

💡 A note on schedules and doses. This chapter gives none. Visit schedules, supplementation regimens and screening panels follow national guidance and change; take them from current Nepali guidance rather than from a revision note.

What antenatal care is for

THE FIRST VISIT — establishing the baseline DATING confirms gestation, which every later decision depends on. Ultrasound dating is more reliable than dates alone. HISTORY THAT CHANGES MANAGEMENT Previous pregnancies and their outcomes — a previous caesarean, pre-eclampsia, preterm birth, stillbirth or postpartum haemorrhage all alter this pregnancy's plan Medical conditions: hypertension, diabetes, epilepsy, cardiac disease, thyroid disease ALL medication, including purchased and traditional remedies Domestic circumstances — pregnancy is a period of increased risk of violence, and asking is part of care EXAMINATION AND TESTS Blood pressure and urine protein — repeated at EVERY visit thereafter Haemoglobin and blood group with rhesus status Screening for syphilis, HIV and hepatitis B, each of which has an intervention that changes the outcome Weight, and fundal height as pregnancy progresses

Note why rhesus status is checked so early. A rhesus-negative woman carrying a rhesus-positive fetus can be sensitised by any bleeding or trauma, and once she has produced antibodies they affect every subsequent pregnancy. Anti-D prophylaxis prevents a problem that would otherwise arrive in the next child — a rare instance of treating one patient entirely for the benefit of a future one.

Prescribing in pregnancy

💡 Exam angle: the trap in this topic is not knowing which drugs to avoid — it is stopping treatment reflexively. Uncontrolled epilepsy, asthma or hypertension harms both mother and fetus more than most of the drugs used to treat them. The right answer to "patient on an antiepileptic is now pregnant" is specialist review and optimisation, not withdrawal. Questions test this by making the drug sound alarming and the disease sound trivial.

FOLIC ACID — the timing is the whole point Neural tube closure is complete within the first few weeks of pregnancy, often before a woman knows she is pregnant. So folic acid started at the first antenatal visit has already missed the window it was designed for. It must be taken BEFORE conception and through early pregnancy. A higher dose is used where risk is increased — previous affected pregnancy, diabetes, certain antiepileptics, and other specified circumstances. This is why preconception counselling matters, and why advice about folic acid belongs in a family planning consultation rather than only in an antenatal one.

Common problems in pregnancy

🔍 What presents, and what must not be missed behind it

AnaemiaVery common, and physiological dilution accounts for part of it — but iron deficiency is frequent and matters, because it reduces reserve for the blood loss of delivery. Investigate rather than assume; consider hookworm and other local causes.

Nausea and vomitingUsual in early pregnancy. Hyperemesis gravidarum is different — persistent vomiting with weight loss, dehydration, ketosis and electrolyte disturbance. It needs assessment, rehydration, antiemetics and thiamine, not reassurance.

Urinary tract infectionAsymptomatic bacteriuria is treated in pregnancy — unlike in non-pregnant adults — because it progresses to pyelonephritis and is associated with preterm birth.

Gestational diabetesScreened for in those at risk. Managed with diet, monitoring and medication where needed, and it marks a substantially raised lifetime risk of type 2 diabetes, so these women need follow-up after delivery rather than discharge.

Reduced fetal movementsAlways warrants assessment. It is one of the few symptoms a woman can monitor herself, and dismissing it is a recognised contributor to stillbirth.

Abdominal painConsider obstetric causes, but remember appendicitis, urinary infection and other surgical problems occur in pregnancy too — and the appendix is displaced upward as the uterus grows.

Abnormal uterine bleeding

💡 Exam angle: post-menopausal bleeding requires urgent investigation to exclude endometrial carcinoma, and this is examined repeatedly because the alternative explanations — atrophy, polyps, hormone therapy — are common and tempting. The correct order is: exclude malignancy first, then attribute to something benign. The same discipline applies to post-coital bleeding, which needs cervical assessment rather than reassurance.

A PRACTICAL APPROACH TO HEAVY MENSTRUAL BLEEDING ASK How many days, how heavy, flooding, clots, impact on daily life? Symptoms of anaemia? Any intermenstrual or post-coital bleeding? EXAMINE Abdominal and pelvic examination; speculum to see the cervix. TEST Pregnancy test. Full blood count and ferritin. Thyroid and coagulation testing if the history suggests them. Imaging and endometrial sampling according to age and risk. TREAT Correct the iron deficiency — this is often forgotten while the bleeding is investigated. Then medical management, with the intrauterine system frequently first-line where contraception is also wanted, and surgical options where medical treatment fails or there is structural disease.

Contraception

The most useful framing in contraceptive counselling is that effectiveness in real life depends mostly on how little the method relies on the user. Methods that require nothing to be remembered outperform those that do, which is why long-acting reversible contraception is offered first — not because the pill fails when taken correctly, but because "taken correctly" is a demanding standard over years.

POINTS THAT COME UP REPEATEDLY MIGRAINE WITH AURA contraindicates combined hormonal contraception because of stroke risk. Migraine WITHOUT aura does not carry the same restriction. BREASTFEEDING — progestogen-only methods are compatible; combined methods are generally deferred in the early postpartum period. EMERGENCY CONTRACEPTION — effectiveness declines with time, so it is provided promptly and without barriers. A copper intrauterine device is the most effective option and also provides ongoing contraception. ENZYME-INDUCING DRUGS — rifampicin and some antiepileptics reduce the effectiveness of hormonal methods, which links back to the tuberculosis chapter. Only CONDOMS also protect against sexually transmitted infection, so dual method use is advised where that risk exists.

Clinical reasoning: four presentations

🔍 Case 1 — the drug that was stopped

PresentationA woman with well-controlled epilepsy discovers she is eight weeks pregnant and stops her antiepileptic immediately, having read that it can harm the fetus. Two weeks later she has a generalised seizure.

TrapTreating drug risk as though it existed without the disease it treats.

ReasoningUncontrolled seizures carry real risk to mother and fetus, including trauma and hypoxia. Abrupt withdrawal is more dangerous than most of the medication decisions available.

AnswerUrgent specialist review to restart or optimise treatment, high-dose folic acid, and counselling. The lesson generalises: never stop essential treatment in pregnancy unilaterally — the decision belongs with a specialist, ideally before conception.

🔍 Case 2 — the bleeding that was explained away

PresentationA 58-year-old, five years post-menopausal, reports two episodes of light vaginal bleeding. She is otherwise well. A clinician attributes it to vaginal atrophy and offers a topical treatment.

TrapA plausible benign explanation accepted before malignancy is excluded.

ReasoningPost-menopausal bleeding is endometrial carcinoma until proven otherwise. Atrophy is common and may well be the answer — but only after investigation, not instead of it.

AnswerUrgent referral for assessment, including imaging and endometrial sampling per local pathway. Light bleeding and feeling well do not lower the priority.

🔍 Case 3 — the folic acid that came too late

PresentationA woman attends her first antenatal visit at 14 weeks. She has not taken folic acid. She asks whether starting it now will prevent a neural tube defect.

Key clueNeural tube closure occurs in the first few weeks.

ReasoningBy 14 weeks the neural tube has long since closed, so folic acid can no longer serve its preventive purpose in this pregnancy. This is exactly why the advice belongs in preconception care.

AnswerBe honest that the window for that specific benefit has passed, continue routine antenatal care and screening, and ensure she has preconception advice for any future pregnancy. Do not imply a protection that is no longer available.

🔍 Case 4 — the contraceptive choice

PresentationA 29-year-old requests the combined pill. She has migraine preceded by visual zigzag lines lasting 20 minutes, and smokes occasionally.

Key clueVisual aura preceding the headache.

ReasoningMigraine with aura carries an increased stroke risk, which combined hormonal contraception compounds. Migraine without aura does not carry the same restriction — so the history must be taken precisely.

AnswerAvoid combined hormonal contraception. Offer progestogen-only or long-acting reversible methods, discuss smoking, and explain the reason rather than simply refusing the request.

Commonly confused

Confusion	The distinction	Why it matters
Antenatal care vs reassurance	It is a screening programme	Its value is in the few it detects early.
Drug risk vs disease risk	Uncontrolled disease often harms more	Stopping treatment unilaterally is the greater danger.
Folic acid timing	Preconception, not first visit	The neural tube has already closed by then.
Vomiting vs hyperemesis	Weight loss, dehydration, ketosis	One needs reassurance, the other admission.
Asymptomatic bacteriuria in pregnancy	It IS treated, unlike in non-pregnant adults	It progresses to pyelonephritis and preterm birth.
Post-menopausal bleeding vs atrophy	Exclude cancer first, attribute later	A benign explanation accepted early delays diagnosis.
Migraine with vs without aura	Only aura contraindicates combined contraception	The history must be taken precisely.

Rapid revision

MUST-KNOW FACTS 1. Antenatal care is a SCREENING programme, not reassurance. 2. Blood pressure and urine protein at EVERY visit — pre-eclampsia is silent. 3. Accurate DATING underpins every later decision. 4. Check haemoglobin, blood group and RHESUS status early. 5. Anti-D prevents sensitisation affecting FUTURE pregnancies. 6. Screen for syphilis, HIV and hepatitis B — each has an effective action. 7. FOLIC ACID must start BEFORE conception; higher dose if at risk. 8. By the first antenatal visit the neural tube has already closed. 9. Avoid ACE inhibitors, ARBs, warfarin, valproate, tetracyclines. 10. Avoid NSAIDs in the third trimester — premature ductus closure. 11. Labetalol, nifedipine and methyldopa are usual for hypertension. 12. NEVER stop epilepsy or asthma treatment unilaterally in pregnancy. 13. Treat ASYMPTOMATIC BACTERIURIA in pregnancy. 14. Hyperemesis: weight loss, ketosis, dehydration — needs treatment and thiamine. 15. Reduced fetal movements always warrant assessment. 16. Gestational diabetes marks a raised lifetime risk of type 2 — follow up. 17. Abnormal uterine bleeding: pregnancy test FIRST. 18. Sort causes into structural and non-structural. 19. POST-MENOPAUSAL BLEEDING IS CANCER UNTIL PROVEN OTHERWISE. 20. Post-coital bleeding needs cervical assessment. 21. Correct iron deficiency while investigating heavy bleeding. 22. Contraceptive effectiveness depends on how little it relies on the user. 23. Long-acting reversible methods are the most effective. 24. MIGRAINE WITH AURA contraindicates combined hormonal contraception. 25. Enzyme inducers such as rifampicin reduce hormonal contraceptive efficacy. 26. Only condoms also protect against sexually transmitted infection. 27. The most valuable output of a visit is a woman who knows when to return.

💡 Exam angle: the reliable threads are (a) never stopping essential treatment unilaterally in pregnancy, (b) folic acid needing to precede conception, (c) post-menopausal bleeding requiring exclusion of malignancy, (d) migraine with aura and combined contraception, and (e) treating asymptomatic bacteriuria. This chapter sits deliberately alongside the obstetric emergencies one — most of what that chapter treats, this one is trying to prevent.

Syllabus points

Antenatal care as a screening programme
The first visit and what it establishes
Rhesus status and anti-D prophylaxis
Prescribing in pregnancy: what to avoid
Why stopping treatment is often the greater risk
Folic acid and why timing is the point
Common problems: anaemia, hyperemesis, bacteriuria
Reduced fetal movements and gestational diabetes
Abnormal uterine bleeding: a structured differential
Post-menopausal and post-coital bleeding
Contraception and effectiveness in real use
Contraindications and drug interactions

Create a free account to tick topics off, take notes as you read, watch the video lessons and get a day-by-day study plan built around your exam date.