Antenatal care (ELearningPage)

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 <Content>
 <HtmlField Name="References"><![CDATA[<ul>
 <li>Danish (written in Danish): 
 <a href="https://www.sst.dk/da/viden/graviditet-og-foedsel/svangreomsorgen/anbefalinger-for-svangreomsorgen">https://www.sst.dk/da/viden/graviditet-og-foedsel/svangreomsorgen/anbefalinger-for-svangreomsorgen</a></li>
 <li>Swedish (written in Swedish): 
 <a href="https://www.sfog.se/natupplaga/ARG76web43658b6c2-849e-47ab-99fa-52e8ac993b7d.pdf">https://www.sfog.se/natupplaga/ARG76web43658b6c2-849e-47ab-99fa-52e8ac993b7d.pdf</a></li>
 <li>Finnish (written in Finnish/Swedish/English): 
 <a href="www.thl.fi">www.thl.fi</a></li>
 <li>Norwegian (written in Norwegian): 
 <a href="https://www.helsedirektoratet.no/retningslinjer/svangerskapsomsorgen">https://www.helsedirektoratet.no/retningslinjer/svangerskapsomsorgen</a> </li>
 <li>Icelandic (written in Icelandic): 
 <a href="https://www.landlaeknir.is/servlet/file/store93/item2548/4407.pdf">https://www.landlaeknir.is/servlet/file/store93/item2548/4407.pdf</a></li>
</ul>]]></HtmlField>
 <HtmlField Name="Author"><![CDATA[Iben Blaabjerg Sundtoft, MD, PhD, Associate Professor, Department of Obstetrics and Gynecology, Aarhus University, Regional Hospital Herning, Herning, Denmark 
 
Riina Jernman, MD, PhD, Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland 
 
Ragnhei&eth;ur I. Bjarnad&oacute;ttir, MD, FRCOG, Associate Professor, Department of Obstetrics and Gynecology, University of Iceland, Landspitali University Hospital, Reykjav&iacute;k, Iceland 
 
Ragnhild Fjelltveit Skagseth, MD, Haukeland University Hospital, Bergen, Norway]]></HtmlField>
 <HtmlField Name="TakeHomeMessage"><![CDATA[<ul>
 <li>The goal of antenatal care is to optimize the wellbeing of mother and fetus</li>
 <li>Antenatal care is offered to every pregnant woman although most pregnancies are low risk</li>
 <li>Antenatal care provides a way of screening for risk factors and asymptomatic diseases as well as a possibility to introduce preventive measures</li>
 <li>Pregnancy may reveal health problems or a predisposition to chronic illness</li>
 <li>Educating the mother and parents-to-be is an important component of antenatal care</li>
</ul>]]></HtmlField>
 <HtmlField Name="PageContent"><![CDATA[<h2>Introduction</h2>
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The goal of antenatal care, which is provided by midwives, obstetricians and general practitioners, is to optimize the health of the mother and newborn. Pregnancies at increased risk for maternal or fetal morbidity and mortality should ideally be identified and a care plan and risk-reducing strategies implemented. In addition to managing pregnancy related and chronic diseases, health education is an important component of antenatal care.
Ideally, antenatal care should start before conception as all women planning to get pregnant should be advised to take folic acid and women with chronic diseases should receive pre-conceptional counseling. When the woman then is pregnant, antenatal care should be initiated in the first trimester as it enables early prenatal screening and diagnostic tests, as well as an accurate estimation of gestational age. In addition to diagnosing and treating disease in pregnancy, antenatal care offers screening for risk factors and asymptomatic disease. Preventive measures such as acetyl salicylic acid or thromboprophylaxis will be initiated for women at increased risk of preeclampsia or thromboembolism, respectively.
The antenatal visits enable health-care professionals to educate on the normal (physiological) changes of pregnancy, labor and delivery, postnatal physical and psychological changes, and on breastfeeding, and thus prepare the future parents for their new role. In antenatal care there is also an opportunity to promote a healthy lifestyle that will benefit both the mother and the baby during pregnancy and in the future.
<h3>Maternal mortality and perinatal mortality rates</h3>
Maternal mortality rate (MMR) and perinatal mortality rate (PMR) are statistical indices used to evaluate the quality of the health and community services related to pregnancy and childbirth.
Maternal mortality rate is most often defined as death during pregnancy or a period postpartum of up to one year. It is sub-defined to direct, indirect and unrelated causes. In high resource countries the nominator for MMR is commonly 100.000 live births.
Perinatal mortality rate most often includes fetal deaths after completed 22 gestational weeks and neonatal deaths during 7 days after birth. Worldwide, the nominator for PMR is 1000 live births.
The rates, MMR and PMR, in the Nordic countries are among the lowest in the world, 5-10 maternal deaths/100.000 births and 2-4 perinatal deaths/1000 births.
<h2>Programs for healthy women in normal pregnancy</h2>
At the first visit an individualized plan is made for the woman&acute;s antenatal care, including screening, and the maternity record is filled out. The maternity record is a document containing information on general health and risk factors for pregnancy complications such as previous obstetric history, familial disposition, BMI, chronic diseases, medication, smoking, substance abuse and psychosocial history. 
 
Table 1 shows programs in the Nordic countries. They include screening for pregnancy-related diseases such as anemia, hypertension, preeclampsia, gestational diabetes as well as for fetal chromosomal aberrations, fetal structural anomalies and fetal growth disorders.
<table style="left: 0px; top: 806px; width: 1175px; height: 1218px;" class="vandret-layout">
 <caption>Table 1. Antenatal care programs in the Nordic countries. A routine for all pregnant women. Note explanatory notes below the table.</caption>
 <thead>
 <tr class="vandret-layoutTableEvenRow">
 <th scope="col" class="vandret-layoutTableEvenCol">GA (weeks)&nbsp;</th>
 <th scope="col" class="vandret-layoutTableOddCol">Denmark&nbsp;</th>
 <th scope="col" class="vandret-layoutTableEvenCol">Sweden*&nbsp;</th>
 <th scope="col" class="vandret-layoutTableOddCol">Finland&nbsp;</th>
 <th scope="col" class="vandret-layoutTableEvenCol">Norway&nbsp;</th>
 <th scope="col" class="vandret-layoutTableOddCol">Iceland&nbsp;</th>
 </tr>
 </thead>
 <tbody>
 <tr class="vandret-layoutTableOddRow">
 <th scope="row" class="vandret-layoutTableEvenCol">6-12</th>
 <td class="vandret-layoutTableOddCol">6-10 (N/GP) 
 Risk assessment 
 Routines 
 Blood tests 
 </td>
 <td class="vandret-layoutTableEvenCol">7-10 (M) 
 Risk assessment 
 Routines 
 Blood tests 
 </td>
 <td class="vandret-layoutTableOddCol">8-10 (N/M) 
 Risk assessment 
 Routines 
 Blood tests 
 </td>
 <td class="vandret-layoutTableEvenCol">8-12 (M/GP) 
 Risk assessment 
 Routines 
 Blood tests 
 </td>
 <td class="vandret-layoutTableOddCol">8-12 (M) 
 Risk assessment 
 Routines 
 Blood tests 
 </td>
 </tr>
 <tr class="vandret-layoutTableEvenRow">
 <th scope="row" class="vandret-layoutTableEvenCol">10-14 
 Combined serum and US screening 
 </th>
 <td class="vandret-layoutTableOddCol">11-14 (US) 
 Offered to all 
 </td>
 <td class="vandret-layoutTableEvenCol">11-14 (US) 
 Different in different regions 
 </td>
 <td class="vandret-layoutTableOddCol">10-14 (US) 
 Offered to all 
 </td>
 <td class="vandret-layoutTableEvenCol">10-14 (US) 
 Offered to risk groups 
 </td>
 <td class="vandret-layoutTableOddCol">11-14 (US) 
 Offered to all 
 </td>
 </tr>
 <tr class="vandret-layoutTableOddRow">
 <th scope="row" class="vandret-layoutTableEvenCol">13-16</th>
 <td class="vandret-layoutTableOddCol">13-15 (M) 
 Risk assessment Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">X</td>
 <td class="vandret-layoutTableOddCol">13-16 (N/M) 
 Health questionnaire Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">X</td>
 <td class="vandret-layoutTableOddCol">16 (M) 
 Routines Screening for depression and anxiety 
 </td>
 </tr>
 <tr class="vandret-layoutTableEvenRow">
 <th scope="row" class="vandret-layoutTableEvenCol">16-20</th>
 <td class="vandret-layoutTableOddCol">X</td>
 <td class="vandret-layoutTableEvenCol">20 (M) 
 Nulliparas 
 Routines 
 </td>
 <td class="vandret-layoutTableOddCol">16-18 (GP) 
 Routines 
 US (+/-) 
 </td>
 <td class="vandret-layoutTableEvenCol">X</td>
 <td class="vandret-layoutTableOddCol">X&nbsp;</td>
 </tr>
 <tr class="vandret-layoutTableOddRow">
 <th scope="row" class="vandret-layoutTableEvenCol">17-22 
 Fetal structural anomaly US screening 
 and placenta location 
 </th>
 <td class="vandret-layoutTableOddCol">20-22 (US) 
 Offered to all 
 </td>
 <td class="vandret-layoutTableEvenCol">17-20 (US) 
 Offered to all 
 </td>
 <td class="vandret-layoutTableOddCol">18-21 or &gt;24(US) 
 Offered to all 
 </td>
 <td class="vandret-layoutTableEvenCol">17-18 (US) 
 Offered to all 
 </td>
 <td class="vandret-layoutTableOddCol">20-21 (US) 
 Offered to all 
 </td>
 </tr>
 <tr class="vandret-layoutTableEvenRow">
 <th scope="row" class="vandret-layoutTableEvenCol">22-25</th>
 <td class="vandret-layoutTableOddCol">25 (GP) 
 Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">25 (M) 
 First Leopold&acute;s Routines 
 </td>
 <td class="vandret-layoutTableOddCol">22-24 (N/M) 
 Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">24 (M/GP) 
 Routines 
 </td>
 <td class="vandret-layoutTableOddCol">25 (M) 
 Nulliparas Routines 
 </td>
 </tr>
 <tr class="vandret-layoutTableOddRow">
 <th scope="row" class="vandret-layoutTableEvenCol">26-29</th>
 <td class="vandret-layoutTableOddCol">29 (M) 
 First Leopold&acute;s 
 Routines&nbsp;</td>
 <td class="vandret-layoutTableEvenCol">29 (M) 
 Routines 
 </td>
 <td class="vandret-layoutTableOddCol">26-28 (N/M) 
 Nulliparas 
 Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">28 (M/GP) 
 Routines 
 </td>
 <td class="vandret-layoutTableOddCol">28 (M) 
 Routines 
 </td>
 </tr>
 <tr class="vandret-layoutTableEvenRow">
 <th scope="row" class="vandret-layoutTableEvenCol">30-33</th>
 <td class="vandret-layoutTableOddCol">32 (GP) 
 Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">31+33 (M) 
 Nulliparas 
 Routines 
 </td>
 <td class="vandret-layoutTableOddCol">30-32 (N/M) 
 First Leopold's 
 Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">32 (M/GP) 
 Routines 
 </td>
 <td class="vandret-layoutTableOddCol">31 (M) 
 Nulliparas 
 Routines 
 </td>
 </tr>
 <tr class="vandret-layoutTableOddRow">
 <th scope="row" class="vandret-layoutTableEvenCol">34-36</th>
 <td class="vandret-layoutTableOddCol">35-36 (M) 
 Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">35 (M) 
 Routines 
 Birth plan 
 </td>
 <td class="vandret-layoutTableOddCol">35-36 (GP) 
 Routines 
 Cx 
 US (+/-) 
 Birth plan 
 </td>
 <td class="vandret-layoutTableEvenCol">36 (M/GP) 
 First Leopold's 
 Routines 
 </td>
 <td class="vandret-layoutTableOddCol">34 (M) 
 Routines 
 </td>
 </tr>
 <tr class="vandret-layoutTableEvenRow">
 <th scope="row" class="vandret-layoutTableEvenCol">36-37</th>
 <td class="vandret-layoutTableOddCol">37 (M) 
 Nulliparas 
 Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">37 (M) 
 Nulliparas Routines 
 </td>
 <td class="vandret-layoutTableOddCol">37 (N/M) 
 Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">X</td>
 <td class="vandret-layoutTableOddCol">36 (M) 
 First Leopold's 
 Routines 
 Birth plan 
 </td>
 </tr>
 <tr class="vandret-layoutTableOddRow">
 <th scope="row" class="vandret-layoutTableEvenCol">38-39</th>
 <td class="vandret-layoutTableOddCol">39 (M) 
 Routines &nbsp;</td>
 <td class="vandret-layoutTableEvenCol">39 (M) 
 Nulliparas&nbsp; 
 Routines 
 </td>
 <td class="vandret-layoutTableOddCol">39 (N/M) 
 Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">38 (M/GP) 
 Routines 
 </td>
 <td class="vandret-layoutTableOddCol">38 (M) 
 Routines 
 </td>
 </tr>
 <tr class="vandret-layoutTableEvenRow">
 <th scope="row" class="vandret-layoutTableEvenCol">40-41 
 Booking for post-term visit 
 </th>
 <td class="vandret-layoutTableOddCol">41 (M) 
 Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">40-41 (M) 
 Routines 
 </td>
 <td class="vandret-layoutTableOddCol">41 (N/M) 
 Routines 
 </td>
 <td class="vandret-layoutTableEvenCol">40 (M/GP) 
 Routines 
 </td>
 <td class="vandret-layoutTableOddCol">40-41 (M) 
 Routines 
 </td>
 </tr>
 </tbody>
</table>
Abbreviations in the table and other explanations:
<ul>
 <li>* Sweden has no universal national guidelines. The content of the table describes the typical situation in Swedish antenatal care, but local variations exist</li>
 <li>GA=gestational age</li>
 <li>GP=general practitioner</li>
 <li>M=midwife</li>
 <li>N=Nurse </li>
 <li>US=ultrasound (+/- meaning neither mandatory nor available at all centers) </li>
 <li>Routines=routine measurements including BP=blood pressure, urine dipstick=u-protein and somewhere also u-glucose, body weight; SF=symphysis-fundus measurement (after 20w) </li>
 <li>Doppler=fetal heartbeat (after 12w)</li>
 <li>Leopold's=Leopold's maneuvers (in late second or third trimester for determination of fetal lie and presentation) </li>
 <li>First Leopold&acute;s=When Leopold&acute;s maneuvers are applied for the first time</li>
 <li>Blood tests (see Table 2)</li>
 <li>Cx=cervix status</li>
 <li>Combined serum and US screening (see chapter on prenatal diagnostics)</li>
 <li>Post-term visit: Usually at the hospital at 40+0&ndash;42+0 weeks of gestation, planning for induction of labor if needed</li>
</ul>
<h2>Clinical examination</h2>
Clinical examinations throughout pregnancy include blood pressure measurements, urine examination for protein, and auscultation of the fetal heartbeat with Doppler. As the pregnancy progresses, symphysis-fundus measurements are carried out to assess utero-fetal growth. Leopold&rsquo;s maneuvers are performed to establish fetal lie, presentation and engagement. By palpating the uterus, it is also possible to evaluate the amount of amniotic fluid and estimate fetal weight. 
Screening for fetal chromosomal anomalies is offered as optional, but not a part of routine antenatal care. 
Detected or suspected complications at any time of the pregnancy should be referred to specialists.
<h3>Leopold's maneuvers</h3>
A systematic way to determine the lie and presentation of a fetus by palpating the uterus through the abdomen is called Leopold's maneuvers, named after the German gynecologist Christian Gerhard Leopold. The maneuvers are usually applied in the late second or third trimester. The maneuvers consist of four distinct actions: 
First maneuver: By palpation of the upper part of the uterus, consistency, shape and mobility of the fetal part located in the fundus is determined; the fetal head is hard and round whereas the buttocks are softer. 
Second maneuver: By palpating the body of uterus, the location of the back and extremities is determined; the fetal back is firm and smooth whereas the fetal extremities will be felt as small protrusions or irregularities. 
Third maneuver: The presenting fetal part in or above the pelvic inlet and its mobility (or on the contrary its engagement) is examined by using the thumb and fingers of one hand to get a grip on the fetal part just above the pubic symphysis. 
Fourth maneuver: Facing the maternal feet, the tips of the fingers of both hands are used to apply deep pressure in the direction of the axis of the pelvic outlet. This maneuver is used to determine descent of the presenting part into the pelvis. 
Obesity as well as polyhydramnios makes the examination more difficult.
Video 2. Leopold's maneuvers
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<h3>Symphysis-fundus measurement (SF)</h3>
Fundal height is a measure of the size of the uterus and indirectly of fetal size which can be used to assess fetal growth and amniotic fluid development during pregnancy. It is measured from the highest top of the mother's uterus to the top of the pubic symphysis along the longitudinal axis whether it coincides with the abdominal midline or not. Fundal height is a simple, cheap and valid method, and the measurement roughly corresponds in centimeters to gestational age from 20 to 34 weeks. It should be plotted onto a graph appropriate for the population. A low or too slowly increasing fundal height can be a sign of oligohydramnios and intrauterine growth restriction, while the opposite should raise suspicion of macrosomia, polyhydramnios, or multiple gestation.
Video 3. Symphysis-fundus height measurement
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<h3>Blood tests</h3>
As a part of antenatal care, all pregnant women will be offered a panel of standard screening tests, followed by additional tests for women with higher risk of specific conditions (Table 2) 
The purpose of screening tests of pregnant women is to reveal diseases or anomalies early enough for treatment to give a better outcome for the mother and baby, preventing complications and permanent sequelae.
<table class="vandret-layout" style="width: 1333px; height: 1018px;">
 <caption>Table 2. Standard and selective tests during pregnancy.</caption>
 <thead>
 <tr class="vandret-layoutTableEvenRow">
 <th scope="col" class="vandret-layoutTableEvenCol">Trimester&nbsp;</th>
 <th scope="col" class="vandret-layoutTableOddCol">Denmark&nbsp;</th>
 <th scope="col" class="vandret-layoutTableEvenCol">*Sweden&nbsp;</th>
 <th scope="col" class="vandret-layoutTableOddCol">Finland&nbsp;</th>
 <th scope="col" class="vandret-layoutTableEvenCol">Norway&nbsp;</th>
 <th scope="col" class="vandret-layoutTableOddCol">Iceland&nbsp;</th>
 </tr>
 </thead>
 <tbody>
 <tr class="vandret-layoutTableOddRow">
 <th scope="row" class="vandret-layoutTableEvenCol">1st trimester</th>
 <td class="vandret-layoutTableOddCol">
 GA 8-12 weeks
 SP: 
 - ABO and RhD type Erythrocyte antibody screening 
 - HIV 
 - Syphilis 
 - Hepatitis B
 SS: 
 - Hemoglobin 
 - Gonorrhea 
 - Chlamydia 
 - Hepatitis C 
 - MRSA&nbsp; 
 - Vitamin D&nbsp;
 </td>
 <td class="vandret-layoutTableEvenCol">
 GA 7-10 weeks
 SP: 
 - ABO and RhD type Erythrocyte antibody screening and fetal RhD-typing for RhD-negative mothers 
 - Hemoglobin 
 - Ferritin 
 - P-Glucose, random 
 - S-TSH 
 - HIV 
 - Syphilis 
 - Hepatitis B 
 - Rubella
 SS: 
 - Gonorrhea 
 - Chlamydia 
 - Hepatitis C 
 - MRSA/ESBL/VRE 
 - TBC
 </td>
 <td class="vandret-layoutTableOddCol">
 GA 8-12 weeks
 SP: 
 - ABO and RhD type Erythrocyte antibody screening 
 - Hemoglobin 
 - HIV 
 - Syphilis 
 - Hepatitis B
 </td>
 <td class="vandret-layoutTableEvenCol">
 GA 6-12 weeks
 SP: 
 - ABO and RhD type erythrocyte antibody screening 
 - Hemoglobin 
 - Ferritin 
 - HIV 
 - Syphilis 
 - Hepatitis B 
 - ABU
 SS: 
 - Gonorrhea 
 - Chlamydia 
 - Hepatitis C 
 - MRSA/ESBL/VRE 
 - Rubella 
 - Toxoplasmosis 
 - HbA1c, if high risk of GDM
 </td>
 <td class="vandret-layoutTableOddCol">
 GA 8-12 weeks
 SP: 
 - ABO and RhD type Erythrocyte antibody screening 
 - Hemoglobin 
 - HIV 
 - Syphilis 
 - Hepatitis B 
 - ABU
 SS: 
 - Gonorrhea 
 - Chlamydia 
 - Hepatitis C 
 - MRSA/ESBL/VRE 
 - S-TSH, if high risk of thyroid disease 
 - Fasting P-Glucose, if high risk of GDM
 </td>
 </tr>
 <tr class="vandret-layoutTableEvenRow">
 <th scope="row" class="vandret-layoutTableEvenCol">2nd trimester</th>
 <td class="vandret-layoutTableOddCol">
 GA 18-20 weeks
 SS: 
 - OGTT, if medium risk of GDM 
 
 GA 25 weeks 
 - Erythrocyte antibody screening and fetal RhD-typing for RhD-negative mothers
 </td>
 <td class="vandret-layoutTableEvenCol">
 GA 12-14 weeks
 SS: 
 - OGTT, if previous GDM 
 
 GA 25 weeks
 SP: 
 - Hemoglobin 
 - P-Glucose, random 
 - Erythrocyte antibody screening 
 
 GA 24-28 weeks
 SS: 
 - OGTT if high risk of GDM
 </td>
 <td class="vandret-layoutTableOddCol">
 GA 12-16 week
 SS: 
 - OGTT, if high risk of GDM 
 
 GA 24-26 weeks 
 - OGTT, if high risk of GDM 
 - Erythrocyte antibody screening and fetal RhD-typing for RhD-negative mothers
 </td>
 <td class="vandret-layoutTableEvenCol">
 GA 24-28 weeks
 SS: 
 - OGTT if high risk of GDM 
 - Erythrocyte antibody screening and fetal RhD-typing for RhD-negative mothers
 </td>
 <td class="vandret-layoutTableOddCol">
 GA 24-26 weeks
 SS: 
 - OGTT, if high risk of GDM 
 - Erythrocyte antibody screening and fetal RhD-typing for RhD-negative mothers
 </td>
 </tr>
 <tr class="vandret-layoutTableOddRow">
 <th scope="row" class="vandret-layoutTableEvenCol">3rd trimester</th>
 <td class="vandret-layoutTableOddCol">
 GA 28-30 weeks
 SS: 
 - OGTT, if high risk of GDM
 </td>
 <td class="vandret-layoutTableEvenCol">
 GA 29 weeks
 SS: 
 - Erythrocyte antibody screening and fetal RhD-typing for RhD-negative mothers 
 
 GA 32-36 weeks
 SP: 
 - Hemoglobin 
 - P-Glucose, random
 </td>
 <td class="vandret-layoutTableOddCol">
 GA 28 weeks
 SP: 
 - Hemoglobin 
 
 GA 36 weeks
 SS: 
 - Erythrocyte antibody screening for RhD-negative mothers
 </td>
 <td class="vandret-layoutTableEvenCol">
 GA 28 weeks
 SP: 
 - Hemoglobin
 </td>
 <td class="vandret-layoutTableOddCol">
 GA 28 weeks
 SP: 
 - Hemoglobin
 </td>
 </tr>
 </tbody>
</table>
 
Abbreviations in the table and other explanations:
<ul>
 <li>*Sweden has no universal national guidelines. The content of the table describes the typical situation in Swedish antenatal care, but local variations exist.</li>
 <li>GA = gestational age </li>
 <li>SP = standard panel </li>
 <li>SS = selective screening </li>
 <li>OGTT = oral glucose tolerance test </li>
 <li>GDM = gestational diabetes mellitus </li>
 <li>ABU = asymptomatic bacteriuria </li>
 <li>MRSA = methicillin resistant staphylococcus aureus </li>
 <li>ESBL = extended spectrum beta-lactamase </li>
 <li>VRE = vancomycin-resistant enterococci </li>
 <li>RhD type = Rhesus D antigen positive or negative</li>
</ul>
<h3>Hematology</h3>
Hemoglobin (Hb) is measured to detect anemia. A drop in Hb in pregnancy is physiologically normal, due to hemodilution. Anemia in pregnancy is commonly defined as Hb &lt; 11,0 g/dl in first and third trimester, and less than 10,5 g/dl in 2nd trimester. Anemia in pregnancy is commonly related to iron deficiency and should be treated with oral iron. Ferritin is tested to detect iron deficiency. Ferritin can be low despite Hb levels within normal range and should also be treated with iron. 
ABO blood group and RhD type determination for the pregnant woman are important in case of need for blood transfusion during labor. Antibody screening detects erythrocyte antibodies that can be of potential harm for the fetus and lead to the hemolytic disease of the newborn. Particularly anti-D antibodies in RhD negative mothers can destroy fetal red blood cells if the fetus is RhD positive. Therefore, RhD negative women undergo more detailed screening than RhD positive women, including fetal RhD identification in fetal DNA in maternal blood (see chapter on Alloimmunization in pregnancy).
<h3>Infectious diseases</h3>
Hepatitis B has become more common in the Nordic countries due to increased immigration over the last decades. There is a high risk of transmission of the disease during labor and for the baby to develop chronic hepatitis B if left untreated. The risk of developing chronic hepatitis B is reduced from 90% to 5% if the newborn baby is treated with immunoglobulin and vaccination. If the pregnant woman has a high viral load, antiviral treatment during pregnancy is recommended. 
The risk of transmission of HIV from a positive mother during pregnancy and labor is reduced to about 1% if the woman is treated with antiviral medication during the 3rd trimester, and the baby is treated with antiviral medication after birth. 
If a pregnant woman is infected by treponema pallidum, which causes syphilis, the risk of transmission to the fetus during pregnancy or labor is very high in all stages of the disease. The disease is treated easily with penicillin, which also prevents transmission, especially if revealed and treated early in pregnancy. If left untreated, syphilis causes a high risk of preterm labor, stillbirth, or serious congenital syphilis. 
Rubella is a viral disease that is covered by a standard national vaccination program in most countries, and the disease is in general eliminated in our part of the world thanks to the high vaccination coverage. Due to periods with immigration from more endemic areas we can see flare-ups regionally and periodically, also in our part of the world. The disease is first and foremost harmful to the fetus, where infection early in pregnancy can lead to spontaneous abortion, intrauterine fetal death, or congenital rubella syndrome with malformations in eyes, ears, heart, and brain.
<h3>Endocrinology</h3>
Pregnant women are screened for gestational diabetes mellitus (GDM) if they have risk factors such as obesity, family history of diabetes, ethnic risks group or older age. GDM is becoming more common, and most countries screen for GDM as part of the selective screening program. The importance of diagnosing GDM early in pregnancy is manifest by the increased risk of macrosomia and negative influences on the offspring&acute;s metabolic balance, shoulder dystocia and other delivery complications, preeclampsia and even intrauterine fetal death, if left untreated. Most women with GDM can achieve a stable blood sugar level by changing their diet, but some women will need insulin or metformin to reach the goal. 
Untreated thyroid disease during pregnancy may lead to miscarriage or preterm birth, preeclampsia, low birth weight and other complications. If the pregnant woman has any history of thyroid disease she should be monitored during pregnancy, and preferably before pregnancy as well, to be sure medication is properly adjusted.
<h2>Parental education</h2>
It is a valuable part of antenatal care to educate the mother, and parents to be, about normal, physiological changes in pregnancy and common symptoms and symptoms that can be a matter of concern, as well as how and when to contact a midwife or a doctor. Equally important is education concerning labor and delivery and the postnatal period. This education is commonly given in classes or group meetings, but continuous individual support and education during the antenatal care visits is of great weight.
<h2>Social rights</h2>
<h3>Health insurance</h3>
In the Nordic countries pregnant woman are not charged for routine antenatal care check-up, or for the medical support given during and after labor. The costs related to pregnancy and birth are mainly covered by the national health insurance.
<h3>Maternity leave</h3>
Women in the Nordic countries are offered paid maternity leave by the employer or the social security system. The other parent of the child will also be offered paid leave. The amount and length of paid leave varies between the countries.
<h3>Sick leave in pregnancy</h3>
During pregnancy Nordic women have unaltered rights to sick leave if affected by illness or by pregnancy-related complications.
<h2>Occupational medicine</h2>
As most pregnant women are employed, it is important to prevent exposures posing a hazard to the pregnancy and fetus. Chemical substances as pesticides and anesthetic gases, exposure to biological infection sources, heavy lifting, long workdays and night shifts are among potential risks. Redeployment or absence can be necessary if the working environment poses a possible risk (See chapter on Recommendations during pregnancy).
<h2>Multiple choice quiz</h2>
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