Chapter 6 – The Schedule of Tests and Check-ups

In most cases, expecting a baby is a physiological event that expresses a condition of health, not of illness. And it is important that all future mothers can begin the waiting period with this awareness and, therefore, with peace of mind. The data collected by the Istituto Superiore di Sanità is clear: 67.3% of mothers report no complications during pregnancy and childbirth, 18.5% have minor issues, discomforts that often do not require medical intervention, and only 14.2% report serious problems that require forced bed rest or hospitalization.

The purpose of the tests and periodic check-ups recommended during the nine months is precisely to verify that everything is going well, reassuring the mother, and to highlight possible risk factors to act on early. And at the same time, to reduce maternal stress. Doing more tests than those provided by the Ministry of Health, if not justified by specific indications, does not guarantee better results or greater protection of the pregnancy. And it can generate insecurity and fear in the expectant mother, which is exactly the opposite of what is meant when talking about health promotion.

So, what are the appropriate care interventions to assess the progress of pregnancy, the health conditions of the future mother, the growth, and the wellness of the unborn child? They are those described in the ISS Guidelines and offered free of charge by the public health system of all Regions as part of the LEA, the Essential Levels of Care (21). At the beginning of pregnancy, preferably by the 13th week, the health service offers the expectant mother some blood tests that aim to determine whether she is immune or susceptible to certain infections potentially harmful to her baby. In case of susceptibility, she can take useful measures to reduce the risk of infections. Here is what they are, what they are for, and when they should be done.

The rubella test detects susceptibility to rubella, which during pregnancy can cause miscarriage or congenital damage. Ideally, this test should be done before trying to conceive so that the aspiring mother has time to be vaccinated if she is not immune. After conception, the rubella vaccination is contraindicated, and in case of susceptibility, all that can be done is to avoid contact with infected people. If the expectant woman is not immune, the rubella test is offered a second time between the 15th and 17th week to diagnose any infection contracted during pregnancy in asymptomatic or mild form. After the 17th week, it makes no sense to repeat the test further because, even if the woman contracts rubella and transmits it to the fetus, the risk of damage to the baby would be very low.

The toxoplasmosis test is used to determine immunity or susceptibility to toxoplasmosis, an infection that can be contracted from raw or undercooked meat or by coming into contact with cat feces. In pregnancy, it can cause fetal malformations. There is no vaccine against toxoplasmosis and in case of confirmed susceptibility, the most effective remedy to reduce the risk of infection is to avoid eating raw or undercooked meat, to thoroughly wash fruit and vegetables before consuming them, and to avoid contact with the cat litter box and garden soil where the cat usually roams. For the non-immune woman, the test is offered again every 4–6 weeks to diagnose any infection contracted during pregnancy. If the infection is present, prompt drug therapy will be administered.

The HIV test is used to diagnose an ongoing infection and is offered before conception, at the beginning of pregnancy, and again after 33 weeks, in preparation for childbirth, to implement, in case of positivity, all precautions useful to avoid infecting the baby.

The test for Treponema pallidum, or syphilis, is also offered at the beginning of pregnancy and after the 33rd week. The infection, sexually transmitted, can pass to the unborn child through the placenta or during childbirth. In case of a positive diagnosis, it can be treated effectively and quickly with an antibiotic that is not contraindicated during pregnancy.

The test for hepatitis C is offered by the 13th week because the infection can be transmitted through the placenta, although the event is unlikely. The one for hepatitis B, however, is offered after the 33rd week because the contagion can occur when the baby passes through the birth canal. If the result is positive, the baby must be given a dose of the hepatitis B vaccine and a dose of specific immunoglobulins against the virus within 24 hours of birth.

There are also three tests for the diagnosis of potentially dangerous infections in pregnancy that are carried out using a vaginal swab and not a blood test. By the 13th week, those for Chlamydia trachomatis and Neisseria gonorrhoeae. Both are treated with antibiotic therapy and, if not diagnosed promptly, can cause miscarriage or preterm birth. After the 33rd week, the swab for the search for group B beta-hemolytic Streptococcus, is instead offered, which can infect the baby during passage through the birth canal. This too is treated with antibiotics.

A blood test recommended to assess the health condition of the expectant mother is the complete blood count, which is performed at the beginning of pregnancy and again at 28 and 33 weeks and measures the concentration of red blood cells, white blood cells, and platelets in the blood. Its main function is to diagnose any anemia to be corrected with iron supplementation.

The blood glucose test, which measures the concentration of sugar in the blood, is provided at the beginning of pregnancy to detect any diabetes already present before conception and not diagnosed.

To diagnose possible diabetes that has arisen during pregnancy, the glucose curve test is used, offered to expectant women in the presence of some risk factors: obesity or severe overweight and diabetes during previous pregnancies. It consists of measuring fasting blood glucose followed by the administration of a solution of water and 75g of sugar. Then the glucose is measured again one hour and two hours later, to assess the body’s ability to metabolize sugar. The test is proposed twice: between the 14th and 17th week and again between the 24th and 27th. At the beginning of pregnancy, at the 24th and after the 33rd week, the urine test is proposed, to assess various health parameters of the expectant mother and diagnose any urinary tract infections.

The indirect Coombs test provided at the beginning of pregnancy and a second time at 28 weeks, detects in the mother’s blood the possible presence of antibodies that can attack and damage the unborn child’s red blood cells, causing a hemolytic disease called erythroblastosis fetalis. People who have Rh-positive blood have on the surface of red blood cells a molecule, antigen D. Their immune system recognizes that molecule as part of their own body and does not attack it. Those with Rh-negative blood do not have antigen D and their immune system does not recognize the molecule as their own. The first time the immune system of an Rh-negative person comes into contact with Rh-positive blood, it becomes sensitized against antigen D, meaning it identifies it as an enemy and organizes to attack it. At the second contact, it attacks and destroys the red blood cells that carry it. If an Rh-negative woman is expecting an Rh-positive baby, her immune system can become sensitized to the baby’s antigen D if it comes into contact with their blood. Normally, the placenta prevents the exchange of blood between mother and fetus, but during childbirth, in the case of an invasive test such as chorionic villus sampling or amniocentesis, or in case of threatened miscarriage with bleeding, sensitization can occur. The mother’s body can then begin to produce antibodies directed against antigen D that pass through the placenta and attack the fetal red blood cells. The test is also offered to women with Rh-positive blood, because there are other antigens, in addition to D, with which the mother may have come into contact during pregnancy or following a transfusion and which can trigger an immune reaction. Even if they are antigens that cause clinically mild forms of hemolytic disease, they must still be investigated and not overlooked.

In addition to laboratory tests, at least eight meetings are recommended during pregnancy with the healthcare provider in charge of the expectant mother, whether midwife or gynecologist. These are important appointments, and if possible, it is better to attend them as a couple because they are opportunities to discuss, raise concerns, ask for advice, measure the mother’s weight and blood pressure, and, if necessary, perform an obstetric examination. The provider may have an ultrasound machine in the office, which can be used for a quick check-up to assess the general health conditions of the unborn child.

The two most accurate — and eagerly awaited by mom and dad — ultrasounds are those recommended and offered as part of the Essential Levels of Care (LEA): the first, to be done within the first trimester, is used to accurately date the pregnancy, count the number of embryos, and verify their correct implantation in the uterus. The second, the so-called morphological ultrasound of the second trimester, is used to check the growth of each anatomical structure of the baby and the development of the individual organs. A third ultrasound, once offered between the 30th and 32nd week, is now provided free of charge only in the presence of a maternal or fetal pathology risk. If everything is progressing well, therefore, it is preferred not to subject the expectant mother to one more test, which would be unnecessary and, therefore, inappropriate.