Antenatal Care & Pregnancy Complications for NEET PG — Complete Guide 2026

Version 1.0 — Published March 2026

Antenatal care is a structured programme of supervision throughout pregnancy that reduces maternal and perinatal mortality — and it is a NEET PG goldmine because it spans obstetrics, community medicine, and public health. The student who memorises the WHO 2016 schedule, DIPSI GDM screening, anti-D timing, and APH differentials covers 4–5 marks across papers. Pair this guide with daily MCQ practice on the obstetrics and gynaecology subject hub, cross-reference the OBG high-yield topics overview, and revise the preeclampsia and eclampsia guide for hypertensive complications integration.

ANC schedule — WHO 2016 vs RMNCH+A

Antenatal care is the systematic medical supervision of a pregnant woman from conception to labour onset, and the WHO 2016 model marks a major shift from the older 4-visit Focused ANC.

WHO 2016 — 8 contacts (the new standard):

Rationale for 8 over 4: the 2016 WHO Cochrane review found the 4-visit FANC model was associated with a small increase in perinatal mortality, driving the evidence-based shift.

India RMNCH+A (minimum 4 visits — operational reality):

• Visit 1 — within first trimester (ideally <12 weeks)
• Visit 2 — at 14–26 weeks
• Visit 3 — at 28–34 weeks
• Visit 4 — at 36 weeks to term

Ideal Indian best-practice now recommends 8 contacts aligning with WHO 2016, but field services still often deliver 4. Know both for NEET PG.

Universal supplementation under RMNCH+A:

• Folic acid 400 mcg daily from preconception (ideally 3 months before) through first trimester to prevent NTDs; 5 mg if prior NTD child / anticonvulsants
• Iron: 60 mg elemental iron + 500 mcg folic acid daily from the 4th month for 180 days, then 180 days postpartum (total 360 days)
• Calcium: 1 g daily from the 4th month through pregnancy and 6 months postpartum
• Tetanus toxoid / Td: 2 doses 4 weeks apart in first pregnancy; 1 booster in subsequent

Booking visit investigations

The booking (first antenatal) visit is the foundation of antenatal risk stratification — ideally performed between 8 and 12 weeks.

History:

• LMP (for EDD by Naegele's rule: LMP + 9 months + 7 days)
• Menstrual pattern, contraception, prior pregnancies (G/P/L/A)
• Medical (HTN, diabetes, thyroid, TB, cardiac, epilepsy, haematological)
• Surgical (previous caesarean, myomectomy, other abdominal)
• Drug history (anticonvulsants, warfarin, ACEi)
• Family history (twinning, genetic disorders, hereditary cancers, haemoglobinopathies)
• Social (smoking, alcohol, substance use, occupation, partner HIV status)

Examination:

• Height, weight, BMI calculation
• Vitals (BP in both arms if first antenatal; baseline)
• General exam (pallor, oedema, thyroid, cardiovascular)
• Obstetric exam (fundal height if gestation >=12 weeks, presentation only in T3)

Mandatory labs at booking:

Additional (risk-based):

• OGTT 75 g at booking if high-risk (BMI >30, prior GDM, PCOS, family history T2DM, previous macrosomia or stillbirth)
• Haemoglobin electrophoresis (thalassaemia / sickle cell) — all in India given high carrier prevalence
• Rubella IgG — immunity; do NOT vaccinate in pregnancy
• Varicella IgG — if history unclear
• TORCH screen only if clinically indicated (not universal)

Anomaly scan — 18–22 weeks

The fetal anomaly scan (Targeted Imaging for Fetal Anomalies, TIFFA) is a detailed level-II ultrasound performed between 18 and 22 weeks that screens for major structural abnormalities.

Indian standard: 18–20 weeks (practical, within PC-PNDT Act compliance; sex determination prohibited and not communicated).

Systematic assessment:

1. Head and brain — biparietal diameter, head circumference, ventricles (lateral ventricle <=10 mm), cerebellum, cisterna magna, nuchal fold (<6 mm), face (lips/palate/profile)
2. Spine — longitudinal and transverse views for neural tube defects
3. Heart — four-chamber view, outflow tracts (LVOT, RVOT), three-vessel view, crossing of great vessels
4. Thorax — lung echogenicity, diaphragm
5. Abdomen — stomach bubble, kidneys (bilateral, pelvis <=4 mm), bladder, umbilical cord insertion, three-vessel cord
6. Limbs — all four limbs, hands and feet
7. Placenta — location (rule out previa), cord insertion, amniotic fluid index (AFI 8–18 cm)
8. Cervix — transvaginal for short cervix (<25 mm) in high-risk preterm labour

Soft markers for aneuploidy (Down syndrome):

• Nasal bone absence / hypoplasia (strongest marker)
• Increased nuchal fold (>=6 mm at 15–20 weeks)
• Echogenic intracardiac focus
• Pyelectasis (renal pelvis 4–10 mm)
• Short femur / humerus
• Echogenic bowel
• Single umbilical artery
• Choroid plexus cysts (trisomy 18 marker)

Non-invasive prenatal testing (NIPT) screens cell-free fetal DNA in maternal blood from 10 weeks onwards — high sensitivity for T21, T18, T13. Increasingly available but not universal in India.

Diagnostic (invasive):

• Chorionic villus sampling (CVS) — 10–13 weeks; karyotype
• Amniocentesis — 15–20 weeks; karyotype, AFP, culture

GDM screening — DIPSI vs IADPSG

Gestational diabetes mellitus is carbohydrate intolerance first recognised during pregnancy, and India uses DIPSI as the practical universal screen.

DIPSI (Diabetes in Pregnancy Study Group India) protocol:

• Test: 75 g oral glucose load regardless of fasting status
• Sample: single venous plasma glucose at 2 hours
• Diagnostic cutoff: >=140 mg/dL = GDM
• Timing: at the first antenatal visit and repeat at 24–28 weeks
• Advantage: non-fasting, 1-step, practical for field settings
• Basis: DIPSI-India multicentre validation

IADPSG / ADA 75 g OGTT (alternative, 2-step or 1-step):

Any ONE value >= cutoff = GDM.

Treatment of GDM:

1. Medical nutrition therapy (MNT) first — calorie restriction if BMI >=30; complex carbs, avoid refined sugars
2. Exercise — 30 minutes/day walking
3. Self-monitoring blood glucose — fasting <95, 1-h PP <140, 2-h PP <120
4. Pharmacotherapy if targets not met:
   • Insulin is first-line pharmacotherapy (does not cross placenta)
   • Metformin — increasingly used as first-line in DIPSI protocols in India (crosses placenta but no proven fetal harm)
   • Glyburide — avoided (crosses placenta, causes neonatal hypoglycaemia)
5. Delivery — induce at 39–40 weeks for well-controlled diet-treated GDM; 38–39 weeks for insulin-treated

Maternal risks: preeclampsia, polyhydramnios, operative delivery, T2DM later life. Fetal risks: macrosomia, shoulder dystocia, birth trauma, NICU admission, neonatal hypoglycaemia, hypocalcaemia, jaundice, RDS, stillbirth.

Post-delivery: repeat 75 g OGTT at 6 weeks to identify persistent diabetes; lifelong annual screening.

Rh-negative pregnancy — anti-D and Kleihauer-Betke

Rh-negative pregnancy carries the risk of maternal alloimmunisation to fetal Rh-positive cells, causing haemolytic disease of the fetus and newborn (HDFN) — prevented by anti-D immunoglobulin.

Indian Rh-negative prevalence: ~5–10%, substantially lower than Western populations (~15%).

Pathophysiology:

• Fetomaternal haemorrhage (FMH) → fetal Rh-positive RBCs in maternal circulation
• Maternal production of anti-D IgG antibodies
• IgG crosses placenta in subsequent pregnancy → fetal Rh+ RBC destruction
• First Rh+ pregnancy usually unaffected; later pregnancies increasingly affected
• Severe HDFN: fetal hydrops (oedema, ascites, cardiomegaly), kernicterus

Sensitizing events (all require anti-D):

• Spontaneous or induced abortion (>6 weeks — 50 mcg; >12 weeks — 300 mcg)
• Ectopic pregnancy
• Antepartum haemorrhage (previa, abruption)
• Chorionic villus sampling, amniocentesis, cordocentesis
• External cephalic version
• Abdominal trauma
• Fetal death in utero
• Postpartum if baby Rh-positive

Prophylaxis schedule (NACO, NEOG, FIGO):

• Routine antenatal anti-D: 300 mcg IM at 28 weeks (covers silent FMH in T3)
• Alternative: 100 mcg at 28 and 34 weeks
• Postpartum: 300 mcg IM within 72 hours if baby is Rh-positive
• Each sensitizing event: 300 mcg (100 mcg if <12 weeks)

Indirect Coombs test (ICT):

• At booking (to detect pre-existing anti-D)
• If positive → monitor antibody titre monthly; >=1:16 = significant; consider MCA Doppler, cordocentesis, intrauterine transfusion
• At 28 weeks (before routine anti-D)

Kleihauer-Betke test:

• Acid elution: maternal smear treated with acid → HbA elutes (ghost cells), HbF resistant (pink-staining fetal cells)
• % fetal cells × maternal blood volume = mL of FMH
• Dose of anti-D: 10 mcg covers 0.5 mL of fetal RBCs (1 mL of fetal blood)
• If FMH >30 mL, additional 300 mcg per 30 mL of fetal blood
• Used when massive FMH suspected (abruption, trauma, stillbirth)

Flow cytometry is an alternative quantitative test.

Antepartum haemorrhage — previa vs abruption vs vasa previa

Antepartum haemorrhage (APH) is bleeding from the genital tract after 20 weeks and before delivery — and the differentiation of previa, abruption, and vasa previa is a classic NEET PG table.

Placenta previa — Grades (TVUS):

Morbidly adherent placenta (PAS):

• Accreta — invades decidua
• Increta — invades myometrium
• Percreta — through serosa, into bladder
• Risk factors: previous caesarean + placenta previa, prior myomectomy, grand multiparity
• Management: planned peripartum hysterectomy, interventional radiology (uterine artery balloon / embolisation)

Abruption grades (Sher):

• Grade 1 — minor, diagnosed retrospectively on placental exam
• Grade 2 — clinical bleeding, tender uterus, live fetus, no DIC
• Grade 3a — fetal demise, no DIC
• Grade 3b — fetal demise + DIC

Preterm labor — tocolytics and corticosteroids

Preterm labour is regular uterine contractions with cervical change before 37 weeks — and tocolytic choice is a NEET PG favourite.

Goals of tocolysis (48-hour window):

1. Allow antenatal corticosteroids to work (lung maturity)
2. Allow MgSO4 for neuroprotection (<32 weeks)
3. Allow in-utero transfer to tertiary centre

First-line: Nifedipine (calcium channel blocker):

• Loading: 20 mg oral, can repeat after 30 min if contractions persist
• Maintenance: 10–20 mg every 4–8 hours × up to 48 hours
• Side effects: maternal hypotension, flushing, headache, reflex tachycardia
• Contraindicated in significant cardiac disease

Equal alternative: Atosiban (oxytocin receptor antagonist):

• IV bolus 6.75 mg, then 300 mcg/min × 3 hours, then 100 mcg/min up to 48 hours
• Cleanest side-effect profile
• Expensive — not routine in Indian public sector

Older agents (less preferred):

• Ritodrine / Terbutaline (beta-agonists): tachycardia, maternal pulmonary oedema (especially with multiple pregnancy, infection, fluid overload), hyperglycaemia, hypokalaemia. FDA black-box for terbutaline (not for prolonged use)
• Magnesium sulfate — less effective as tocolytic, but used for fetal neuroprotection
• Indomethacin (COX inhibitor) — effective but premature ductal closure if >=32 weeks; oligohydramnios; used <32 weeks short-term only

Contraindications to tocolysis:

• Gestation >=34 weeks
• Intrauterine fetal death
• Lethal fetal anomaly
• Severe preeclampsia / eclampsia
• Placental abruption with maternal or fetal compromise
• Chorioamnionitis
• Non-reassuring fetal status
• Advanced cervical dilatation (>=5 cm)

Antenatal corticosteroids (ACS):

• Betamethasone 12 mg IM × 2 doses 24 hours apart OR
• Dexamethasone 6 mg IM × 4 doses 12 hours apart
• Window: 24–34 weeks (some protocols extend to 36+6 weeks for late preterm rescue course)
• Benefits: ~40% reduction in RDS, ~50% reduction in IVH, reduced NEC, reduced neonatal mortality
• Single rescue course if >7 days since first and still <34 weeks

Magnesium sulfate for fetal neuroprotection:

• 4 g IV load, then 1 g/h infusion × up to 24 hours
• If imminent preterm delivery <32 weeks
• Reduces cerebral palsy incidence

GBS prophylaxis:

• Penicillin / ampicillin IV at onset of labour if GBS+ / unknown + risk factors
• Preterm labour is a risk factor

PROM vs PPROM

PROM (Premature Rupture of Membranes) is rupture of membranes before the onset of labour at term (>=37 weeks); PPROM (Preterm PROM) is membrane rupture before 37 weeks.

Diagnosis:

• History of gush of fluid
• Pooling of clear fluid in posterior fornix on sterile speculum exam (avoid digital exam to reduce infection)
• Nitrazine paper test: amniotic fluid pH >6.5 turns paper blue (false positive with blood, semen, BV, urine)
• Fern test: dried fluid shows fern-like crystals under microscope
• AmniSure / PAMG-1 — biochemical test
• Ultrasound: oligohydramnios (AFI reduced)

Management of PROM at term:

• Induction of labour (usually within 24 hours) reduces chorioamnionitis risk
• Prophylactic antibiotics if >18 hours
• GBS prophylaxis if applicable

Management of PPROM (24–34 weeks):

• Hospitalisation; bed rest
• Antenatal corticosteroids — betamethasone × 2 doses
• Latency antibiotics: erythromycin 250 mg QID × 10 days (or until delivery) + ampicillin/amoxicillin
  • Avoid co-amoxiclav → associated with neonatal NEC (ORACLE trial)
• MgSO4 neuroprotection if <32 weeks
• Surveillance: daily temperature, fetal heart, WBC, CRP
• Deliver at 34 weeks OR earlier if chorioamnionitis, abruption, fetal distress, or active labour

Chorioamnionitis signs:

• Maternal fever >=38°C
• Fetal tachycardia >160
• Maternal tachycardia >=100
• Uterine tenderness
• Foul-smelling vaginal discharge
• Maternal leukocytosis (not reliable after steroids)

Multiple pregnancy

Multiple pregnancy is the simultaneous gestation of two or more fetuses — chorionicity rather than zygosity is the single most important antenatal determinant of risk.

Types by zygosity:

• Monozygotic (identical) — 1/3 of twins worldwide; fixed rate (~3.5/1000)
• Dizygotic (fraternal) — 2/3; rate varies with maternal age, parity, ART, race (highest in Nigeria)

Types by chorionicity (first-trimester US, 11–14 weeks):

Dizygotic twins are ALWAYS dichorionic diamniotic.

Ultrasound chorionicity signs (first trimester):

• Lambda sign (λ) / twin peak — dichorionic
• T sign — monochorionic

Antenatal management:

• Dating in first trimester with chorionicity determination
• Every 4 weeks for DCDA, every 2 weeks for MCDA, weekly in T3 for MCMA
• Screening for preeclampsia, anaemia, GDM, preterm labour

Specific complications:

• Twin-to-twin transfusion syndrome (TTTS) — MC twins; shared placental anastomoses; donor (oligohydramnios + small) and recipient (polyhydramnios + large + cardiac failure); treatment = fetoscopic laser ablation at 16–26 weeks
• Twin anaemia polycythaemia sequence (TAPS)
• Selective IUGR
• Single twin demise (vanishing twin; increased risk of neurological injury in surviving MC twin)

Delivery timing (uncomplicated):

• DCDA — 38 weeks
• MCDA — 36 weeks
• MCMA — 32–34 weeks with planned caesarean
• Conjoined — caesarean

Mode of delivery (presentation-based):

• Both cephalic: vaginal trial
• First cephalic, second non-cephalic: vaginal with internal podalic version of second OR LSCS
• First non-cephalic: LSCS
• Monoamniotic: always LSCS (cord entanglement)

Maternal complications: preeclampsia (3-fold), PPH, anaemia, hyperemesis gravidarum, operative delivery.

Sources and references

1. World Health Organization. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience (2016 update, reaffirmed 2022).
2. Government of India, Ministry of Health & Family Welfare. RMNCH+A Guidelines for Antenatal Care and Skilled Attendance at Birth by ANMs/LHVs/SNs (2016 update, 2020 reaffirmation).
3. Diabetes in Pregnancy Study Group India (DIPSI). Consensus Guidelines on Screening and Diagnosis of GDM (2020 revision).
4. Williams Obstetrics, 26th Edition (Cunningham, Leveno, Bloom et al., 2022).
5. DC Dutta's Textbook of Obstetrics, 9th Edition (2018) — Chapters on Antenatal Care, APH, Preterm Labour, Multiple Pregnancy, Rh Isoimmunisation.
6. Kenyon SL et al. (ORACLE II Collaborative Group). Broad-spectrum antibiotics for preterm, prelabour rupture of fetal membranes: the ORACLE I randomised trial. Lancet 2001; 357:979-988.
7. Royal College of Obstetricians and Gynaecologists (RCOG). Green-top Guideline No. 27: Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia (2018).

Frequently asked questions

How many ANC and pregnancy complication questions appear in NEET PG?

Antenatal care and pregnancy complications contribute 4-5 direct questions per NEET PG paper across obstetrics, community medicine, and pharmacology. WHO 2016 ANC schedule, anti-D timing in Rh-negative pregnancy, DIPSI GDM screening, APH differentials, and tocolytic choice are the most tested subtopics based on 2019-2025 pattern analysis.

What is the WHO 2016 antenatal care schedule?

WHO 2016 recommends 8 antenatal contacts (a shift from the older 4-visit Focused ANC model) because 4 visits were associated with higher perinatal mortality. The revised schedule: 1 contact in first trimester (before 12 weeks), 2 contacts in second trimester (at 20 and 26 weeks), and 5 contacts in third trimester (at 30, 34, 36, 38, and 40 weeks). India still operates a minimum 4-visit schedule under RMNCH+A, but the 8-contact model is the international standard.

What investigations are done at the booking visit?

Booking visit (ideally at 8-12 weeks) includes complete history and exam, BP, height/weight, CBC, blood group and Rh typing, urine routine and albumin, HIV (opt-out), VDRL, HBsAg, random blood sugar, thyroid screen (TSH), and dating ultrasound. Baseline OGTT is done if high-risk (BMI over 30, prior GDM, prior macrosomia, PCOS, family history). An optional rubella IgG and a baseline ECG are added in select protocols.

When is the anomaly scan done and what does it look for?

The fetal anomaly scan is done between 18 and 22 weeks of gestation (Indian standard is 18-20 weeks under the PC-PNDT Act). It assesses major structural anomalies of the head, spine, heart (four-chamber view, outflow tracts), abdomen, kidneys, and limbs. Markers like nasal bone absence, increased nuchal fold, echogenic intracardiac focus, and ventriculomegaly prompt karyotyping. Earlier scans (11-14 weeks, NT scan) screen for aneuploidy but miss most structural anomalies.

What is DIPSI and how is GDM screened?

DIPSI (Diabetes in Pregnancy Study Group India) recommends universal GDM screening with a 75 g oral glucose challenge regardless of fasting status, with a single venous plasma sample at 2 hours. A value greater than or equal to 140 mg/dL is diagnostic of GDM. DIPSI is practical for low-resource settings because it does not require fasting. Screening is done once at 24-28 weeks (and at booking if high-risk). Alternative: IADPSG 75 g OGTT with fasting, 1-hour, and 2-hour samples (fasting greater than or equal to 92, 1-hour greater than or equal to 180, 2-hour greater than or equal to 153 — any one diagnostic).

When is anti-D given in Rh-negative pregnancy?

Anti-D immunoglobulin 300 micrograms IM is given to Rh-negative unsensitized women at 28 weeks (antenatal prophylaxis) and within 72 hours postpartum if the baby is Rh-positive. Additional doses after any sensitizing event: spontaneous or induced abortion, ectopic pregnancy, antepartum hemorrhage, external cephalic version, amniocentesis, chorionic villus sampling, or abdominal trauma. Kleihauer-Betke test quantifies fetomaternal hemorrhage to decide if more than the standard 300 micrograms is needed.

What is the Kleihauer-Betke test?

The Kleihauer-Betke (acid elution) test detects fetal red blood cells in maternal circulation and quantifies fetomaternal hemorrhage. Maternal blood smear is treated with acid buffer — adult haemoglobin (HbA) elutes leaving ghost cells, while fetal haemoglobin (HbF) is acid-resistant and stains pink. The percentage of fetal cells guides additional anti-D dosing beyond the standard 300 micrograms (each additional 30 mL of fetomaternal bleed needs one more 300 microgram dose).

How do you differentiate placenta previa, abruption, and vasa previa?

Placenta previa is painless, causeless, recurrent, fresh bleeding with a soft relaxed uterus and normal fetal heart sounds — ultrasound shows placental edge less than 2 cm from the internal os. Abruption is painful, dark bleeding with a tender hypertonic uterus, fetal distress or demise, and possible DIC — ultrasound is often falsely negative. Vasa previa is painless bleeding at rupture of membranes with rapid fetal distress or demise (Apt test detects fetal blood).

What is the first-line tocolytic for preterm labor?

Nifedipine is first-line for preterm labor tocolysis in most contemporary guidelines because of oral availability, efficacy, low maternal side effects, and no link to neonatal pulmonary oedema (seen with beta-agonists). Loading dose 20 mg oral, then 10-20 mg every 4-8 hours. Atosiban (oxytocin receptor antagonist) is an equally efficacious alternative with the cleanest side-effect profile but is expensive. Ritodrine and terbutaline (beta-agonists) are older agents with more maternal and fetal side effects.

What is the difference between PROM and PPROM?

PROM (Premature Rupture of Membranes) is rupture of membranes before the onset of labor at term (at or after 37 weeks). PPROM (Preterm PROM) is rupture of membranes before 37 weeks. Diagnosis relies on visual pooling of liquor in the posterior fornix, positive nitrazine test (pH more than 6.5 — blue colour change), positive fern test, and ultrasound showing oligohydramnios. PPROM management includes corticosteroids for lung maturity (24-34 weeks), broad-spectrum antibiotics (erythromycin) for latency, and delivery at 34 weeks or earlier if chorioamnionitis, abruption, or fetal distress occurs.

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Written by: NEETPGAI Editorial Team Reviewed by: Pending SME Review Last reviewed: March 2026

This article is reviewed by qualified medical professionals for clinical accuracy and exam relevance. For corrections or updates, contact the editorial team.