Ante-natal care Flashcards
(71 cards)
1
Q
Pregnancy
- changes to normal body Physiology
A
- Increased blood volume (7.5l)
- Dilutional anaemia - Increased GFR
- 120ml/min +
- Glucosuria - Hyperemesis
2
Q
Ante-natal timeline
A
Ante-natal timeline
- <10 weeks
- Booking appt
- BMI, BP, Urine dip - 10-14
- USS (g. age, multiple pregnancy) - 14-17
- Quadruple test (anomaly ) - 18-20
- USS Anomalies
- Placental location - 24 weeks
- Symphysis-fundal height
- Fetal movements - 28 weeks
- Rhesus Anti-D
- FBC, blood group, antibody - 36 weeks
- Abdominal palpation (position)
- USS confirmation - 37+ weeks
- Induction for high risk - 41+
- Induction
3
Q
Fetal growth
- when to measure SFH
A
Fetal growth
- SFH measurement
- Each appointment after 24 wks
- USS instead:
- multiple pregnancy
- BMI >35
- Fibroids (large/multiple)
4
Q
Rhesus D
- Sensitising events
- Antibody Test
- Prophylaxis
A
Rhesus D
- Sensitising events
1. Amniocentesis
2. Antepartum bleed
3. Abdominal trauma - Antibody Test
1. Khleihauer-Betke - Prophylaxis
1. 28 weeks
2. 34 weeks
5
Q
what vaccines are offered in pregnancy
A
- whooping cough offered at 16-20w
- RSV offered at 28w
- influenza when available in autumn or winter
avoid live vaccines such as MMR
6
Q
booking clinic screening
A
- blood group, antibodies and rhesus D status
- full blood count for anaemia
- screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
- HIV, hepatitis B and syphilis
7
Q
Down’s syndrome screening
- tests and when
A
- combined test (11-14 weeks)
- quadruple test (14-20 weeks)
8
Q
combined test results
A
- ultrasound for nuchal translucency (>6mm)
- B-HCG → raised
- pregnancy-associated plasma protein-A (PAPPA) → decreased
9
Q
quadruple test - results
A
- B-HCG - high
- AFP - low
- serum oestriol low
- inhibin-A - high
10
Q
downs syndrome screening
- further tests
A
- CVS - before 15 weeks
- Chorionic villus sampling - Amniocentesis - after 15 weeks
- NIPTT
- non invasive perinatal testing
11
Q
Pregnancy advice
- Food
- Exercise
- Smoking
- Alcohol
- Recreational drugs
- Travel
- vitamins
A
Pregnancy advice
- Food
1. Avoid raw meat, fish, eggs, dairy
2. Wash fruit and veg (toxoplasmosis) - Exercise
1. Same level as pre-pregnancy
2. Not vigorous or high risk (sfga) - Smoking
1. Cessation - Alcohol
1. FAS
2. Avoid completely - Recreational drugs
1. Cocaine especially
2. Most misuse has consequences
3. Methadone programme for heroin - Travel
1. VTE stockings/ prophylaxis
2. Active daily and well hydrateed
3. Can fly till 37 weeks (32 if multiple pregnancy) - Vitamins
1. Folic acid 400mcg from before pregnancy to 12 weeks
2. Vitamin D
12
Q
trimesters in pregnancy
A
- first trimester - up to 12 weeks
- second trimester - 13-26 weeks
- third trimester - 27 weeks till birth
13
Q
Pregnancy
- Naegele’s rule to work out estimated due date
A
LMP
- regular
- no hormonal contraception
- add 7 days and subtract 3 months from LMP
14
Q
Term
- Post
- Pre
A
Term (37-40)
- Post (40+)
- Pre (-37)
15
Q
Gestational diabetes
- diagnostic criteria
A
- FBG 5.6
- Post prandial 7.8
16
Q
GDM
- Pathophysiology
A
GDM
- Pathophysiology
- Oestrogen and progesterone cause Increased insulin resistance
17
Q
GDM
- Risk factors
A
- BMI
- FH
- Baby 4.5kg
- Ethnicities
- Polyhydramnios
- Antipsychotics
- Previous GDM
- 12-16wk GTT
18
Q
GDM
- Fetal complications
A
- Increased fetal insulin
- anabolism - macrosomia
- shoulder and belly - dystocia
- Fetal polyuria
- polyhydramnios
- stretched uterus - preterm labour
- Neonatal hypoglycaemia
- Delayed lung maturity
19
Q
GDM
- Maternal complications
A
- DKA
- Hyperglycaemia
- Infection
- TII DM risk
20
Q
GDM
- Mx
A
four weekly ultrasound scans to monitor fetal growth and amniotic fluid volume from 28-36 weeks gestation
fasting glucose <7mmol/l → trial diet and exercise for 1-2
fasting glucose >7mmol→ start insulin +/- metformin
fasting glucose above 6mmol/L plus macrosomia (or other complications) → start insulin +/- metformin
21
Q
What is obstetric cholestasis?
A
Intrahepatic cholestasis of pregnancy caused by reduced bile acid outflow - build up in blood
resolves after delivery.
22
Q
when does obstetric cholestasis develop and what causes it?
A
- After 28 weeks
- due to oestrogen and progesterone
- south asian
23
Q
obstetric cholestasis
SSx
A
- itching is main symptom - especially palms of the hands and soles of the feet
- other symptoms:
- fatigue
- dark urine
- pale, greasy stools
- jaundice
24
Q
obstetric cholestasis
DDx
A
if rash present consider polymorphic eruption of pregnancy or pemphigoid gestionis
- gallstones
- acute fatty liver
- autoimmune hepatitis
- viral hepatitis
25
obstetric cholestasis
Ix
- abnormal LFTs mainly ALT, AST and GGT
- raised bile acids
- its normal for ALP to raise in pregnancy
26
obstetric cholestasis
Mx
- emollients to soothe the skin
- antihistamines can help sleeping
- water soluble vitamin K if clotting is deranges (fat soluble vitamin K not being absorbed)
- consider planned delivery - early delivery reduces risk of stillbirth
27
Vasa previa
- Definition
1. Umbilical cord travels through the membranes before inserting
- Velamentous insertion
2. If membranes rupture
- Vessels burst
28
Vasa previa
- Mx
1. Admit at 32 weeks
29
Pre-eclampsia
- Prevalence (%)
- Pathophysiology
Prevalence (%)
1. 5% of all pregnancies
Pathophysiology
1. Abnormal placentation
2. Poor invasion of the tunica muscularis media
3. High resistance, low-flow uteroplacental circulation
4. Systemic inflammatory response
- endothelial cell dysfunction
30
Pre-eclampsia
- Risk factors
- Chronic HTN
- previous pre-eclampsia
- CKD/DM
- Autoimmune disease
- Nuliparity
- Increased maternal age
- Maternal BMI
- FHx
- High pregnancy interval
- Multiple pregnancy
31
Pre-eclampsia
- Clicinical features
new onset of hypertension (**over 140 mmHg systolic or over 90 mmHg diastolic**) after **20 weeks of pregnancy** and the coexistence of 1 or more of:
- **proteinuria** (protein:creatinine ratio > 30 mg/mmol)
- **maternal organ dysfunction**
32
Pre-eclampsia
- Symptoms
1. Headaches
- frontal
2. Visual disturbance
- blurred/double/halos/flashing lights
3. Epigastric pain
- hepatic capsule distension/infarction
4. Odoema
— sudden/non-dependent
5. Hyper-reflexia
33
Pre-eclampsia
- Maternal Complications
1. HELLP syndrome
- haemolysis/liver enzames/low platelets
2. Eclampsia
3. AKI
4. DIC
5. ARDS
6. HTN
7. Cerebrovascular haemorrhage
8. Death
34
Pre-eclampsia
- Fetal complications
1. Prematurity
2. Intrauterine growth restriction
3. Placental abruption
4. IU fetal death
35
Pre-eclampsia
- BP aim
- BP Mx
- delivery
aim for BP <135/85
admit if >160/110
1. Labetalol (avoid in asthma)
2. Nifedipine
3. Methyldopa
- Alpha-agonist
4. ACEi
- Contra-indicated
plan for early birth if BP can't be controlled or complications
36
pre-eclampsia prophylaxis
aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors.
37
what is HELLP syndrome
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
38
placenta praevia
definition
Placenta praevia describes a placenta lying wholly or partly in the lower uterine segment
39
low-lying placenta vs praevia
- low-lying placenta - within 20mm of the internal cervical os
- placenta praevia - over the internal cervical os
40
placenta praevia
complications
- antepartum haemorrhage
- emergency caesarian section
- emergency hysterectomy
- maternal anaemia and transfusions
- preterm birth and low birth weight
- stillbirth
41
placenta praevia
RF
- previous caesarean sections
- previous placenta preavia
- older maternal age
- maternal smoking
- structural uterine abnormalities e.g. fibroids
- assisted reproduction
42
placenta praevia
- presentation
- many asymptomatic
- may present with painless vaginal bleeding in pregnancy around 36 weeks
43
placenta praevia
Mx
- repeat USS at 32 and 36 weeks
- corticosteroids at 34-36 weeks
- plan C section 36-37 weeks
44
maternal VTE
- RF
- smoking
- parity ≥3
- age >35
- BMI >30
- reduced mobility
- multiple pregnancy
- pre-eclampsia
- gross varicose veins
- immobility
- family history of VTE\thrombophilia
- IVF pregnancy
45
VTE
prophylaxis
- indication
- drug
starting prophylaxis from:
- 28 weeks if 3 risk factors
- first trimester if 4 or more risk factors
LMWH - until 6 weeks postnatal
46
VTE
diagnosis
management
doppler USS for DVT
CTPA or VQ scan for PE
wells score not valid in pregnancy
LMWH - dose based on weight
47
placenta accreta
definition
where the placenta implants deeper, through and past the endometrium - making it difficult to separate the placenta after delivery leading to postpartum haemorrhage
48
accreta
increta
percreta
- accreta - implants on the surface of the myometrium but not beyond
- placenta increta - placenta attaches deeply into the myometrium
- placenta percreta - placenta invades past the myometrium and perimetrium, potentially reaching organs such as the bladder
49
placental accreta
- cause
- RF
due to defect in endometrium
- previous placenta accreta
- previous endometrial curettage procedures (for miscarriage or abortion)
- previous caesarean section
- multigravida
- increased maternal age
- low-lying placenta or placenta praevia
50
placenta accreta
Mx
- plan delivery 35-36 weeks
- give steroids
- C section
1. hysterectomy
2. uterus preserving surgery
3. expectant management - high risk
if found after delivery - hysterectomy
51
top 2 causes of maternal sepsis
- choriamnionitis → infection of the chorioamniotic membranes and amniotic fluid (group B strep)
- urinary tract infection (e.coli)
52
signs of chorioamnionitis
- abdominal pain
- uterine tenderness
- vaginal discharge
53
maternal sepsis
Mx
- sepsis 6
- continuous maternal and fetal monitoring
- early delivery may be necessary - c-section
- general anaesthetic is required
- example antibiotic regimes:
- piperacillin and taxzoxin + gentamicin
- amoxicillin, clindamycin + gentamicin
54
types of twin pregnancy
- best prognosis
Zygosity:
- Monozygotic = identical twins
- Dizygotic = non-identical twins
Chorionicity & Amnionicity:
- Diamniotic = two amniotic sacs
- Monoamniotic = one sac
- Dichorionic = two placentas
- Monochorionic = one placenta
Best prognosis: Diamniotic, Dichorionic – each fetus has its own nutrient supply.
55
How is a multiple pregnancy diagnosed and what signs indicate chorionicity?
Diagnosed on booking ultrasound
Signs on scan:
Dichorionic diamniotic = lambda sign / twin peak sign
Monochorionic diamniotic = T sign
Monochorionic monoamniotic = no dividing membrane
56
maternal complications of multiple pregnancies?
Maternal risks:
Anaemia, polyhydramnios, hypertension, malpresentation
Preterm birth, operative delivery, PPH
57
fetal complications of multiple pregnancies?
Fetal/neonatal risks:
Miscarriage, stillbirth, growth restriction, prematurity
congenital abnormalities
Twin-twin transfusion syndrome (TTTS)
Twin anaemia polycythaemia sequence (TAPS)
58
Twin-twin transfusion syndrome (TTTS)
- what is it?
- Mx
Shared placenta, unbalanced blood flow
Recipient: fluid overload, polyhydramnios, heart failure
Donor: anaemia, oligohydramnios, growth restriction
Needs referral; severe cases treated with laser ablation of placental vessels
59
Twin anaemia polycythaemia sequence (TAPS)
- similar to twin-twin transfusion syndrome but less acute
- one twin becomes anaemic whilst the other develops polycythaemia
60
how is multiple pregnancy managed
- FBC at booking, 20 and 28 weeks
- extra scans for growth
- planned early birth
- steroids before delivery
monoamniotic - need C-section
diamniotic - possibility of vaginal delivery
61
assessment of RFM
* Ask what’s normal for her baby
* Assess viability: doppler, CTG
* Assess growth: SFH or growth scan
* Check BP and urine
* Recurrent RFM → ultrasound
* Before 24 weeks and never felt movements → refer to fetal medicine for neuromuscular concerns
62
when are fetal movements felt from and when is RFM a red flag?
Fetal movements usually start at 18–20 weeks
After 28 weeks, reduced FM = red flag
63
stillbirth
- definition and causes
fetal death after 24 weeks gestation
Causes:
Unexplained (~50%)
Pre-eclampsia, abruption, vasa praevia, cord issues
Cholestasis, diabetes, thyroid disease
Infections: rubella, parvovirus, listeria
Congenital/genetic abnormalities
64
3 red flags for stillbirth
Reduced fetal movements
Abdominal pain
Vaginal bleeding
65
stillbirth
Mx
- Ultrasound to confirm absence of heartbeat
- Vaginal birth preferred unless contraindicated
Options: Expectant management vs Induction (mifepristone + misoprostol)
post-stillbirth postmortem and support family
66
VBAC
pros
- ~72–75% success rate
- Shorter hospital stay and faster recovery
- Better chance of successful vaginal birth in future pregnancies
- Lower risk of neonatal respiratory problems (2–3%)
- Avoids surgical risks of multiple C-sections (e.g., placenta accreta)
67
VBAC cons
- 0.5% risk of uterine rupture (higher with induction)
- 5% risk of anal sphincter injury
- 0.08% risk of neonatal hypoxic ischaemic encephalopathy
- Risk of emergency C-section if VBAC fails
68
VBAC
absolute contraindications
Classical (vertical) caesarean scar
Previous uterine rupture
Placenta praevia or other contraindications to vaginal delivery
69
VBAC relative contraindications
Complex uterine scars (e.g., T or J incisions)
More than 2 previous lower segment caesareans
70
VBAC
mx
* Must be in hospital with emergency theatre access
* Continuous CTG
* Caution with analgesia – may mask rupture signs
* Avoid induction if possible; mechanical > prostaglandins if needed
* Senior input required for induction/augmentation
* After 39 weeks, elective C-section is advised
71
TORCH infections
transmitted from mother to baby
- Toxoplasma gondii
- Other agents (like syphilis and hepatitis B)
- Rubella
- Cytomegalovirus (CMV)
- Herpes simplex virus (HSV)
