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Antenatal care Flashcards

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1
Q

hypothyroid management in pregnancy

A

levothyroxine dose needs to be increased (30-50%)

Treatment is titrated based on TSH level, aiming for low-normal TSH level.

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2
Q

hypertension medication to be stopped during pregnancy

A

ACE-inhibitors (ramipril)
Angiotensin receptor blockers (e.g losartan)
Thiazide and thiazide-like diuretics (e.g. indapamide)

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3
Q

epilepsy in pregnancy

A

Folic acid 5mg daily from 3months prior conception.

Safe anti-epileptic medication
- Lamotrigine, carbamazepine, levetiracetam

Medications to avoid

  • Sodium valproate (neural tube defects & developmental delay)
  • Phenytoin (cleft lip and palate)
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4
Q

rheumatoid arthritis in pregnancy

A

Ideally, well-controlled for at least 3 month prior to becoming pregnant

Contraindicated
- Methotrexate (miscarriage & congenital abnormalities)

Safe

  • Hydroxychloroquine (1st line)
  • sulfasalazine
  • corticoteroids can be used during flare-ups
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5
Q

gestational diabetes suggestive features

A

large for date fetus
Polyhydramnios
Glucose on urine dipstick

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6
Q

Screening test for Gestational Diabetes

A

Oral Glucose Tolerance Test

  • Fasting >5.6
  • 2 hours >7.8
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7
Q

Management of gestational diabetes

A

Fasting glucose <7
- diet and exercise for 1-2 weeks then metformin then insulin

fasting glucose >7
- start insulin +/- metformin

Monitor blood sugar levels

4 weekly US from 28-36 weeks

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8
Q

Complications of Gestational diabetes

A 
shoulder dystocia 
neonatal hypoglycaemia 
polycythaemia 
jundice
congenital heart disease
cardiomyopathy
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9
Q

features of congenital rubella syndrome

A

congenital deafness
congenital cataracts
congenital heart disease
learning disability

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10
Q

pregnancy and rubella

A

women planning to become pregnant should ensure they have had MMR vaccine

Vaccine not given during pregnancy as it is live

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11
Q

Chickenpox in pregnancy complications

A

more severe cases in mother: varicella pneumonitis, hepatitis, or encephalitis

Fetal varicella syndrome

Severe neonatal varicella infection

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12
Q

Exposure to chickenpox in pregnancy

A

Previous exposure: safe

Not immune
- IV varicella Immunoglobulins (given within 10 days of exposure)

Chickenpox rash
- oral acyclovir if present within 24 hours and >20 weeks gestation

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13
Q

listeria in pregnancy

A

high rate of miscarriage or foetal death

Avoid high-risk foods (e.g. blue cheese) and practice good food hygiene

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14
Q

congenital cytomegalovirus features

A 
Fetal growth restriction 
microcephaly
hering loss
vision loss
learning disability
seizures

note; most cases of CMV in pregnancy do not cause congenital CMV

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15
Q

parvovirus B12

A

‘slapped-cheek’ syndrome

Supportive treatment in pregnancy
need referral to fetal medicine to monitor for complications and malformations

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16
Q

complications of parvovirus b12 infection in pregnancy

A

miscarriage or fetal death
severe fetal anaemia
hydros fettles
Maternal pre-eclampsia-like syndrome

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17
Q

small for gestational age

A

fetus that measures below 10th centime for gestational age.

Measures on US used to assess

  • estimated fetal weight
  • fetal abdominal circumference
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18
Q

Fetal Growth restriction aetiology

A

Placenta mediated

  • idiopathic
  • pre-eclampsia
  • maternal smoking & alcohol
  • anaemia
  • malnutrition
  • infection

Non-placenta mediated

  • genetic abnormaltiies
  • structural abnormalities
  • fetal infection
  • errors of metabolism
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19
Q

signs of fetal growth restriction

A

reduced amniotic fluid volume
abnormal doppler studies
reduced fetal movements
abnormal CTGs

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20
Q

large for gestational age

A

macrosomia
Weight of newborn >4.5 kg at birth
During pregnancy, estimated fetal weight above 90th percentile

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21
Q

aetiology of macrosomia

A 
constitutional 
maternal diabetes
previous macrosomia pregnancy
maternal obesity or rapid weight gain 
overdue
male baby
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22
Q

risks of macrosomia

A

Risks to mother

  • shoulder dystocia
  • failure to progress
  • perineal tears
  • intrumental delivery or caesarean
  • postpartum haemorrhage
  • uterine rupture (rare0

Risks to baby

  • birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
  • neonatal hypoglycaemia
  • obesity in childhood & later life
  • T2DM in adulthood
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23
Q

NAIDs in pregnancy

A

e.g. ibuprofen and naproxen

Generally avoided in pregnancy

3rd trimester: premature closure of ductus arteriosus
Can delay labour

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24
Q

Beta-blockers in pregnancy

A

labetalol

- 1st line for high BP caused by pre-eclampsia

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25
ACE-inhibitors and ARBs in pregnancy
Can cross the placenta and enter fetus - in fetus mainly affect kidneys and reduce production of urine Possible complications - oligohydramnios - miscarriage/ fetal death - hypocalvaria - renal failure in neonate - hypotension in neonate
26
neonatal abstinence syndrome
caused by use of opiates in pregnancy ``` Presents 3-72 hours after birth Irritability Tachypnoae High temperatures Poor feeding ```
27
Warfarin in pregnancy
Avoid in pregnancy Teratogenic and can cross the placenta possible complications - fetal loss - congenital malformations - bleeding during pregnancy
28
sodium valproate
Avoid in pregnancy | can cause neural tube defects and developmental delay
29
lithium in pregnancy
avoid in pregnancy and when breastfeeding Possible complications -congenital cardiac abnormalities (Ebsteins anomaly) a
30
SSRIs in pregnancy
Can cross placenta into fetus. | Risks need to be balanced against benefits of treatment.
31
Isotretinoin (roaccutane) in pregnancy.
highly teratogenic Causes miscarriage and congenital defects. Women need very reliable conception before, during and for one month after taking isotretinoin
32
twin-twin transfusion syndrome
Occurs when foetuses share a placenta. Connection between blood supplies of the two foetuses. One fetus may receive majority of blood from the placenta while the other is starved of blood. Recipient: fluid overloaded -> heart failure & polyhydramnios Donor: growth restriction, anaemia and oligohydramnios
33
placenta accrete
placenta implants deeper, through and past endometrium making it difficult to separate the placenta after delivery of the baby
34
types of placenta accrete
superficial placenta accreta - placenta implants in surface of myometrium placenta increta - attaches deeply into myometrium placenta percreta -invade past myometrium and perimetric
35
placenta accrete management
ideally diagnosed antenatally by US to allow for planning of birth. Delivery - planned between 35 and 36+6 weeks gestation to reduce risk of spontaneous labour and delivery - antenatal steroids to mature fetal lungs Caesarean -hysterectomy with placenta remaining in uterus
36
placenta previa
placenta is arched in lower portion of the uterus, lower than presenting part of fetus. Placenta is over internal cervical os
37
placenta previa presentation
20 week anomaly scan
38
management of placenta previa
repeat Transvaginal US - 32 weeks - 36 weeks (guide decisions about delivery) Planned delivery 36-37 weeks gestation. -planned caesarean
39
low lying placenta
placenta within 20mm of internal cervical os
40
placental abruption
placenta separates from wall of uterus during pregnancy. Site of attachment can bleed extensively after placenta separates. Significant cause of antepartum haemorrhage
41
placental abruption presentation
sudden onset severe abdo pain vaginal bleeding shock (hypotension & tachycardia) Abnormalities on CTG characteristic 'woody' abdomen on palpation
42
severity of antepartum haemorrhage
minor: <50ml major: 50-1000 ml masive >1000ml or signs of thick
43
concealed abruption
cervical os remains closed and any bleeding that occurs remains within uterine cavity. Severity of bleeding can be significantly underestimated with concealed haemorrhage.
44
placental abruption management
EMERGENCY ``` bloods Crossmatch 4 units of blood fluid and blood rests as required CTG monitoring of foetus Close monitoring of mother ``` Antenatal steroid offered between 24 and 34 + 6 weeks gestation anti-d prophylaxis
45
kleihaur test
used to quantify how much fetal blood is mixed with maternal blood, to determine dose of anti-D required.
46
pre-eclampsia
new high BP in pregnancy with end-organ dysfunction, notably proteinuria Triad of features: hypertension, proteinuria, oedema
47
symptoms of pre-eclampsia
``` headache visual disturbacne nausea and vomiting upper abdo or epigastric pain oedema reduced urine output brisk reflexes ```
48
diagnosis of pre-eclampsia
High BP (>140/90) PLUS any of: Proteinuria (1+ or more on urine dipstick) Organ dysfunction - raised creatinine, elevated liver enzymes, seizures, thrombocytopenia, haemolytic anaemia) Placental dysfunction -fetal growth restriction/ abnormal doppler studies Placental Growth Factor Testing -Low in pre-eclampsia
49
management of pre-eclampsia
anti-hypertensive: labetalol IV magnesium sulphate: during and 24hours after labour to prevent seizures Fluid restriction: during labour if severe pre-eclampsia to avoid fluid overload
50
eclampsia
seizures associated with pre-eclampsia Management: IV magnesium sulphate
51
HELLP syndrome
Complication of pre-eclampsia Haemolysis Elevated liver enzymes Low platelets
52
pregnancy-related rashes
``` polymorphic eruption of pregnancy atopic eruption of pregnancy melasma Pyogenic granuloma pemphigoid gestations ```
53
polymorphic eruption of pregnancy
itchy rash that tends to start in third trimester. Usually begins on abdomen Characteristics: urticarial papules. wheals and plaques
54
polymorphic eruption of pregnancy management
control symptoms topical emollients oral antihistamines Topical steroids
55
atopic eruption of pregnancy
eczema that flares up during pregnancy | Presents in first and second trimester.
56
melasma
mask of pregnancy | Increased pigmentation to patches of the skin on the face.
57
Pyogenic granuloma
lobular capillary haemangioma Benign, rapidly growing tumour of capillaries. discrete lump that develops over days up to 1-2 cm in size. Often occurs on fingers, upper chest, back, neck or head
58
Pemphigoid gestations
rare autoimmune skin condition that occurs in pregnancy typically 2nd to 3rd trimester itchy red popular or blistering rash around the umbilicus, that then spreads to other parts of the body. Over several weeks, large fluid-filled blisters form.
59
stillbirth
birth of a dead fetus after 24 weeks | Result of intrauterine fetal death
60
management of stillbirth
US: investigation of choice for diagnosis Rhesus-D negative require Anti-D prophylaxis Vaginal birth - induction of labour or expectant management Induction of labour: mifepristone + misoprostol Dopamine agonists - e.g. cabergoline - suppress lactation after birth
61
UTI in pregnancy
Pregnancy women at higher risk of developing lower UTI and pyelonephritis. UTIs in pregnancy increase risk of preterm delivery
62
presentation of UTI
Lower UTI - dysuria - suprapubic pain or discomfort - increassed frequency of urination - urgancy - incontinence - haematuria pyelonephritis - fever - loin, suprapubic pain or back pain - generally unwell - vomiting - losss. of appetitie - haematuria - renal angle tenderness on exam
63
investigation of UTI
urine dipstick - nitrites produce by gram -ve bacteria (e.g. E.coli) - leukocyte esterase
64
Causes of UTI
Most common: E. coli Klebsiella pneumoniae Enterococcus Pseudomonas aeruginosa Sstaph. aprophyticus
65
Management of UTI in pregnancy
7 days of ABx - Nitrofurantoin (avoided in 3rd trimester) Amoxicillin (once sensitivities known -Cefalexin
66
Nitrofurantoin in pregnancy
needs to be avoided in 3rd trimester | -Risk of neonatal haemolytic
67
Trimethoprim in pregnancy
needs to be avoided in 1st trimester - works as a folate antagonist. Can cause congenital malformations, particularly neural tube defects Generally avoided throughout pregnancy
68
vasa praevia
foetal vessels placed over internal cervical os before the foetus Fetal vessels: 2 umbilical arteries & single umbilical vein type I: fetal vessels are exposed s a velamentous umbilical cord Type II: fetal vessels exposed as they travel to an accessory placental lobe
69
risk factors for vasa praaevia
low-lying placenta IVF pregnancy Multiple pregnancy
70
Presentation of vasa praevia
May be diagnosed by US during pregnancy antepartum haemorrhage during 2nd or 3rd trimester may be detected by vaginal exam during labour -pulsating fetal vessels are seen in membranes through dilated cervix
71
management of vasa praevia
asymptomatic - corticosteroids from 32 weeks - elective c-section: 34-36 weeks Antepartum haemorrhage -emergency c-section
72
screening for anaemia in pregnancy
Booking clinic 28 week gestation Haemoglobinopathy screening offered at booking clinic - identify thalassaemia and sickle cell disease Additional investigations -ferritin, B12, folate
73
posible causes of anaemia (& indicative MCV)
Low MCV - iron deficiency Normal MCV - physiological anaemia due to increased plasma volume of pregnancy Raised MCV - B12 or folate deficiency
74
Management of anaemia in pregnancy
Iron - Ferrou sulphate 200mg 3x daily B12 - Low B12: test for pernicious anaemia (check for intrinsic factor antibodies) - Intramuscular hydroxycobalamin injections Folate - All women: folic acid 400mcg per day - Deficiency: 5mg daily
75
acute fatty liver disease of pregnancy
rare condition that occurs in 3rd trimester of pregnancy | Rapid accumulation of fat within liver cells (hepatocytes) causing acute hepatitis.
76
aetiology acute fatty liver disease of pregnancy
impaired processing of fatty acids in placenta LCHAD deficiency in fetus Autosomal recessive condition
77
presentation acute fatty liver disease of pregnancy
``` general malaise and fatigue nausea and vomiting jaundice abdo pain anorexia ascites ```
78
bloods in acute fatty liver disease of pregnancy
``` LFTs: elevated liver enzymes (ALT &AST) raised bilirubin raised WBC count Deranged clotting - raised prothrombin time and INR low platelets ```
79
management acute fatty liver disease of pregnancy
obstetric emergence Prompt admission & delivery of baby Most recover after delivery
80
obstetric cholestasis
intrahepatic cholestasis of pregnancy Reduced outflow of bile acids from the liver. Associated with increased risk of stillbirth
81
pathophysiology obstetric cholestasis
Result of increased oestrogen and progesterone. Bile acids are produced in the liver from the breakdown of cholesterol. Bile acids flow from liver to hepatic ducts, past the gallbladder and out of bile duct to intestines. In obstetric cholestasis: outflow of bile acid is reduced, causing them to build up in the blood, resulting in itching
82
presentation of obstetric cholestasis
usually develops later. in pregnancy (~28 weeks) ``` itching: affects palms of hands and soles of feet Ftigue Dark urine Pale-greasy stools jaundice ```
83
investigations of obstetric cholestasis
liver function tests -Abnormal: ALT, AAST and GGT (Note: normal for ALP to increase in pregnancy as its produced by placenta) Raised bile acids
84
Management of obstetric cholestasis
Urseodeoxycholic Acid Symptoms of itching -Emollients to soothe skin

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