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Antenatal care Flashcards

(48 cards)

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1
Q

Aim of fetal anatomy scans

A

To optimise ANC by providing accurate diagnostic information

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2
Q

Indications for earlier scans (before routine anomaly scan)

A

Abnormal first trimester scan
Parent with congenital anomaly
Prev fetal anomaly
Teratogenic drugs
High risk first trimester screening
Consanguinity
Two inconclusive NIPS

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3
Q

When would a single repeat scan be done

A

Done if optimal images not seen by 26/40
Can be due to:
- increased BMI
- large fibroids
- abdominal scarring
- suboptimal fetal position
* if second USS doesn’t give clear images, should be referred for fetal med review

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4
Q

NB things to be noted on anomaly scan

A

Fetal biometry: BPD, HC, AC, FL. Discrepancy >10-14/7, rescan in 2/52
Amniotic fluid: DVP <2= oligo, >8 - poly
Number of pregnancies
Placenta location including leading edge
Cardiac function
Placental cord insertion

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5
Q

Definition and management of low-lying placenta

A

<20mm from os
Repeat USS at 34/40
If low-lying and > PAS –> fetal med reivew

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6
Q

Risk factors for vasa praevia

A

Velamentous cord insertion
Placenta dysmorphology
Low lying or bilobed placenta
Multiple pregnancy
IVF

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7
Q
A
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8
Q

When to give prophylactic progesterone

A

Hx of spontaneous PTL <34/40
Pregnancy loss from 16/40
Cx length </= 25mm on TVUS from 16-24/40

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9
Q

When to stop PV progesterone

A

34/40

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10
Q

When to do cerclage

A

Cx <25mm
PPROM in prev pregnancy
Hx cervical trauma

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11
Q

Dx and mx PPROM

A

Spec +/- amniosure
Erythromycin 250mg QDSx 10/7
Screen for infection - FBC, CRP, VS, MSU
CTG

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12
Q

When NOT to do cerclage

A

infection
Active PVB
Uterine ctx

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13
Q

When to consider cerclage

A

Between 16-24/40
Dilated cx + unruptured membranes

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14
Q

Management of PTL with intact membranes

A

Suspected labour </=29+6
- tocolysis
- maternal corticosteroids
At 30+
- TVUS for cx length
— >15mm: unlikely PTB
— < 15mm: tocolysis and steroids

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15
Q

Use of fetal fibronectin

A

Likelihood of birth within 48 hours
+= tocolysis and steroids

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16
Q

Considerations for tocolytics

A

Consider:
- suspected/ dx labour
- gestational age
- likely benefit of corticosteroids
- NICU availability
Consider nifedipine 24 - 33+6 if intact membranes and suspected PTL
Oxytocin receptor antagonists if nifedipine contraindicated

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17
Q

When to give maternal corticosteroids

A

Offer 24 - 35+6
Consider single repeat dose if <34/40
- already had corticosteroids > 7/7 ago AND
- very high risk birth
Do not give more than 2 doses for PT babies

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18
Q

When to use MgSO4 in PTL

A

23 - 23+6 and delivery within 24 hours
Offer from 24 - 29+6 if established PTL or planned PTB within 24 hours
Consider from 30 - 33+6 if established PTL or planned PTB within 24 hours

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19
Q

Dosing of MgSO4

A

4g IV bolus over 5 minutes then 1g/hr until birth or for 34 hours
* if oliguric or renal failure, monitor Mg

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20
Q

Invasive fetal monitoring in PTL

Study These Flashcards
A

Do not use FSE <34/40
Can use FSE if 34+0 - 36+6
Do not use FBS < 34/40

21
Q

High risk patients for PTL

Study These Flashcards
A

Prev PTL
Prev cone biopsy, multiple LLETZ procedures
Prev fully dilated section
Short cx/ open cx at anatomy scan
Mid trimester ROM
Third trimester ROM

22
Q

Incidence of PPROM

Study These Flashcards
A

2% pregnancies
40% of PTL

23
Q

PPROM complications leading to NND

Study These Flashcards
A

Prematurity
Sepsis
Pulmonary hypoplasia

24
Q

Signs of chorioamnionitis

Study These Flashcards
A

Maternal tachy
Pyrexia
Leucocytosis
Uterine tenderness
Malodourous PV discharge
Fetal tachy
Labs: raised WCC, CRP

25
Ix in PPROM
SSE +/- amniosure to dx/ confirm Weekly FBC and HVS Fetal monitoring USS Home monitoring can be considered after 72 hours observation - twice daily temp checks
26
Management of PPROM
Erythromycin 250mg QDS x 10/7 Steroids if 24-34/40 If chorio suspected- broad spectrum IV ab to cover GBS, E coli, listeria, anaerobes - co-amox not recommended d/t risk of NEC - Delivery Consider delivery after 34/40, no later than 36+6 - increased risk of chorio - decreased risk of resp problems
27
Risk factors for PAS
Prev CS (7x inc risk) Increased risk with more CS (67% w 4+ CS) Uterine surgery - myomectomy, D&C AMA ART Placenta praevia and CS
28
Maternal morbidity assoc w. PAS
MOH Median loss >2000ml 80% require RCC
29
Incidence of PAS
1 in 2000 pregnancies
30
Diagnosis of PAS
Clear documentation of placenta site at anatomy scan if prev CS Suspicious features --> US by fetal medicine Standardised reporting for PAS ultrasound features MRI for suspicious USS
31
2D grayscale features suspicious for PAS
Loss of clear zone - loss/ irregularity of hypoechoeic plane in myometrium under placental bed Abnormal placenta lacunae Bladder wall interruption Myometrial thinning - myometrium overlying placenta <1mm or undetectable Placental bulge - deviation of uterine serosa away from expected plane Focal exophytic mass - placental tissue breaking through serosa and extending beyond it
32
2D colour doppler features of PAS
Uterovesical hypervascularity Subplacental hypervascularity Bridging vessels - often perpendicular to myometrium, extend from placenta across myometrium and beyond serosa Placental lacunae feeder vessels
33
3D USS +/- doppler features of PAS
Complex irregular arrangement of numerous placental vessels, exhibiting tortuous courses and varying calibres
34
Antenatal care of PAS
MDT: fetal med, anaestetics, surgeon w expertise in complex pelvic surgeries (onco-gynae) ? PAS <24/40 - review at 24/40 ? PAS > 24/40 - review within 7/7
35
Outpatient ANC for PAS
Suitable for PAS with no bleeding Clearly documented delivery plan in chart Routine FBC Small risk of FGR - US for growth at 28, 32 and 34/40 Physio referral Antenatal eduction
36
Delivery considerations in PAS
If recurrent APH, admit until delivery, XM available Delivery at 34 - 36+6 (individualised) Consent with senior Decision for hyst vs conservative: MDT decision; consider woman's preference, severity and surgical expertise IR on case-case basis Aortic balloon
37
Postnatal considerations in PAS
VTE Fe 6/52 if anaemic antenatally Physio PNMH Debrief at 6/52 Specimen for pathology to be reported as per FIGO Final histo r/v at MDT
38
Risk factors for placenta praevia
Prev CS (incr w number of CS) sTOP Multiple pregnancy AMA Smoking ART Deficient endometrium: MROP, endo, curettage, fibroids
39
Diagnosis placenta praevia
low lying: <20mm from internal os on TV or TA USS after 16/40 Covering os = praevia
40
Complications of placenta praevia
Maternal: - anaemia - infection - mat shock - coagulopathy - incr hospital stay - psych trauma - blood transfusion Fetal: - hypoxia - SGA/ IUGR - prematurity (SOL/ iatrogenic) - fetal death
41
DDx APH
Abruption Praevia Vasa praevia Ca cxS
42
Screening for placenta praevia
Placental localisation at anomaly scan Low-lying at anomaly --> rpt at 32/40 Still low-lying at 32/40 --> TVUS at 36/40 if no PVB
43
Ix if ? praevia
SSE USS: placenta location, FH FMH: Kleihauer CTG
44
Management placenta praevia if active bleeding
MDT Admit, consider d/c if no bleeding for >48 hours IV access, bloods, G+XM, coag +. fibrinogen USS SSE Dexa if <34/40 MgSO4 if <32/40 +/- antiD
45
Delivery of placenta praevia
Hx bleeding: 34- 36+6 No bleeding: 36 - 37 Deliver in unit w onsite transfusion service Senior obs and anaesthetics present Rapid infusion and warming devices available Consider vertical skin +/- uterine. if transverse lie to avoid placenta, esp <28/40
46
Placenta praevia grades
Minor: - 1. Low lying, not reaching os - 2. reaches os, doesn't cover Major: - 3. Covers int os asymmetrically - 4. Covers internal os symmetrically
47
Teratogenic drugs
TERATOWA T- Thalidomide, Tobacco E- Epileptic meds (valproate, phenytoin) R - Retinoids (vit A, tretinoin, isotretinoin) A- ACE inibitors, ARBs T- The third element, lithium O- oral contraceptives, hormones W- Warfarin A- Alcohol
48

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