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Antenatal Care Flashcards

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1
Q

PACES: Pre-pregnancy counselling for people with epilepsy

A

Aim for monotherapy where possible and emphasise the importance of maintaining good compliance
High dose folic acid (5 mg OD)
Provide advice about the risk of congenital malformations

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2
Q

What AED should be avoided in all girls and women of child bearing age?

A

Sodium valproate is highly teratogenic so should be avoided in all girls and women of child-bearing age

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3
Q

What are antiepileptic drugs associated with an increased risk of?

A

Neural tube defects
Cleft palate
Congenital heart defects

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4
Q

Safest AEDs in pregnancy

A

Lamotrigine
Levetiracetam
Carbamazepine

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5
Q

Can you breastfeed with AEDs in pregnancy?

A

Yes, all are safe

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6
Q

Differentials for seizures in pregnancy

A

Eclampsia
Intracranial infection (e.g. encephalitis)
Space-occupying lesion
Cerebrovascular accident
Thrombotic thrombocytopaenic purpura
Overdose
Metabolic abnormalities (e.g. hypoglycaemia)

NOTE: NOTE: it is important to be wary of other causes of seizures in pregnancy even if a patient has a background of epilepsy

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7
Q

What is sampled in chorionic villus sampling?

A

Foetal trophoblast cells

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8
Q

What route is chorionic villus sampling done via?

A

transabdominal or transvaginal route

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9
Q

What is chorionic villus sampling associated with?

A

small risk of miscarriage

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10
Q

When is chorionic villus sampling done in comparison to amniocentesis?

A

Can be performed earlier in the pregnancy than amniocentesis

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11
Q

What is amniocentesis?

A

Amniocentesis involves passing a needle into the amniotic sac and aspirating around 15-20 mL of fluid that contains these cells

NOTE: The amniotic fluid contains amniocytes and fibroblasts that have shed from the foetal membranes, skin and genitourinary tract

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12
Q

What is cordocentesis?

A

Involves passing a needle into the umbilical cord and sampling some foetal blood
Usually used in suspected severe foetal anaemia and thrombocytopaenia

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13
Q

Risk of amniocentesis

A

Associated with a small risk of miscarriage

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14
Q

Risk of cordocentesis

A

Associated with a risk of miscarriage

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15
Q

Prenatal genetic test with biggest risk of miscarriage

A

cordocentesis

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16
Q

Only prenatal genetic test with no risk of miscarriage

A

Cell-free foetal DNA (cffDNA)

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17
Q

When is cordocentesis typically used?

A

Usually used in suspected severe foetal anaemia and thrombocytopaenia

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18
Q

What is cell-free foetal DNA?

A

Foetal DNA is extracted from a maternal blood sample
It may be used to determine the foetal blood group and Rhesus status and to determine the sex of the foetus

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19
Q

What is cell-free foetal DNA typically used for?

A

used to determine the foetal blood group and Rhesus status and to determine the sex of the foetus

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20
Q

Safest prenatal genetic test

A

Cell free foetal DNA

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21
Q

Most dangerous prenatal genetic test

A

Cordocentesis - biggest risk of miscarriage

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22
Q

What is Haemolytic disease of the newborn?

A

Haemolytic disease of the newborn caused by the generation of maternal antibodies against RhD antigen on foetal red cells.

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23
Q

Pathophysiology of HDN

A

If the barrier between the circulations of a RhD-negative mother and a RhD-positive baby is breached, it can sensitise the maternal immune system against RhD.
The initial antibodies produced are IgM, which cannot cross the placenta and, so, do not cause any issues during the initial pregnancy.
IgG antibodies will be produced later as the immune response matures.
If the mother becomes pregnant with another RhD positive foetus, the IgG antibodies will then be able to cross the placenta, destroy foetal red cells and cause severe foetal anaemia (resulting in hydrops fetalis).

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24
Q

What are initial antibodies produced in HDN?

A

IgM

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25
What are the mature antibodies produced in HDN that are able to cross the placenta?
IgG
26
What does HDN lead to?
Hydrops fetalis
27
Examples of sensitising events
Invasive prenatal diagnosis (e.g. amniocentesis) Antepartum haemorrhage External cephalic version Ectopic pregnancy Surgical evacuation of molar pregnancy Intrauterine death or stillbirth Miscarriage after 12 weeks' gestation Surgical termination of pregnancy
28
What is management of HDN?
Anti-D Immunoglobulin
29
How does Anti-D Immunoglobulin work?
Works by destroying foetal red cells within the maternal circulation before the maternal immune system has a chance to generate antibodies against the RhD antigen
30
Indications for anti-D immunoglobulin
Antepartum Haemorrhage Abdominal Trauma in Pregnancy Amniocentesis or Chorionic Villus Sampling Surgical Management of Ectopic Pregnancy Surgical Management of Miscarriage Evacuation of Molar Pregnancy All RhD-negative Women Undergoing Termination of Pregnancy External Cephalic Version
31
What is Kleihauer test?
Used in some situations to measure the extent to which foetal blood mixed with the maternal circulation This allows titration of the dose of anti-D immunoglobulin
32
Who is routine anti-D immunoglobulin given to?
Given to RhD-negative women at 28 weeks' gestation (and may also be given at 34 weeks' gestation
33
How many antenatal appointments are there typically during pregnancy?
10 visits in all FIRST pregnancies if uncomplicated 7 visits in subsequent pregnancies if uncomplicated
34
What tests are offered at antenatal booking?
Ultrasound Scans Dating Scan: 10-14 Weeks Measures crown-rump length to determine gestational age and to establish estimated delivery date Measures nuchal translucency as part of antenatal screening Anomaly Scan: 18-21 Weeks Determine placental site Blood Test Screen Infections: HIV, Hepatitis B and Syphilis Haemoglobinopathies: Sickle Cell Disease and Thalassemia Establish RhD status
35
When is the dating scan done? what is it for?
Dating Scan: 10-14 Weeks Measures crown-rump length to determine gestational age and to establish estimated delivery date Measures nuchal translucency as part of antenatal screening
36
When is the anomaly scan done? What is it for?
Anomaly Scan: 18-21 Weeks Determine placental site
37
What is screened for in the blood test screen in antenatal booking?
Infections: HIV, Hepatitis B and Syphilis Haemoglobinopathies: Sickle Cell Disease and Thalassemia Establish RhD status
38
What infections are screened for in antenatal booking?
Infections: HIV, Hepatitis B and Syphilis
39
What haemoglobinopathies are screened for at antenatal booking?
Haemoglobinopathies: Sickle Cell Disease and Thalassemia
40
What must be established at antenatal booking?
RhD status
41
PACES: Key questions to ask at booking visit
Last Menstrual Period Any previous pregnancies (incl. Miscarriages) Past medical and surgical history Ethnic origins of patient and partner (screen for inherited conditions and gain understanding of cultural factors affecting pregnancy) Employment of patient and partner Current living situation How the patient is feeling about the pregnancy
42
PACES: Common Sx in pregnancy
Nausea   Heartburn   Constipation   SOB   Dizziness   Swelling   Backache   Abdominal discomfort   Headache
43
PACES: Risks of smoking in pregnancy
FGR Preterm labour   Placental abruption   Intrauterine foetal death   Provide support through smoking cessation programmes  
44
PACES: Advice regarding diet in pregnancy
DO NOT eat for two - maintain normal portion side and try avoid snacking Recommend high fibre foods (oats, beans, lentils, grains) Base meals on starchy substances (potatoes, bread, pasta, rice) Restrict intake of fried food and high sugars
45
PACES: Advice regarding exercise in pregnacny
Aerobic and strength conditioning is safe to continue and may help recovery after delivery and improve overall wellbeing Avoid contact sports Pelvic floor exercises can reduce risk of incontinence
46
PACES: Advice regarding breastfeeding
Recommend initiation of breastfeeding within an hour of birth  Recommend exclusive breastfeeding for the first 6 months  Can continue breastfeeding up to 2 years of age Early education about breastfeeding is advocated to improve uptake and to engage women with breastfeeding services
47
Options for delivery
Home birth Midwifery units or birth centres Hospital birth centres
48
Advantages about home birth
ADVANTAGES: familiar surroundings, no interruption of labour to go to hospital, no separation from family members, continuity of care  
49
Disadvantages of home birth
DISADVANTAGES: 45% of first-time mothers are transferred to hospital, poor perinatal outcome is twice as likely for home births, limited analgesic options  
50
Advantages of midwifery units or birth centres
ADVANTAGES: continuity of care, fewer interventions, convenient location  
51
Disadvantages of midwifery units or birth centres
DISADVANTAGES: 40% of nulliparous women require transfer to a hospital birth centre, limited access to analgesic options  
52
Advantages of hospital birth centre
ADVANTAGES: trained personnel and facilities available to manage any potential complications
53
Disadvantages of hospital birth centre
DISADVANTAGES: lack of continuity of care, greater likelihood of intervention 
54
Summary of antenatal appointments
55
How is trisomy 21 screened for in pregnancy?
First trimester - combined test Second trimester - quadruple test
56
What is the combined test for? when is it offered?
for trisomy 21 screeening,Offered from 11+3 to 13+6 weeks
57
What is in the combined test?
Nuchal Translucency (NT) Increased in trisomy 21 Maternal b-hCG and PAPP-A Trisomy 21 is associated with high b-hCG and low PAPP-A GET INCREASED B-HCG AND NUCHAL TRANSLUCENCY, LOW PAPP A
58
What is the quadruple test for? When is it offered?
Screening for trisomy 21, Offered from 14-20 weeks
59
What is in the quadruple test?
a-Fetoprotein - low b-hCG - high Unconjugated Oestriol - low Inhibin A - high
60
Mnemonic to remember trisomy's screened for in prengnancy
61
trisomy 13
patau
62
trisomy 18
edward
63
trisomy 21
down's
64
What further test may be offered if a pregnancy is deemed as being at high risk of trisomy 21 upon screening?
Chorionic Villous Sampling Offered at 11-15 weeks Associated with a small risk of miscarriage Amniocentesis Offered at over 15 weeks Associated with small risk of miscarriage Cell Free Foetal DNA Not associated with any risk of foetal harm as it involves taking a peripheral blood sample from the mother
65
When is chorionic villus sampling offered to test for down's?
Offered at 11-15 weeks, If a pregnancy is deemed as being at high risk of trisomy 21 upon screening NIOTE: Associated with a small risk of miscarriage
66
When is amniocentesis offered to test for down's?
Offered at over 15 weeks, If a pregnancy is deemed as being at high risk of trisomy 21 upon screening NIOTE: Associated with a small risk of miscarriage
67
What test can be done to test for down's that offers no risk to foetus? Why?
Cell Free Foetal DNA Not associated with any risk of foetal harm as it involves taking a peripheral blood sample from the mother
68
When are those with SLE advised to get pregnant?
after their disease has been inactive and stable on treatment for over 6 months
69
Effect of pregnancy on SLE
no increased risk of flares
70
Effect of SLE on mother in pregnancy
Increased risk of miscarriage Increased risk of pre-eclampsia
71
Effect of SLE on foetus in pregnancy
Increased risk of stillbirth Increased risk of IUGR Increased risk of preterm delivery Neonatal lupus syndrome Congenital heart block
72
SLE medications that are safe for conception in pregnancy
Safe: Hydroxychloroquine, Azathioprine
73
SLE medications that are unsafe for conception i pregnancy
Ensure good disease control prior to conception (aiming for at least 6 months without flares before attempting to conceive)
74
Baseline investigations for SLE in pregnancy
Renal Function (lupus nephritis is particularly strongly associated with poor pregnancy outcomes) Anti-dsDNA Blood Pressure Quantification of Proteinuria Anti-Ro and Anti-La antibodies (associated with congenital heart block)
75
What medication is reccomended for SLE in pregnancy? Why
Recommend aspirin from 12 weeks' onwards to reduce the risk of pre-eclampsia
76
What are mothers with SLE in pregnancy at increased risk of? How do we treat this?
Pre-eclampsia, reccomend aspirin from 12 weeks onwards
77
What additional scans to offer for SLE in pregnancy?
Offer growth scans at 28, 32 and 36 weeks' gestation
78

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