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Flashcards in Antenatal Care Deck (34):
1

Common modes of inheritance

Autosomal D/r

X-linked D/r

Codominant

Mitochondrial

2

3 commonest severe congenital abnormalities

Heart Defects

Neural Tube Defects

Downs

3

4 General considerations for perscribing in pregnancy

1) Pre-pregnancy counselling optimises medication

2)Balance risk to fetus with benefit to mother

3)Assess on individual basis, give information so that an informed decision can be made

4)LOWEST POSSIBLE DOSE FOR SHORTEST TIME POSSIBLE

4

3 Physiological changes in pregnancy relevant to perscribing

Affects distribution

1) Increase in total body water

2)Increase in fat stores

Affects metabolism

1)Increaase in cardiac output

5

Pharmokinetic changes in pregnancy

Absorption

  • Dec due to n & v (nausea + vomiting)

Distribution

  • Inc plasma volume
  • Dec plasma binding

Metabolism

  • Cyt P450 induction
  • Increase eGFR

Elimination

  • No change

Generally dec drug conc due to haemodilution, inc distridution + metabolism

6

Teratogenic drugs in pregnancy

Thalidomide

Diethylstilboestrol (used in breast and prostate cancer and recurrent miscarriage)

Warfrin

Phenytoin

Lithium

Methotrexate

Testosterone

Progesterone

Valproate

Benzodiazopine

Most anti-psychotics except: quetiapine, olanzapine, or risperidone

All AED except (Lamotrogine + levetricetam)

7

Time line of antenatal screening

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8

What happens at a booking appointment

First contact with midwife

  • Information gathered
    • General info taken (name, age gestation)
    • Risk assessed (obs hx, drug use, domestic abuse, PMH, )
    • Baseline obs taken - BP, temp, weight
  • Bloods taken - Hb, iron, rhesus, blood group, downs, spina bifida, HIV, syphillis, thalasaemia, Hep B, 
  • Urine dip
  • Information given
  • Pregnancy plan initiated

9

Standard antenatal screening offered to women

8-12 weeks - Bloods for infectious disease Syphilis, Hep B + HIV (usually done at booking apt)

>10 weeks - Bloods for Sickle and Thalesaemia (usually done at booking apt)

10 weeks - Booking appointment

10-14 weeks - Combined test Bloods for T21 (downs), T18 (edwards) and T13 (Pataus)

11-14 weeks - Dating scan and early anomoly scan (the same scan aka Nuchal Translucency), supports combined test and looks for other defects

14-20 weeks - Quadruple test Bloods for T21 and spina bifida (not offered to everyone)

18-21 weeks - Anomoly scan detailed USS for structural abnormalities incl T18 T21, supports quadruple bloods

 

 

 

10

Main reasons to be CLC

  1. <16/>40 years
  2. Grand multip >6
  3. >35 BMI
  4. Won't take blood products
  5. Cervial suture/LLETZ
  6. HTN
  7. Familial genetic abnormalities
  8. Drug user
  9. Alcoholic
  10. STI e.g. herpes
  11. If only risk is smoking MLC, but need serial growth scans in 3rd trimester
  12. Pre-eclampsia
  13. Gestational diabetes
  14. Shoulder distocia
  15. 3/4th degree tear
  16. Previous C section
  17. Epilepsy
  18. Multiple pregnancy
  19. Antepartum haemorrhage
  20. Recurrent UTI

full list at: https://www.nuh.nhs.uk/handlers/downloads.ashx?id=62572

11

Aim of screening

Monitor normal pregnancy

Identify complicated pregnancy

Identify risks and requirements of mother and fetus

12

Risks of and management of VBAC

Risks

  • 0.5% scar dehiscence
  • Think about future pregnancies, no  more than 3 c-sections recommended + risk of placenta accreta 
  • Emergency c-section

Management

  • CLC
  • Counsell for risks before (70% successfull)
  • Should be done in hospital access to c-section
  • Pain between contractions can indicate rupture
  • Continuous CTG
  • Maternal pulse changes can indicate rupture
  • Check for bleeding can indicate rupture
  • Induction caries 1.5 increase risk of rupture

 

13

Risks of and management of Group B strep infection

Risks (fetal)

  • Septicaemia
  • Pneumonia
  • Meningitis

Management

  • Intrapartum antibiotic prophylaxis (IAP)
  • If in urine given treatment at time of diagnosis not indicated for vaginal/rectal
  • IAP not needed in c-section if membranes have not ruptured
  • Once membranes ruptured induction is recommended at 37w

14

Risks of, risks for and management of breech

Risks for

  • High parity
  • Uterine/pelvic abnormalities 
  • Previous breech
  • Placenta abnormalities
  • Fetal abnormalities
  • Multiple pregnancy
  • Low birth weight/pre-term
  • Polyhydramnious
  • Space occupying lesion

Risks of 

  • Cord Prolapse
  • Hypoxia to baby
  • Head entrapment

Managment

  • Counsell mother with risks + create a birth plan
  • Terms breech trial says planned c-section has better outcomes, recent studies conflict. Green top says women should be told c-section has small decrease in perinatal mortality but vaginal is better for mum + normal counselling for c-section and vaginal birth Re-read green top http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.14465/full
  • ECV (check contraindications)
  • Labour in hospital access to c-section
  • Induction not recommended
  • Continuous CTG
  • Consider c-section if descent is delayed in 2nd stage of labour
  • If 2nd twin = breech can do total breech extraction

15

Types of breech, best and worst

  1. Frank/extended breech- crossed legs next to ears
  2. Complete breech-crossed legs above buttock
  3. Footling breech-presenting part is foot WORST

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16

Contraindications and risks of ECV

Contraindications

  • Preterm
  • Multiple pregnancy
  • Significant third trimester bleeding
  • IUGR
  • Oligohydramnion
  • PROM
  • PIH(pregnancy induced HTN)/PET
  • Nonreassuring foetal monitoring patterns
  • All contraindications to vaginal birth

Risks

  • Umbilical cord entanglement
  • Abruptio placenta
  • Premature rupture of the membranes (PROM)
  • Severe maternal discomfort
  • Doesn't work

17

Complications of breech that contraindicate vaginal birth

  1. Hyperextended neck on ultrasound.
  2. High estimated fetal weight (more than 3.8 kg)
  3. Low estimated weight (less than tenth centile).
  4. Footling presentation.
  5. Evidence of antenatal fetal compromise.

  6. Normal contraindications to vaginal birth

18

Risk of and management of epilepsy in pregnancy

Risks

  • SE of medication (valproate, phenytoin, phenobarbitone)
  • Increase risk of seizure: tiredness, stress, labour + stopping meds
    • Risks to mum
      • Falls

      • Trauma

      • Possible brain injury

      • Lack of freedom e.g. driving

      • Death (SUDEP)

    • Risks to baby

      • Hypoxia

      • Trauma

      • Lactic acidosis

      • Placental abruption

      • Miscarriage

      • Preterm labour

      • Premature birth

Management

  • CLC
  • Pre-conception counselling
  • Monotherapy, least effective dose, not valproate, phenytoin, phenobarbitone. Preferably lamotrogine + levetracitam
  • High dose folic acid 5mg PO/day
  • Good pain control in labour

19

Risks for, of and mangement of multiple pregnancy

Risks for having multiple pregnancy

  • FH
  • Advanced age
  • IVF

Risks of having multiple pregnancy

  • Anaemia
  • PET
  • Assisted deliver/c-section
  • PPH
  • Premature birth
  • IUGR
  • Twin-to-twin transfusion syndrome

Management

  • CLC
  • DCDA USS every 4 weeks
  • MCDA/MCMA USS every 2 weeks after 16w

20

Types of twins

Dichorionic diamniotic DCDA - two placentas, two chorions, two amniotic sacs

Monochorionic diamniotic MCDA(identical) - one placenta, one chorion, two amniotic sacs

Monochorionic monoamniotic MCMA - one placenta, one chorion, one amniotic sac

21

Layers of placenta

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22

Aetiology of, risks for, risks of and management of pre-eclampsia

Aetiology

  1. Absence of secondary trophoblastic invasion of placenta
  2. Therefore thin, elastic spiral aa's are not converted to high vol, low resistance aa's
  3. Leads to IUGR + eclampsia 
  4. Only cure is to remove placenta (and hopefully baby)

Risks for PET

  • Primip/new partner
  • Diabetic
  • Multiple pregnancy
  • Previous PET
  • HTN
  • CKD
  • <16/>40
  • Family history
  • BMI >30

Risks of PET

  • DIC/HELLP syndrome
  • High BP, causes a lot of these
  • CVA
  • Renal nephropathy
  • IUGR
  • Eclampsia (convultions)

Management

  • CLC
  • Admit to assess severity, consider outpatient if mild/moderate
  • Monitor BP, urine, symptoms, fetal movements, epigastric pain/vomiting
  • Control BP, seizures (anti-hypertensives + magnesium sulphate)
  • Plan delivery date + method based in stability
  • Post partum fluid management

 

23

Causes of, risks of and management of antepartum haemorrhage

APH is classed as bleeding after 24w

Causes of APH

  • Placenta abruption
  • Placenta previa
  • Local causes (vagina, vulva)
  • Unexplained

Risks of APH

  • Pre-term delivery
  • Infection
  • Anaemia
  • Fetal hypoxia
  • IUGR

Management of APH

  • Woman should report to their care provider e.g. midwife
  • Admit for assessment
  • If severely compromised: acute appraisal + resus prioritise mother
  • Take full history: pain, extent of bleeding, cardiovascular state of mother, risk factors for possible causes, smear history, rupture of membranes +  fetal wellbeing
  • Examination: Auscultate fetal heart, maternal pulse, mat. BP, abdo palpation, speculum, VE
  • Investigations: USS, rhesus status, FBC, co-ag screen, u+e, LFT, group + save, CTG
  • All women with bleeding more than spotting should remain in hospital until bleeding has stopped

24

Risks for Placenta abruption

  • Tobacco
  • Cocaine
  • Amphetamine
  • Previous abruption
  • Pre-eclamp
  • IUGR
  • Prematue ROM
  • Trauma/domestic violence

25

Risks for placenta previa

Can't have VEs, PR and sex

  • Previous placenta previa
  • Previous c-section
  • Previous TOP
  • Multip
  • >40 yrs
  • Multiple pregnancy
  • Smoking

 

26

Causes of, risks for, risks of and mangaement of UTI in pregnancy

Causes 

  • Growing uterus puts pressure on bladder = stagnant urine

Risks for

  • Sex
  • Anatomy anomaly
  • Catheter
  • Pregnancy

Risks of 

  • Recurrent UTI
  • Acute pyelonephritis
  • Kidney damage
  • Sepsis
  • Prematurity
  • SFD baby
  • Mental retardation
  • Developmental delay
  • Miscarriage

Management

  • Fluids
  • Antiobiotics: penicillins and cephalosporins e.g. Cephalexin, Ampicillin

 

 

27

Risks for, risks of and managment of DVT in pregnancy

Risks for (see pictures)

  • Previous VTE
  • Thrombophilia
  • Several co-morbidities

Risks of

  • Embolism (PE, stroke, MI)

Management

  • Score >4 consider thromboprophylaxis from first trimester. If 3 consider from 28 weeks. If 2 or under consider for 10 days. Consider if admitted to hospital. 
  • Diagnosed with history and ultrasound
  • Treated urgently with Low Molcular Weight Heparins e.g. enoxaparin until proven to not be DVT

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28

Risks for, risks of and management of 3/4th deg tears

Risks for

  • Primip
  • South asain ethnicity
  • Prolonged second stage labour
  • Assisted delivery
  • LFD baby
  • Previous tear

Risks of 

  • Infection
  • Incontinence

Management

  • Pain relief
  • Repair
  • Give antibiotics
  • Laxatives

29

Stages of labour

First stage

  • Cervix going from 0-10
  • Last 6-36 hours
  • Established labour: contractions are 5 mins apart and last at least a minute

Second stage

  • Baby going down birth canal and being born
  • Lasts 30 mins-hour (epidural slows it)
  • This is the pushing part

Third stage

  • Placenta delivery, two methods
  • Physiological management: wait for it to come out naturally, can take up to an hour, breast feeding helps
  • Active management: given syntoncinon in leg as shoulders are delivered, to help placenta seperate and decrease blood flow

30

Difference between syntocinon, ergometrine and syntometrine

Syntocinon

  • artificial oxytocin
  • Can be given IV for induction of labour, PPH prevention or established and incomplete, inevitable or missed miscarriage
  • Intramuscular for active management of third stage of labour (unliscenced)

Ergometrine

  • Ergot alkaloid works non-specifically as 5-HT agonist and vasoconstrictor
  • Used to prevent PPH (generally with syntroncinon i.e. oxytocin as syntometrin) and for active management of third stage of labour
  • Can't be used in women with hypertension/pre-eclampsia

Syntometrine

  • Combo of syntocinon and ergometrine
  • Prevention of PPH, active management of third stage of labour and bleeding due to incomplete abortion/miscarriage
  • Can't be used in hypertension/pre-eclampsia

31

Risks for, risks of and management of anaemia in pregnancy

Risks for

  • Mulitple pregnancy
  • Excessesive vomiting
  • Young or old maternal age
  • Anaemia before pregnancy
  • Bad diet

Risks of

  • Preterm
  • SFD baby
  • Blood transfusion
  • Post partum depression
  • Folate deficiency = neural tube defects
  • Increased susceptibility to infection
  • PPH

Managment

  • All women screened at booking and 28 weeks
  • Dietry advice should be given to all
  • If <110 Trail iron for diagnostic and therapeutic reasons check in three weeks if unsuccessfull check serum ferritin and refer to consultant obstetrician
  • If <90 higher dose of iron and refer to obstetrician if symptomatic
  • If <70 refer urgently to obstetrician, offer transfusion if actively bleeding/symptomatic
  • If uncontrolled at delivery decrease risk of bleeding: CLC, IV access, group and save, active third stage labour, prompt management of PPH, prophylactic syntoncinon infusion

32

Aetiology of, risk for developing, risks of and management of gestational diabetes

Aetiology

  • Body is not able to produce suffiecient insulin to keep up with pregnancy demands

Risks for developing

  • BMI >30
  • Previous >4.5 kilo baby
  • Previous gestational diabetes
  • FH diabetes

Risks of 

  • LFD baby therefore increased risk of induction, instrumental and c-section
  • Polyhydramnios
  • Premature birth
  • Pre-eclampsie
  • Neonate jaundice and hypoglycaemia
  • Still birth

Management

  • Screened at 18-12 weeks 
  • If at risk/random glucose in urine will be ofered oral glucose tolerance test
  • Fasting >5.6 or 2 hour >7.8
  • Review in antenatal/diabetic clinic within a week
  • Educate: implication of diagnosis, importance of control, how to self-test, diet and excersice.
  • Use same glucose targets as for non-pregnant diabetics 
  • Refer to dietitian
  • If diet and excerise doesn't make targets in 1-2 weeks offer metformin
  • If metformin contra-indicated/unacceptable offer insulin
  • Use a mix of diet, exercise, metformin and insulin to women who are difficult to control
  • If metformin doesn't work and woman can't/won't take insulin offer glibenclamide
  • CARE IS VERY DIFFERENT IF YOU ALREADY HAVE DIABETES SEE https://www.nice.org.uk/guidance/ng3/chapter/1-Recommendations#gestational-diabetes-2 

33

Risks of and management of high BMI in pregnancy

Risks of high BMI in pregnancy

  • Gestational diabetes
  • Pre-eclampsia
  • Sleep apneoa 
  • Miscarriage
  • Neural tube defects
  • Macrosomia
  • Stillbirth
  • Preterm birth
  • Anaesthetic complications
  • VTE
  • Slow labour progression
  • Shoulder distocia
  • PPH

Management

  • Asses VTE, pre-eclampsia, gestational diabetes risk
  • Counsell risks high BMI posses
  • Counsell how to decrease said risks
  • CLC during labour

 

34

contraindication to vaginal birth

  1. Cephalopeliv disproportion
  2. Brown presentation
  3. Cord/limb prolapse
  4. Untreated HIV
  5. Severe space occupying lesion
  6. High birth weight
  7. Placenta previa
  8. Persistent fetal distress
  9. High number c-sections
  10. Maternal distress
  11. Active herpes
  12. Failure to progress
  13. Acreta