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Antenatal Care Flashcards

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1
Q

Give 2 gynae symptoms and 3 signs of pregnancy before 12 weeks

A
  • AMENORRHOEA

Breast engorgement + nipple darkening

Vulva becomes more vascular

Cervix softens

Uterine body is more globular

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2
Q

Give a GI symptom of pregnancy BEFORE 12 weeks

A

Nausea and vomiting

Significantly more/hyperemesis = scan around 8 weeks to check for twins or molar pregnancy

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3
Q

Give 4 minor GI symptoms of pregnancy AFTER 12 weeks

A

Nausea and vomiting!

Abdominal Pain

Constipation

Reflux/Heartburn

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4
Q

Why do you become constipated during pregnancy and what is the management?

A

Decrease in gut motility due to mass or increased progesterone.

Don’t give stimulant laxatives as can increase uterine activity.

Ensure adequate fluid intake i.e. more lifestyle but can lead to haemorrhoids/varicose veins

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5
Q

Why do you get reflux in pregnancy? What is the management?

A

Fundus of the uterus presses on UGIT and + increase in progesterone relaxes the pyloric sphincter.

Give Ranitidine or Rennies.

Avoid smoking, spicy food and use more pillows so can sit up.

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6
Q

Give 3 MSK symptoms of pregnancy

A

Backache

Pubic symphysis dysfunction - pain as pelvic ligaments and muscle relaxation

Cramp

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7
Q

Give 4 other minor symptoms of pregnancy

A

Ankle Oedema
- - venous return
Check BP and urine dip (?pre-eclampsia)
Check for DVT

Urinary Frequency
Baby’s head presses on bladder (later on)
++ GFR and ++ urinary output - make sure it’s not a UTI

Breathlessness
Fundus of the uterus = - - space for lungs. Make sure it’s not a VTE

Headache +/- palpitations +/- fainting
Dilation of peripheral circulation due to + + progesterone
May also feel hot n sweaty

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8
Q

What is the naegele rule?

A

How to calculate the due date ASSUMING THAT the gestational age is 280 days (40 weeks)

Add 1 year. Subtract 3 months. Add 7 days to origin of gestational age.

Example: if LMP was 01/09/2019 then the due date will be 08/06/2020

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9
Q

What are 4 risks of smoking during pregnancy?

A

++ risk of miscarriage

++ risk of placenta problems
implanting in the wrong place (placenta praevia)
Coming away from the wall of uterus before labour (placental abruption)

++ risk of baby not growing enough (foetal growth restriction)

++ risk of going in to labour too soon (preterm labour)

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10
Q

What is the impact of alcohol during pregnancy?

A
  • FAS at high consumption

- Crosses placenta

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11
Q

What are the risks of recreational drug use during pregnancy?

A
  • same as smoking but also risks intrauterine death
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12
Q

What are the nutritional supplements recommended in pregnancy?

A

Folic Acid Supplementation

Vitamin D Supplementation
Darker skin = ++ risk
Limited skin exposure = ++ risk

Avoid Vitamin A
High in liver
Teratogenic

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13
Q

Why is folic acid recommended?

A

Reduces risk of neural tube defects e.g. spina bifida (helps the spinal cord to form properly) and cleft lip

Take 400mcg per day until week 13 (+before conception if trying)

OR take 5mg/day until week 13 if: previous hx, diabetic, Sickle cell disease, obese, on anti epileptics or HIV and on co-trimoxazole

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14
Q

Which foods should be avoided during pregnancy and why?

A

Reducing listeriosis risk

  • ONLY DRINK UHT/pasteurised milk
  • ripened/soft cheese
  • pate
  • undercooked meats

Reducing salmonella risk

  • partially cooked eggs/mayo
  • undercooked meats
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15
Q

Which blood tests are used for screening at booking (10 weeks)?

A
  • FBC (anaemia)
  • Infections (HIV, HEP B, Syphillis
  • Haemaglobinopathy (sickle cell and thalassaemia)
  • Blood grouping and Red Cell alloantibodies
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16
Q

Which USS findings are used for screening at booking? (3)

A
  • Dating:
    CRL if 10-14 weeks
    or head circumference if CRL >84 mm or 14+1-20 weeks

Nuchal translucency - Trisomy 21 screening

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17
Q

Which USS findings are used for screening during the 20 week scan?

A
  • Structural abnormalities
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18
Q

What happens during the week 36 visit?

A

Breastfeeding info

Labour and birth prep + baby position

Vit K prophylaxis

Care of new baby

Post natal self care

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19
Q

What is the triple/combined test?

A

Nuchal Translucency + free B-hCG + pregnancy associated plasma protein + woman’s age between 11 and 13+6 weeks. (USS + Blood test)

Detects 90% of all aneuploides

Results are as a risk factor and 2% of women will be ‘high risk’. They are then offered CVS sampling or amniocentesis.

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20
Q

What is the quadruple test and when can it be offered?

A

Blood test

for late bookers between week 15-20

4.1% false positive

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21
Q

What is amniocentesis and when can it be performed?

A

Aspiration of foetal cells from skin and gut. Needle is put transabdominally and using USS

Done >16 weeks

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22
Q

What are the positives of amniocentesis? (3)

A

can diagnose foetal infections

lower miscarriage rate [than cvs]

can get results in 3 working days for trisomies

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23
Q

What are the negatives of amniocentesis?

A

Done later in pregnancy so less thinking time if considering termination

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24
Q

What is chorionic villi sampling and when can it be done?

A

Take sample from the placenta either transabdominally or transcervically under USS

Done between week 10-13

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25
What are the positives of CVS? (2)
Happens earlier so more time and safer if considering termination. Results within 3 days for trisomies.
26
What are the negatives of CVS? (4)
miscarriage rate is 1-2%, increased risk of BBV transmission false positives. Can’t have if dichorionic multiple pregnancy.
27
Give 6 sensitising events/ events where maternal and foetal blood could mix
Birth Last Trimester ECV Amniocentesis and CVS Termination Late miscarriage
28
When are rhesus groups a problem?
If a Rh - (rr) mother + Rh + (Rr) father Results in an Rh + baby even though mother is Rh - This is not a problem in the first pregnancy but is definitely a problem in subsequent pregnancies.
29
What does incompatible rhesus groups between mother and foetus result in?
Haemolytic disease of the newborn
30
During which sensitisation events does anti-d need to be given?
- ECV - CVS - Amniocentesis - Termination - Miscarriage (unless threatened and before 12 weeks)
31
Why would a Kleihauser test be performed? What is it?
- See if eligible for anti-D | - Measures amount of foetal Hb in maternal supply so that amount of anti-d can be determined.
32
What are the physiological cardiovascular changes that occur during pregnancy?
SV up 30%, HR up 15% & cardiac output up 40% systolic BP is unaltered diastolic BP is reduced in the 1st and 2nd trimester, returning to non-pregnant levels by term enlarged uterus may interfere with venous return which can lead to ankle oedema, supine hypotension and varicose veins
33
What are the physiological respiratory changes that occur during pregnancy?
increase in pulmonary ventilation Increase in oxygen requirements so over breathing leads to a fall in pCO2 - this can give rise to a sense of dyspnoea that may be accentuated by elevation of the diaphragm BMR up 15% (increase in thyroxine and adrenocorticoids)
34
What are the physiological haematological changes that occur during pregnancy?
Increase in blood volume in 2nd half of pregnancy Physiological anaemia due to ↓ Hb but ↑ plasma Increased risk of VTE due to ↓ fibrinolytic activity and ↑ in clotting factors
35
What are the physiological urinary changes that occur during pregnancy?
blood flow increase by 30% GFR increases by 30-60% Salt and water reabsorption is increased by elevated sex steroid levels Urinary protein losses increase
36
What are the physiological biochemical changes that occur during pregnancy?
Increase in calcium requirements esp during T3 Calcium actively transported across placenta so serum conc falls Gut absorption of calcium increases
37
What are the physiological uterine changes that occur during pregnancy?
100g → 1100g hyperplasia → hypertrophy later I ncrease in cervical ectropion & discharge Braxton-Hicks: non-painful 'practice contractions' late in pregnancy (>30 wks)
38
What is the definition of foetal lie?
Relationship between the long axis of foetus and mother
39
What is the definition of foetal presentation?
Part of baby that first enters maternal pelvis
40
What is the definition of foetal position?
Position of foetal head as it enters the birth canal (ideally occipito-anterior). Think of that lady who gave birth really quickly as occipto-posterior and got the third degree tear.
41
What is the most common malpresentation?
Breech where baby is feet/bum first but this normally resolves by week 36 as the baby usually turns to head first by then
42
How is breech presentation diagnosed?
Baby is longitudinal but cannot feel head in the pelvis Smooth round mass @ funds (head) May have pain under ribs USS is gold standard. Have to do to rule out placenta praevia as this is CONTRAINDICATED for breech?
43
What is the management of breech presentations?
ECV if vag delivery is planned and is after 36 weeks If ECV doesn't work then elective c section at 39 weeks
44
What is external cephalic version?
Gentle, firm pressure on the abdomen to move the baby. Uncomfortable and sometimes painful. Works 40% of the time in primips and 60% in multips. Kim Kardashian had one with Saint.
45
What investigations must happen before an ECV?
CTG (and do after) | Maternal HR and BP
46
What are 5 contraindications to ECV/
Diagnosed placenta praevia Uterine scars or abnormalities Abnormal CTG Foetal abnormality Pre-eclapmisa/maternal HTN
47
Should medications be given alongside ECV?
Yes | Anti-D if Rhesus NEGATIVE afterwards
48
What are the risks of ECV? (4)
Might not work/ baby might turn back. Effective in about 40% first time mams and 60% if had baby before. Discomfort. Shouldn’t be painful but will stop if so. Cause some stress to baby Risk of placenta coming away from the wall of the uterus (abruption)
49
What is the definition of rupture of membranes?
Breakage of the amniotic say so that the baby can be born Most women will spontaneously labour 24 hrs after ROM as PGE2 is released = uterine contractions 6% won’t be in spontaneous labour after 96 (!!!) hours and the earlier it is then this is more likely to happen
50
What is the definition of premature rupture of membranes (PROM)?
Rupture of membranes before the onset of uterine contractions/labour
51
What is the definition of pre-term premature rupture of membranes
PROM before 37 weeks of gestation
52
What are 4 causes of PROM?
Cervical incompetence Cerclage (the stitch) Insufficiency (cervix shortens and opens too early) Amniocentesis Infection Chorioamnionitis/inflammation
53
Give 4 maternal risk factors for PROM
- Previous hx of PPROM/ preterm delivery - Uterine irritation e.g. placental abruption - Lifestyle e.g. smoker - Age above 40 or below 20
54
Give 3 uteroplacental risk factors for PROM
- Stretched uterus e.g. multiple pregnancy - Cervical insufficiency - intra-amniotic infection
55
Which investigation should you never do in a lady with PROM?
DO NOT DO A DIGITAL VAGINAL EXAMINATION AS THIS INCREASES RISK OF ASCENDING INFECTION
56
Which investigations should be done to diagnose PROM?
Sterile Speculum Examination - Have a look and see if amniotic fluid is there Nitrazine stick (checks the pH) Can also test for: Insulin-like growth factor binding protein-1 Placental alpha microglobin-1 Foetal fibronectin Don’t use in isolation just help with diagnosis USS - check gestation and liquor volume Foetal monitoring via CTG
57
When should you admit a lady with PROM?
Admit to hospital if PPROM or ascending infection is suspected Need to monitor signs of infection and RFM
58
What is the medical management of PROM?
Abx Prophylaxis: Give to reduce complications of preterm delivery and postnatal infection Erythromycin for 10 days Give BenPen if GBS is isolated IM Betamethasone at 0 and 12h if gestation is between 24-36 weeks
59
When should you deliver the baby in PROM?
``` GBS infection - ascending infection from uterus + can trigger early labour etc. Can also be passed to baby during childbirth. See later. HIV for vag delivery Chorioamnionitis Foetal stress/meconium liquor HSV infection ```
60
What are the maternal, placental complications of PROM?
Abruption Retained placenta PPH, SPH
61
What are the other maternal complications of PROM
- infection endometritis chorioamnionitis
62
What is the relevance of GBS infections in pregnancy?
Ascending infection from birth canal that can lead to preterm birth/PROM/chorioamnionitis or sepsis in the baby
63
What are 5 risk factors of GBS in pregnancy?
previous hx of a baby with GBS current pyrexia ROM for >24 hours Preterm birth suspected chorioamnionitis
64
What is the management of a mother with a history of: A previous baby with GBS or GBS on high vaginal swab ?
Give prophylactic abx BenPen or Cephalosporins
65
What is the management of a mother with PPROM?
give prophylactic abx during labour (infection likely cause)
66
What is the management of a mother with PROM + known GBS?
induction of labour + give prophylactic abx
67
What is the management of a mother with no GBS suspected + intact membranes?
no abx
68
Define obstetric cholestasis
Pruritus during 2nd half of pregnancy Esp on palms and soles of feet Worse at night No rash
69
Give 3 other symptoms of obstetric cholestasis (4)
Insomnia Liver stuff - pale stools/steatorrhoea, dark urine, jaundice Malaise Abdo pain
70
What is the deal with jaundice in obstetric cholestasis?
Unusual If it does happen then it’ll be around 2 weeks after pruritus develops and has quick onset with a rapid plateau. Constant til delivery.
71
What are the differentials of pruritus during pregnancy?
Liver disease - Acute fatty liver disease of pregnancy Hepatitis - viral/autoimmune/drug induced Extra-hepatic obstruction from gallstones
72
What is acute fatty liver disease of pregnancy?
A v rare but serious condition Get abdominal pain, jaundice, headache and vomiting +/-thrombocytopenia and pancreatitis Associated with pre-eclampsia
73
What are the Ix to diagnose obstetric cholestasis?
Liver USS Bloods = LFTs!!! LFTs - measure weekly until delivery Moderately high transaminase V high ALP Increased serum total bile acid x10 Mild bilirubin increase
74
Why is ALP raised in obstetric cholestasis?
Raised anyway in pregnancy from placenta so has to be abnormally high
75
What is the foetal management of obstetric cholestasis?
Increased foetal monitoring
76
What is the maternal management of obstetric cholestasis?
Conservative: - Inform increased risk of: passage of meconium and prematurity - Topical calamine lotion Medical: - Oral vitamin K - Urseodeoxycholic acid
77
What is the role of oral vitamin K in obstetric cholestasis?
Vitamin K is fat soluble and have fat malabsorption in liver disease Vitamin K is needed for clotting and so is protective for PPH
78
What is the role of ursodeoxycholic acid in obstetric cholestasis?
Displaces bile salts and protects hepatocytes
79
What are the maternal complications of obstetric cholestasis?
PPH Liver impairment if lasting several weeks - Reduction in vitamin K reabsorption or decreased PATIENT production = increased prothrombin time
80
What are the foetal complications of obstetric cholestasis?
Intrauterine death Foetal distress Prematurity
81
When should delivery be considered in a patient with obstetric cholestasis?
37-38 weeks ``` Earlier if: Multiple pregnancy Foetal distress Increasing LFTs Serum bile acids >40 mol/l ```
82
How many antenatal appointments should uncomplicated women receive?
10 antenatal visits in the first pregnancy if uncomplicated 7 antenatal visits in subsequent pregnancies if uncomplicated women do not need to be seen by a consultant if the pregnancy is uncomplicated
83
How should chickenpox EXPOSURE be managed in a pregnant lady?
Urgent blood test for varicella antibodies Not immune = give varicella-zoster immunoglobulin asap (can give up to 10 days after exposure)
84
How should chickenpox be managed in a pregnant lady?
Obstetrics referral Oral acyclovir if ?20 weeks and within 24 hours of rash
85
What is the dose of folic acid that should be taken in a normal woman who wants to get pregnant?
400 micrograms to prevent NTD Until 12 weeks
86
What is the dose of folic acid that should be taken in a higher risk woman who wants to get pregnant?
5 milligrams from before conception to 12 weeks To prevent NTD
87
Which women are at higher risk of NTDs?
- Previous Hx, FHx, has coeliac, diabetes or a thalassaemia | - On anti-epileptics,has a BMI of >30
88
Define zygosity
Degree of genetic similarity between a pair of twins
89
Define chorionicity
Number of placentae
90
What are the signs and symptoms of multiple pregnancy?
Uterus is large for dates Hyperemesis Polyhydramnios 2+ poles Multiple foetal parts 2 foetal HR
91
What are the ix to diagnose a multiple pregnancy?
USS at 11-13 weeks - establish chorionicity Get more monitoring as high risk
92
Which chorionicity is the highest risk?
Monochorionic - get scans every 2 weeks from 16 Check for twin to twin transfusion and foetal growth restriction
93
What are the maternal complications of a multiple pregnancy?
Anaemia APH due to bigger placenta Hyperemesis Increased risk VTE
94
What are the foetal complications of a multiple pregnancy?
Twin to twin transfusion syndrome Increased risk prematurity FGR Increased perinatal mortality (vasa praaevia, cord entanglement, malpresentation)
95
What are the complications of a multiple pregnancy during pregnancy?
Polyhydramnios Pre-eclampsia APH Anaemia
96
What are the complications of a multiple pregnancy during labour?
PPH Malpresentation Premature separation of the placenta Cord entanglement - cuts off supply
97
What is twin to twin transfusion syndrome?
Twins that share a placenta and blood vessels = blood can pass from one twin to the other at ~16-25 weeks ``` Recipient = cardiac failure and polyhydramnios Donor = oliguria, oligohydramnios and FGR ```
98
What is the delivery management for uncomplicated multiple pregnancy?
Dichorionic = elective birth @ 37 weeks Monochorionic = elective birth @ 36 weeks Majority need c-section but can do vaginally +/- forceps
99
Which women need prophylactic antibiotics to prevent GBS and which abx would you give?
Previous Hx GBS sepsis GBS on high vaginal swab (give intrapartum) PPROM - give during labour PROM + known GBS = induction + give NO GBS and membranes in tact = don't give Give BenPen or Cephalosporin IV Or vancomycin if anaphylaxis allergic

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