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Antenatal care Flashcards

(115 cards)

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1
Q

Gravidity

A

How many times a woman has been pregnant

Includes ectopics etc

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2
Q

Parity

A

How many babies have been delivered at 24+ weeks

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3
Q

Primigravid

A

First ever pregnancy

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4
Q

Nulliparous

A

No delivery of a baby >24 weeks

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5
Q

Multiparous

A

1+ Babies delivered >24 weeks

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6
Q

1st trimester

A

1-12 weeks

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7
Q

2nd trimester

A

13-27 weeks

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8
Q

3rd trimester

A

28wks- delivery

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9
Q

What happens at the booking visit?

A 
Obstetric Hx
BP, Urinalysis, BMI
Antenatal screening 
Place of birth
Advice
Access to services
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10
Q

When is the booking visit

A

8-12 weeks ideally <10

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11
Q

When is the early dating scan and what happens

A

10-13+6

Confirms dates, Excludes multiple pregnancy

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12
Q

What is the combined test?

A 
11-13+6 usually at dating scan 
Nuchal translucency 
HCG
PAPP-A
Detects 85%- Trisomies
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13
Q

What results in the combined test would suggest Down’s syndrome?

What about the quadruple test?

A

High HCG
Low PAPP-A <1
Nuchal translucency >3.5mm

Low AFP, Low oestriol, inc Inhibin-A

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14
Q

Apart from Down’s what else can thickened NT suggest?

A

Abdominal defect

Cardiac defect

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15
Q

What happens at the Anomaly/Anatomy scan?

A 
18-20+6
Quadruple test
PLACENTAL LOCATION
Assess gestational age 
Anatomic survey
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16
Q

What is the Quadruple test

A

14-17 weeks but up to 20 weeks
AFP, HCG,Oestriol, Inhibin A
75% detection 4.1% false +ves

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17
Q

From the quadruple or combined test what risk is defined as high risk?
What do you do?

A

1/150 or more

CVS or amniocentesis

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18
Q

What is CVS?

A

Chorionic villous sampling
11-14 weeks
Miscarriage rate 1-2%
LA,Large needle

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19
Q

What is amniocentesis?

A

15+ weeks
Miscarriage rate 0.5-1%
Thin needle +/- LA

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20
Q

How do you diagnose Downs/Trisomies antenatally?

A

CVS/Amniocentesis

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21
Q

What is the IONA screen?

A

99% sensitivity for Down’s
Detects free-foetal DNA in maternal circulation
Still need amnio for Dx

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22
Q

How do you calculate gestational age in the dating scan?

A

Crown rump length (mm)

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23
Q

When can you see foetal heart activity?

A

6-7 weeks

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24
Q

What happens at fetal wellbeing/growth scans?

A

Estimate foetal weight and plot (Biparietal diameter, Head circumference, Abd circumference, Femur length)

Amniotic fluid index- Sum of deepest verticle pools
Doppler studies- EDF, MCA, Pulsatile index

If high risk have these regularly

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25
Minor problems in 1st trimester?
N+V- resolution likely 16-20wks Urinary symptoms as GFR inc (Dec Cr and urea) constipation (decreases with gestation)
26
Minor problems in 3rd trimester?
``` Obstetric cholestasis Acute fatty liver of pregnancy Reflux Stress incontinence Varicose veins (inc with gestation) Backache/sciatica Haemorrhoids ```
27
Normal Vaginal discharge in pregnancy?
Increased vaginal and cercival blood flow results in whit/clear muccoid discharge Infection= Offensive, coloured, Itchy RoM- Watery + profuse
28
Thresholds for giving oral iron for anaemia antenatally?
1st Tm < 110g/l 2nd TM <105g/l 3rd TM <100g/l
29
How do you treat obstetric cholestasis?
Urosdeoxycholic acid for symptoms Induce at 37 weeks Weekly LFTS and Vit K supplementation
30
Key diagnostic features of hyperemesis gravidarum
5% pre-pregnancy Wx loss Dehydration Electrolyte imbalance Exclude UTI, Thyrotoxicosis
31
Admission criteria for hyperemesis gravidarum
Not tolerating oral fluids and dehydrated
32
Treatment of hyperemesis gravidarum
Check electrolytes and LFTs IV fluids +/- Promethiazine or cyclizine +/- Ondansetron, Metoclopromide If prolonged may need vitamin supplementation and high dose corticosteroids
33
Fetal consequences of hyperemesis gravidarum
Growth restriction | Pre-term
34
Key risk factors for SGA 'starved small'
``` Pre-eclampsia Hx IUGR Multiple pregnancy Maternal medical disorders Drug abuse, smoking ```
35
Key risk factors for SGA 'abnormal small'
Chr, infection, genetics
36
SGA definition
Newborn birth Wx <10th percentile for gestational age | Estimated foetal Wx <10th percentile for gestational age
37
IUGR vs SGA
IUGR a subtype of SGA | could be constitutionally small
38
Investigation of SGA
UA doppler Pulsatile index EDF +/- MCA PI +/- CPR
39
When would you consider delivery of an SGA baby at 32 weeks?
Absent/Reversed EDF in UA | Would also do 2 weekly scans
40
What do you want the resistance index and pulsatile index to be?
<1 | Suggests easy blood flow getting through in both sys and dias
41
What would you do if an SGA baby had UA PI>95th centile and +ve EDF
UA doppler 2X weekly Growth every 2 weeks Delivery at 37 weeks
42
If the doppler is normal in an SGA baby when would you consider >34 week deliver
Static growth for 3 weeks or MCA <5th centile
43
When should you feel foetal movements?
18-20 weeks
44
Priorities when someone presents with reduced foetal movements? Consider DDx
Rule out IUD- Doppler heart beat and CTG (24+) Infection- Bloods IUGR- foetal assessment, 48 hr growth scan
45
What does amniotic fluid volume tell us about fetal sufficiency?
Sparing effect limits non-central organ blood flow | Good indicator of fetal insufficiency
46
What is prolonged pregnancy? What investigations are important?
Exceeding 42 weeks from LMP | Daily CTG after 42 weeks, Report any decrease in fetal movements, initial USS for growth and liquor volume
47
Management of prolonged pregnancy
Estimate EDD as accurately as possible +/- induction if high risk Stretch and sweep at 41 weeks IoL at 41-42 weeks
48
How do you estimate EDD at Booking visit?
LMP +7/7 +9/12
49
What is PPROM?
Preterm Prelabour RoM <37Wks
50
Investigations to do if PPROM?
``` Bloods for infection Sterile Spec exam with HVS, VVS, PH CTG and MSU USS for foetal presentation NO DIGITAL EXAM ``` Dx- Pooling of amniotic at the back of the vaginal fornix
51
In PPROM What would suggest chorioamnionitis?
Fever, Abd pain, Purulent discharge,, Temp, Tachycardia (Mat or foetal), Yellow brown discharge on speculum
52
Management of pregnancy if Chorioamnionitis?
Broad Spec Abx- Oral Eryhtromycin Dexamethasone or Betamethasone 12mg IM Deliver N.B Bleeding risk is increased
53
Management of PPROM if no chorioamnionitis?
Inform neonatal team Admit Abx- Oral Erythro? Stertoids- Dex or Beta 12mg IM 2x doses 12 hour apart Tocolytic like Nifedipine to allow time for steroids to work Deliver at 34 weeks as the risk of chorionaminionitis increases as the pregnancy progresses but the risk of RDS decreases, so a trade-off
54
What is IUGR and what causes it?
Wx <10th percentile MOSTLY A FAILURE OF PLACENTA + multiple pregnancy, infection, APS, Maternal health, Warfarin, Anticonvulsants, Sickle cell, SMOKING, DRUGS, ALCOHOL May need to attend consultant antenatal clinics
55
Difference between dizygotic and monozygotic twinning?
Dizygotic- seperate ova fertilised... No more identical than normal siblings... Dichorionic and Diamniotic Monozygotic... Identical features... Type depends on timing of division
56
Why is the timing of the division in monozygotic twins significant?
EARLIER= BETTER Day 0-3 Dichorionic Diamniotic... Division is before implantation so better Day 4-8 Monochorionic Diamniotic Day 8-13- Monochorionic Monoamniotic HIGHEST RISK
57
Principles of management in Multiple pregnancy
Early Dx and consultant led High dose folic acid and iron 75mg daily aspirin as 5x more likely to get pre-eclampsia Extra growth scans
58
Delivery of Dichorionic twins
38 weeks | Planned
59
Delivery of MCDA and MCMA
MCDA- 36-37 Weeks | MCMA- Elective C-section 32 weeks + 2 weekly USS
60
Main complication of MCMA
Twin-Twin Transfusion Syndrome Recipient- Polycythaemia, HTN, Cardiac Hypertrophy, Oedema (Hydrops), Polyhydramnios Donor- Anaemia, IUGR, Hypotension, Oligohydramnios Can ablate anastamoses via laser
61
Complications of Multiple pregnancy
LOTS FOR MOTHER AND BABY IUGR, Poly, Preterm, abruption, Cord prolapse Praevia, Placental disease, HTN, PPH
62
Different types of HTN in Pregnancy
Chronic HTN- Pre-existing and uncommon Gestational HTN- BP >140/90 after 20 weeks without proteinuria Pre-eclampsia- BP >140/90 after 20 weeks + >0.3g/24hrs Proteinuria (PCR >30mg/Mol 2+ on dipstick) without UTI
63
1st line treatment for Gestational HTN What Anti-HTN should be stopped?
Oral labetolol, Nifedipine if asthmatic Important to stop Thiazides, ACEi, ARBs because inc congen abnormalities
64
Target BP for Gestational HTN
<150/90 | Note the maternal BP decreases in 1st TM to inc placental Blood flow... hence why its Dx post 20 weeks
65
How does pre-eclampsia present
Headache, Visual disturbance, Facial oedema, periorbital oedema, Hyper-reflexia, Clonus, Papilloedema, Hepatic capsule engorgement Monitor for Pul.Oedema and IC haemorrhage
66
How do you monitor pre-eclampsia
FBC, Cr, LFTs, U+Es (3x week if Sev, 2x if not) USS (Growth, Liquor, Doppler)... Also do a G+S Measure BP, 4X daily if mild.mod, >4 if Sev NOT PROTEINURIA
67
What is mild, Moderate and Severe Pre-eclampsia
Mild >140/90 Mod >150/100 Sev >160/110 OR ALTERED HAEMATOLOGY OR SIG SYMPTOMS
68
What is HELLP syndrome
Haemolysis LFTS inc- Rise in Transaminase not ALP (this is raised anyway in pregnancy) Low Platelets
69
Management of pre-eclampsia
200mg oral labetolol (Alt= Nifedipine) try 2nd dose then IV if no effect 10mg Oral nifedipine Mg sulphate until 24 hours post-delivery or last seizure Hydralazine can be considered ?Steroids
70
Prophylactic management of pre-eclampsia
75mg Aspirin from 12 weeks if high risk
71
Who is high risk of pre-eclampsia
Hx pregnancy related HTN, Multiple pregnancy, CKD, SLE, APS, DM, Chronic HTN Moderate= Fhx, 1st preg, BMI >30, Mat age >30
72
Principles of delivery in Pre-eclampsia
Timing= 34+ weeks BP MUST BE CONTROLLED BEFORE C-SECTION Maternal steroids up to 34 weeks Repeat scnas
73
Management of eclampsia
ABC- 02 and intubate Left lateral position IV Mg Sulphate Iv labetolol or Hydralazine CURE= PLACENTAL DELIVERY Can be postnatal...
74
Principles of management for pre-existing DM in pregnancy
Serial growth scans Induction at 38-40 weeks +/- C section if LGA BMI>27= must lose weight 5mg folic acid and 75mg aspirin from 12 weeks Detailed anomaly scan Stop ACEi and Statins Monitor BG- Fasting, Pre-meal, 1 hour post meal, Bedtime Monitor eyes and renal function as function may deteriorate
75
Diagnosis of Gestational Diabetes
OGTT- 75g oral glucose 2 hour venous plasma glucose >7.8 (or fasting >5.6) No role for HBA1C
76
Key RF for GDM? Who needs screening?
PCOS + Obesity= OGTT at 26 weeks, Previous GDM= OGTT at 16 weeks Screen- BMI>30, 1st relative with GDM, previous large baby >4kg, High risk ethnicity, Hx still birth (unexplained) Polyhyramnios
77
Key Principles of management in GDM
Fasting <7mmol/l then trial diet and exercise If target not met within 1-2 weeks then Metformin Finally add insulin if needed
78
What are the complications of GDM?
No increase in Miscarriage or congen abnormalities Shoulder dystocia, Stillbirth, maternal tears, neonatal hypoglycaemia Check maternal fasting glucose 6 weeks post-partum for underlying DM
79
What prophylaxis would someone with a Hx of VTE receive?
Antenatal and 6 week postnatal LMWH
80
When would you consider antenatal thromboprophylaxis?
Hospital admission, High risk thrombophilia, medical comorbidities, Any surgery, OHSS, Single VTE B/C surgery (Previous VTE is an absolute indication for antenatal LMWH)
81
4 or more of what risk factors would make you consider LMWH from 28 weeks?
BMI>30, 35+ yrs, parity >3, Smoker, Varicose veins, Curret pre-eclampsia, Immobility, Low risk thrombophilia, Multiple preg, IVF, FHx unprovoked oes related VTE in 1st degree
82
What VTE test is useless in pregnancy?
D-Dimer B/C always raised
83
What are the benefits of VBAC? What are the risks?
Less risk for mum but Increased risk of uterine rupture (0.5% in spont delivery 3% in induced) 75% success inc to 90% if 2nd VBAC Deliver on labour ward with CTG Always the risk of an emergency C-section which is higher risk than an elective C-section
84
Risks of an LCSC
Infection, Bleeding, Adjacent organ injury, scalpel injury to baby, Anaesthesia risk, VTE increased therefore prophylaxis 2nd time the scar tissue is more complex In the future- Inc rupture risk, adherent placenta, Stillbirth, VD may be higher risk
85
Safest anti-convulsants in pregnancy
CBZ, Lamotrigine, Levetiracetam
86
Principles of management in an epileptic pregnant lady?
5mg daily folic acid Oral Vit K last 4 weeks Avoid Sodium Valproate, Phenytoin, Phenobarbitone
87
Managing a UTI in pregnancy
Nitrofuranoin preferred UNLESS 3RD TM Avoid Trimethoprim in 1st trimester Dont use tetracyclines as tooth discolouration
88
Principles of chicken pox management in pregnancy
Check Ab -> Not immune-> IV IG ASAP | Presents within 24 hours of onset of rash? Oral Aciclovir
89
Analgesia of choice Antenatally?
Paracetamol NSAIDS inc miscarriage and malformations and premature DA closure
90
When would you test for anaemia
Booking visit (8-12wks) give if <11g/dl, 28 weeks give if <10.5g/dl
91
What antibiotic should be avoided in pregnancy?
Co-Amox because of NEC risk to baby
92
When are the 1st and 2nd doses of Anti-D given?
28 and 34 weeks IM Anti-D also given after delivery if baby is Rh +VE
93
Sensitising events in pregnancy?
Amniocentesis, Placental abruption, Trauma, Heavy bleed <12 weeks, Any bleed >12 weeks, EVAC of retained products/Ectopic/Abortion
94
When do you test for Rh status?
Booking visit | Give at 28 and 34 weeks if Rh -ve and not sensitised
95
Pathophysiology of Rh status in pregnancy
R-ve mum -> R+ve child with D -antigen-> Leakage of foetal RBC into Maternal circulation -> Anti-D antibody crosses placenta in later pregnancies-> Normocytic anaemia and haemolysis, jaundice in foetus
96
What does the Anti-D IG do?
Neutralise foetal D-antigen so no maternal Antibodies are created
97
Indications for high dose (5mg) folic acid
``` Parent with NTD, or FHx of NTD Antiepileptic drugs Coeliac DM Thalassemia BMI>30 ```
98
Causes of folic acid deficiency
Methotrexate Pregnancy Alcohol excess Phenytoin
99
Sequela of folic acid deficiency
Macrocytic megaloblastic anaemia | NTD
100
What folic acid advice should be given to all women
Pre-conceptual 0.4mg folic acid until 12 weeks gestation
101
Key points to cover in an antenatal clinic
``` Movements Previous preg Urinalysis BP Abdo exam Frequency (New-onset?) ```
102
Causes of polyhydramanios?
``` 50% Idiopathic Congenital problems in foetus Trisomy Maternal DM Multiple preg Fetal anaemia Hydrops fetalis Substance abuse ```
103
What does polyhydramanios increase your risk of?
``` Prolapsed cord Malpresentation UTIs Preterm PPH ```
104
Causes of Oligohydramnios
Either excess loss of fluid or Decreased foetal urine production -> RoM, Renal agenesis, renal obstruction, decreased renal perfusion, placental abruption
105
When is anaemia screened for?
``` Booking (<11g/Dl) 28 weeks (<10.5g/DL) ```
106
What is the 'dilutional effect' in pregnancy?
Plasma volume increase is greater than Red cell mass increase Decreased haematocrit is normal Normal MCV Low HB (Normal now ~115g/L)
107
What Mean corpuscular Hb
MCH= Amount of HB found in RBC
108
What is Mean Corpuscular Hb concentration?
Concentration of HB in a given volume
109
What is ferritin
Iron stores
110
What is Haematocrit
% of Plasma volume that is RBCs ~40%
111
How does iron deficiency anaemia present on blood results
Microcytic hypochromic anaemia (Decreased MCV, MCH & Dec/Norm MCHC)
112
How does B12 or folaye deficiency anaemia present on Blood results?
Macrocytic Hypochromic anaemia (Inc MCV, Dec MCH and MCHC)
113
What tests should you do if there is abnormal Hb on a FBC?
Haematinics (Folate, B12, Ferritin, EPO)
114
Management of iron deficiency anaemia
100-200mg elemental iron daily For at least 3 months + 6 weeks post partum Do not take with tea/coffee
115
Changes to the CV system in pregnancy
Inc HR, inc SV, Inc CO Inc circulating volume to compensate for blood loss in labour PVR will be decreased (Hence fainting) but if pathology this will be inc

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