Antenatal Care/ Congen Abnorm/ Infections Flashcards
(137 cards)
1
Q
Why is preferred to have a health check done before conception?
A
- Pick up any abnormal smear
- Rubella immunization
- If diabetic
- Regular medications can be changed to ones that are safe for pregancy
- Start 0.4mg/day folic acid
- Advice with regards to drinking and smoking
2
Q
What is preconceptual 0.4mg/day folic acid useful for?
A
Reducing the chance of neural tube defects
3
Q
When during pregnancy is the booking visit?
A
before 10 weeks
4
Q
During a booking visit, why is past obstetric history important?
A
Many disorders have a small but significant recurrent rate
pre-term labour SGA IUGR still-birth ante & post partum haemorrhage pre-eclampsia gestational diabetes
5
Q
What are the sections of an antenatal examination?
A
General Health and Nutritional status
- BMI
- BP
Abdominal Exam (not much use before third trimester)
- Once uterus is palpable around 12 weeks, FHR can be auscultated
Routine vagina examination and clinical assessment of pelvic capacity
6
Q
When during pregnancy is an USS scan done? What is it for?
A
between 11 & 13+6 weeks
- dating using crown-rump length if less than 14 weeks unless IVF
- detects multiple pregnancies
- screening for chromosomal abnormalities
7
Q
What are the routine booking investigations?
A
Urine culture
FBC - pre-existing anaemia
Antibody Screen - anti-d
Serological tests for syphilis
Rubella immunoglobulin G
USS
Screening for chromosomal abnormalities
Haemoglobin electrophoresis - sickle-cell, thalasaemia
HIV and Hep B OFFERED
8
Q
Why is it impt to do a Urine MC&S?
A
Asymptomatic bateruria in pregnancy can lead to pyelonephritis
9
Q
How long should Folic acid be taken for? what dose?
A
till 12 weeks
0.4mg/day
10
Q
What groups of recommended to take Vit D and what dose?
A
BMI > 30
South Asian
Afro-carribean
Low-sunlight
10 micrograms/day
11
Q
When would sex be contra-indicated in pregnancy?
A
1, placenta praevia
- membranes have ruptured
12
Q
How can listeriosis be avoided?
A
Only drink pasteurized or UHT milk
avoid soft and blue cheese
avoid pate
uncooked or partially cooked food
13
Q
What exercise is recommended for pregnant women?
A
swimming
14
Q
What is the recommended sleeping position in pregnancy?
A
left lateral position
15
Q
What are the components of the follow up antenatal appointments?
A
History Reviewed
Assess physical and mental health
BP
Urinanalysis (looking for protein, glucose, leucocytes and nitries)
Abdo examined - but presentation is variable and unimportant until 36 weeks
FHR
16
Q
During the 16 week antenatal visit, what is assessed?
A
Chromosomal Abnormality and booking blood tests are reviewed
IF chromosomal abnorm test is missed a TRIPLE TEST is offered
17
Q
During the 18-21 weeks antenatal visit, what is assessed?
A
Anomaly scan performed
Repeat
aranged of 32 weeks if the placenta is low
18
Q
What is the use of the 25 week antenatal visit for?
A
For nulliparous women, to exclude early onset pre-eclampsia
19
Q
During the 28 week antenatal visit, what is assessed?
A
Fundal height is measured
FBC and antibodies
glucose tolerance test
anti-D is given to rhesus-negative women
20
Q
During the 36, 38 and 40 week antenatal visit, what is assessed?
A
Fundal height
Fetal Lie
Presentation
IF presentation is breech, a referral for external cephalic version
21
Q
During the 41 week antenatal visit, what is assessed?
A
Fundal height is measured
Fetal Lie
Presentation
Membrane sweeping is offered
22
Q
If someone who is pregnant presents with itching, what should be looked out for? What tests can be ordered?
A
Liver Pathology
sclerae for jaundice, LFTs, bile acids
23
Q
While most likely benign, what are some conditions that can be looked out for in pregnancy when patient presents with Abdominal Pain?
A
Appendicitis
Pancreatitis
UTIs
Fibroids
24
Q
While most likely to be heartburn, what can epigastric pain also be a presentation of?
A
Pre-eclampsia
25
What supplement can exarcerbate constipation?
Oral Iron
26
What is a treatment option for vaginitis?
Imidazole vaginal pessaries
27
What is the difference between a screening test and a diagnostic test?
screening test - For all women, a measurement of risk of a fetus being affected by a certain disorder
diagnostic test - test on high risk women to confirm/refute the diagnosis
28
What are methods of testing samples from CVS/Amnio?
FISH
Karyotyping
Micro-array CGH
29
What blood tests can be used to diagnose congenital abnormalities?
Alpha Fetoprotein - neural tube defects
Beta -HCG
Pregnancy - associated plasma protein A (PAPP-A)
Oestriol
Inhibin A
30
When is a USS used to identify congenital abnorm? What is measured?
1st during 11-14 weeks to measure nuchal translucency
with the combined blood test
(larger the gap the higher the risk of abnormalities)
2nd scan 18-20 weeks for structural abnormalities
31
What can amniocentesis used for? When can it be done? What risk is associated?
Can pick up chromosomal abnorm, CMV, toxoplasmosis, sickle-cell, thallassaemia and CF
>15 weeks
1% risk of misscarriage
32
What is CVS? when is it done? What is the disadvantage compared to amniocentesis?
Chorionic Villus Sampling, biopsy of trophoblast through abdo wall/cervix
>11 weeks, which is within the abortion period
higher miscarriage rate than amniocentesis
33
What are the differences between exomphalos vs gastroschisis?
exomphalos - hole in belly button
- intestines covered by protective sac
gastrochisis - hole next to belly button
- intestines not covered by protective sac
34
What is the detection rate?
proportion of affected individuals who will be indentified by the screening test
35
What is a false positive?
proportion of unaffected individuals that show up as higher risk/screen +ve
36
What is a flase -ve?
proportion of affected individuals that show up as low risk/screen -ve
37
What are the similarities between Edward's and Patau's? which chromosomes are affected in each?
incidence of both increase with maternal age
most will die antenatally, still born or shortly after birth
Edward's - trisomy 18
Patau's - trisomy 13
38
What is the screening test for T21, T18, T13?
The combined test - nuchal transparency and serum testing (PAPP-A & beta- hCG)
nuchal transparency offered if crown-rump length 45 - 84mm (11-14 wks)
39
What is the risk that qualifies you for a diagnostic test after undergoing combined trisomy test?
1 in 150, any less likely than this = low risk
40
What is offered if the combined test is not possible? (late booker, nuchal transparency not obtained)
Quadruple test
head circ. 101mm - 173mm (14-20 wks)
41
What does the quadruple test contain?
AFP
beta-hCG
Oestriol
inhibin A
42
What other information is taken into account for the quadruple test?
scan movements
mother's D.o.b.
ethnicity
smoking
diabetes
43
If the combined or quadruple test comes up as positive, what are the diagnostic tests possible?
CVS or amniocentesis
non-invasive prenatal testing in private
44
What is the use of an early USS?
1. gestational age
2. mult pregnancies
3. anencephaly
4. exomphalus
5. increased nuchal transparency
45
What is the use of an mid USS?
1. major abnormality
2. conditions that may benefit from antenatal treatment
3. optimise postnatal treatment
4. termination
46
What are the main infectious diseases being scanned for in pregnancy?
HIV
Hep B
Syphilis
47
When would you screen for haemoglobinopathies? What would you be screening for?
recommended at 8-10 weeks
sickle cell
thalassaemias
48
From an USS, what would present as risk factors for Down's?
Thickened nuchal translucency
Some structural abnormalities
absent or shortened nasal bone
tricuspid regurg
49
From a blood test, what would present as risk factors for Down's?
1st trimester - LOW PAPP-A
1st/2nd trimester - HIGH beta hCG
LOW AFP
2nd trimester - LOW oestriol
HIGH inhibin
50
What are the components being screened in the NEWBORN HEEL PRICK TEST?
Sickle Cell
Cystic Fibrosis
Congenital Hypothyroidism
```
Phenylketonuria
MCADD
Maple Syrup disease
Isovaleric Acidaemia
Glutaric Aciduria
Homocystinuria
```
51
What are the components of the Newborn & Infant Physical Exam (NIPE)
```
Gen. Physical Exam
Eye Problems
Congenital Heart Defects
Dysphasia of the Hips
Undescended testes
```
52
What are the fetal consequences of a CMV infection?
Symptomatic -IUGR, Pneumonia and Thrombocytopenia
Asymptomatic - risk of deafness
53
How is a CMV infection diagnosed and managed?
CMV IgM remains positive long time after infections, there AMNIOCENTESIS will confirm/refute vertical transmission
there is no prenatal treatment or vaccine
termination is offered
54
How would you diagnose and manage a Herpes Simplex infection?
Clinically clear in other
referall to GU clinic, caesarean recommended
mother given daily acyclovir in late pregnancy
if infant exposed, given acyclovir as well
55
What are the fetal consequences of a rubella infection? how can it be managed?
deafness, cardiac disease, eye problems and retardation?
termination offered if mother is infected before 16 weeks
vaccine is live and therefore contraindicated
56
What is the organism responsible for toxoplasmosis?
Toxoplasma Gondii
57
How is toxoplasmosis diagnosed and managed?
USS - hydrocephalus sometimes, IgM ---- amniocentesis to confirm
Spiramycin as soon as mother is diagnosed
58
What are the risks involved with Herpes Zoster infection in pregnancy?
Chicken Pox has severe maternal consequences in pregnancy
Teratogenicity
59
What is management of a Herpes Zoster Infection?
Immunoglobulin for prevention esp in women who aren't immunised
Aciclovir for treatment
If neonate is delivered 5 days after/ 2 days before maternal infection - prophylactic immunoglobulin and then acyclovir if infected
60
How does Parvovirus present?
'slapped cheek' + arthralgia but can be asymptomatic
in neonates - anaemia, thrombocytopenia, fetal death 10%
61
How would you diagnose Parvovirus?
+ve maternal IgM
| Anaemia and oedema detectable on USS
62
How does group B strep present in mother's?
aymptomatically
63
What situations are risk factors for vertical transmission of group b strep? What can be done to prvent this?
Infected normally during labour after membranes ruptured
Pre-term labours
Prolonged labours
Maternal fevers
IV penicillin
64
Which individuals are at risk for group b strep infection?
previous infected neonate
+ve urine culture
preterm labour
rupture of the membranes >18hrs
Maternal fever during labour
65
How to prevent vertical transmission of group b strep?
anal and vaginal cultures at 35-37 wks
Urine culture
Infant previously affected
if any of the above are positive IV high dose penicillin given
66
What is group A strep responsible for?
Puerperal sepsis
| most common cause of maternal death
67
how doe group A strep present?
most common symptom is sore throat
chorioamnionitis with abdo pain, diarrhoea and severe sepsis
infected fetus usually dies and labour will ensue
68
how to manage group A strep?
Early recognition
Culture
High dose Abx
69
Whats the percentage of infants that become chronic carriers of Hepatitis B?
90%
70
How would you reduce the risk of HIV vertical transmission? Would this be the same in poorer countries?
Maternal antiretroviral
Caesarean Section
No breastfeeding
Neonatal Antiretroviral
In poorer countries, nevirapine in labour and to neonate, as it will be vaginal delivery
breast feeding still advised for 6 months with antiviral
71
How can antiretrovirals affect pregnancy?
Not teratogenic but are folic acid antagonists
72
What are risk factors for pre-eclampsia?
```
young female
blacks
multifetal pregnancies
hypertension
rena disease
collagen vasc. disease
```
73
What are the 4 forms of hypertension in pregnancy?
gestational
pre-eclampsia -eclampsia
chronic hypertension
pre-eclampsia superimposed upon chronic htn/renal disease
74
How would you define chronic HTN?
Diagnosed before pregnancy
Present during pregnancy and not resolved postpartum
75
How would you define gestational HTN?
Starts after 20 wks gestation
>140/90
no or little proteinuria
76
How would you define pre-eclampsia?
How would you class mild, moderate and severe?
after 20th week
Increased BP (>140/90) + proteinuria (0.3g/24hr/>2 on urine dipstick)
mild - proteinuria and mild to mod htn (140/90 -149/99) (150/100 - 159/109)
mod - proteinuria and severe htn (160/110+) with no maternal complications
severe - proteinuria & any hypertension <34 weeks/ with maternal complications
77
What is Eclampsia?
Pre-eclampsia + generalised tonic-clonic
78
What is pathophysiology behind pre-eclampsia?
Incomplete trophoblastic invasion of spiral arterioles. results in decreased uteroplacental blood flow
this causes an ischaemic placenta via exaggerated maternal inflammation response ----- widespread endothelial damage
causing
1. vasocontriction
2. increased vascular permeability
3. clotting dysfunction
79
How would you pre-eclampsia present?
headache, drowsiness, visual disturbances, nausea/vomiting or epigastric pain
80
What are the complications of pre-eclampsia?
Eclampsia
Cerebrovascular Hemorrhage
Liver and Coagulation problems - HELLP (hemolysis, elevated liver enzymes and low platelet count)
DIC
Liver Failure
Liver Rupture
Renal Failure
Pulmonary Oedema
81
What is the most common fetal associated problem with pre-eclampsia?
IUGR
82
What can be given to reduce the risk of pre-eclampsia?when?
low-dose aspirin before 16 weeks
83
On admission with pre-eclampsia? What medications can be given?
labetalol
magnesium sulphate (increases cerebral perfusion)
Steroids (for fetal development)
84
Why is the presence of proteinuria impt?
One or more fetal or maternal complications are likely to occur within 2 weeks of proteinuria onset
85
When should delivery be if mother has
I) gestational htn?
ii) mild pre eclampsia
iii) moderate - severe pre eclampsia?
iv) severe with complications?
i) without fetal compromise - induction by 40 weeks?
ii) 37 weeks
iii) 34-36 weeks
if less than 34 weeks - conservative specialist unit, weigh up the maternal vs fetal risks - give steroids, CTG and fluid balance
iv) requires delivery - less than 34 weeks (C-section)
- more than 34 weeks (labour induced with prostaglandins)
86
Why is oxytocin preferred to ergometrine in the 3rd stage of pregnancy?
ergometrine caused increased BP
87
What should be monitored post natally for 24hrs? why?
Delivery cures pre-eclampsia but only after 24 hrs
monitor LFTs. platelets and renal function
fluid balance
blood pressure - maintain around 140/90mmHg with beta -blocker
88
How would you confirm diagnosis of pre-eclampsia?
MSU and urine protein measurement (PCR or 24-h collection)
89
What are the consequences of diabetes on the fetus? How do these changes occur?
Macrosomia
raised fetal blood glucose levels leads to fetal hyperinsulinaemia
This leads to fat deposition and excessive growth
90
What are the differences between the NICE definition for gestational diabetes and the Internal Consensus?
NICE : Fasting glucose > 7.0mmol/L
after 2 hrs, 75g glucose load >7.8 mmol/L
International Consensus : fasting > 5.1mmol
1 hr after 75g glucose load > 10.0mmol
2 hrs after.... : >8.5 mmol/L
91
What are some fetal complications of gestational diabetes?
Congenital Abnormalities
Preterm labour
Decreased fetal lung maturity
Increased body weight due to increased urine output
and polyhydramnios
Dystocia and birth trauma more common
Fetal compromise, distress and sudden death
92
What are some maternal complications of diabetes?
Hypoglycaemia
UTIs
wound or endometrial infection after delivery
pre-eclampsia more common
IHD worsens
Diabetic retinopathy often deteriorates
93
How would monitoring differ in a woman with diabetes?
Visits fortnightly up to 34 weeks
then weekly thereafter
glucose levels checked by patient before and after food - levels ideally should be below 6mmol/L
In addition to usual scans - fetal echo, USS for fetal growth and liquor volume, renal function, retinae screen
94
How would management differ in a woman with diabetes?
In type 2 - may need addition of insulin on top of usual medication
careful diet + one night-time-long/intermediate acting + 3 preprandial short-acting insulin injections
doses of regular medication may increase with pregnancy
glucagon prescribed in case of hypoglycaemia
75mg Aspirin daily from 12 weeks to reduce risk of pre-eclampsia
95
When should delivery be for women with diabetes? when is a C-section indicated? how is medication managed during labour?
by 39 weeks
C-section indicated where estimated fetal weight is >4kg
during labour glucose levels maintained with 'sliding scale' or insulin and dextrose infusion
96
What complications can arise with a neonate from a diabetic mother?
hypoglycaemia
respiratory distress syndrome occasionally occurs even if older than 38 weeks
breast feeding is advised
97
What pre-existing risk factors can be used to screen for gestational diabetes?
previous largebaby
explained still birth
first degree relative w/ diabetes
BMI > 30
south asia, black, middle eastern
PCOS
*all of above would indicate 28 week GTT
98
What pregnancy risk factors can be used to screen for gestational diabetes?
polyhydramnios
persistent glycosuria
99
What would management for gestational diabetes be?
diet advice + glucose monitoring @ home
metformin (will be under control for 60%)
insulin
100
What changes on the cardiovascular system happens during pregnancy?
40% increase in cardiac output
40% increase in blood volume
50% decrease in systemic vascular resistance
101
What kind of murmur is present in 90% in pregnant women? Why?
Ejection Systemic Murmur caused by increased blood flow
102
What are some cardio specific medications contra-indicated during pregnancy?
Warfarin
ACE-I
103
Should thromboprophylaxis be continues during pregnancy? what should be used?
LMWH
104
During labour, what steps should be taken for a mother who has cardiac pathology?
Fluid balance checked
Elective epidural analgesia reduced afterload
Elective Forceps (reduced stress of pushing)
Abx recommended against endocarditis
105
Out of PDA, VSD, ASD and Pulm. Hypertension, which is contra-indicated for pregnancy?
Pulmonary Hypertension
106
What is peripartum cardiomyopathy? What are the consequences ? how is it treated?
Cause of HF in pregnancy
Occurs in either last month of pregnancy or first 6 months AFTER
causes 15% mortality , mostly due to left ventricular dysfunction
Treated with diuretics and ACE-I
107
What changes does pregnancy have on the respiratory system?
40% increase in tidal volume, while no change in resp rate
Asthma common in pregnancy
108
Why do women on long-term steroids require an increase dose during pregnancy?
Adrenal cortex is chronically supressed
109
What are some major issues pertaining to mothers that have epilepsy and are pregnant?
Seizure control can decrease in pregnancy
Epilepsy is a major causes maternal death, therefore anti-epileptics are continued
However, anti-epileptics cause a risk of congenital abnormalities which is dose-dependent
110
What is management plan for pregnant women with epilepsy? What drugs are safe?
To achieve seizure control with the least amount of drugs at the lowest dosage
Folic Acid
Ideally avoid Sodium Valproate
Carbamazepine and Lamotrignine are safest
111
What risks are associated with sodium valproate during pregnancy?
Congenital Malformation
Reduced IQ
Autism risk
112
What is the biggest risk of untreated hypothyroid and hyperthyroid during pregnancy?
High Perinatal Mortality
113
What is the treatment for hypothyroid during pregnancy?
Thyroxine + TSH monitoring every 6 weeks
114
What is the treatment for hyperyroid during pregnancy? What fetal risk is associated with this treated?
PROPHYLTHIOURACIL (PTU) - can cross placenta and cause fetal hypothyroid
115
What is characteristic of Intrahepatic Cholestatis of pregnancy? What causes it?
Itching without skin rash but abnormal LFTs
Caused by abnormal sensitivity to cholestatic effects of oestrogens
116
What risks are associated with intrahepatic cholestatis of pregnancy?
Increase risk of stillbirth and preterm
117
What is treatment of intrahepatic cholestatis of pregnancy?
Vit K 10mg/day for 36 weeks
Ursodeoxycholic Acid relieves itching
Induction of labour around 38 weeks is advised
118
What is characteristic of Antiphospholipid syndrome?
Lupus anti-coagulant and/or anti-cardiolipin antibodies in association with adverse pregnancy complications
119
What presentations are common in antiphospholipid syndrome?
reccurent miscarriage + IUGR + early pre-eclampsia
caused by placental thrombosis
120
How would you treat antiphospholipid syndrome?
Aspirin + LMWH
USS and elective induction by term
Postnatal anticoagulation recommended to prevent VTE
121
What is the clinical criteria of antiphospholipid syndrome?
vascular thrombosis
1+ fetus death >10 weeks
Pre-eclampsia or IUGR requiring delivery <34 wks
3+ fetal losses <10 weeks otherwise unexplained
122
What changes does pregnancy have on the renal system?
glomerular filtration rate increases by 40% this causes a decrease in urea and creatinine levels
123
What complications can renal disease cause during pregnancy?
pre-eclampsia
IUGR
polyhydramnios
pre-term
124
What are risk factors make pregnant women prone to thromboses?
inherited prothrombotic conditions
family hx
personal hx
125
How would VTE be treated during pregnancy?
subcut LMWH - if poss treatment stopped shortly before labour
but restarted after
126
What would factors would qualify a women as HIGH VTE risk?
previous VTE - 6 weeks of LMWH
127
What would factors would qualify a women as INTERMEDIATE VTE risk?
thrombophilia, c-sect, BMI > 40, prolonged hosp stay, IV drug abuser
1 week LMWH if 1+
128
What would factors would qualify a women as MOD VTE risk?
```
BMI > 30
> 35 y/o or parity >/3
smoker
varicose veins
pre-eclampsia
immobility
PPH
labour > 24 hrs
```
1 week LMWH if 2+
129
Maternal risks of obesity during pregnancy
VTE
pre-eclampsia
diabetes
wound infections
PPH
Maternal death
130
Management of obese preg ladies?
high dose preconceptual folic acid
vit D
weight MAINTAINED
screen gest diabetes
131
What is red blood cell isoimmunisation?
When mother mounts an immune response against antigens on fetal red cells that enter her circulation
The resulting antibodies then cross the placenta and cause fetal red blood cell destruction
132
In terms of D rhesus when would red blood cell isoimmuniation occur?
if small of amount of fetal blood from a baby that is D rhesus +ve, enters a mother who's D rhesus -ve blood, there will be an immune response, producing anti-D antibodies
133
What are some potential sensitizing events?
termination
evacuation of retained products of contraception
ectopic pregnancy
vaginal bleeding
invasive procedure (amniocentesis or CVS)
intrauterine death
delivery
134
When is anti-D given and at what dose?
1500IU anti-D given to all women who are rhesus -ve @ 28 wks
also to same women within 72 hrs of sensitising event
135
What is the Kleihauer test?
Postnatal test to assess the number of fetal cells in the maternal circulation.
performed 2 h after birth to detect occasional larger fetomaternal haemorrhage that require larger doses of anti-D to 'mop-up'
136
What complications can arise from red blood cell isoimmunisation?
mild - neonatal jaundice or neonatal anaemia
| moderate - in utero anaemia (cardiac failure, ascites, oedema and fetal death)
137
How would you assess fetal anaemia and subsequently treat it?
Assessed using USS fortnightly
transfuse if fetus anemic and deliver is more than 36 weeks
all neonates born to rhesus-negative women - FBC, blood film and bilirubin
