Antenatal care pt 3

Question 1

How to you calculate EDD?

Answer 1

Naegele’s rule - LMP + 1 year - 3months and 7 days.

Question 2

What is polymorphic eruption of pregnancy and its management?

Answer 2

Itchy rash which starts in 3rd tirmester. Usually begins on abdomen. Characterised with urticarial papules, wheals and plaques.
Managed: topical emollients, topical steroids, oral antihistamines and maybe oral steroids

Question 3

What is atopic eruption of pregnancy?

Answer 3

Presents in the 1st and 2nd trimester.
E-type/eczema type: Red, itchy skin affects elbows, knees, neck, and chest.
P-type/puringo-type: itchy papules affecting abdo, back and limbs

Question 4

What is Melasma?

Answer 4

Patches of increased pigmentation on the face. Usually symmetrical.
No active treatment - avoid sun, use make up, lightening creams etc.

Question 5

Describe features of pyogenic granuloma?

Answer 5

Lobular capillary haemangiomas - rapidly growing lump that develops over days to 1-2cm in size. Often on fingers and may ulcerate or bleed.
More common in pregnancy. Need to rule out nodular melanoma

Question 6

Describe features of pemphioid gestationis

Answer 6

Autoimmune skin disease which occurs in pregnancy. Antibodies created which damage connection between epidermis and the dermis. This causes bulae. Typical in 2nd or 3rd trimester and initially presents with a itchy red papular rash around umbilicus.
Typically resolves after delivery but can use topical emolients/steroids, oral steroids or immunosuppressants.

Question 7

Describe features of obstetric cholestasis

Answer 7

It is stasis of bile flow due to increased oestrogen and progesterone levels.
Results in pruritis, jaundice and raised bilirubin. Associated with increased risk of premature birth and stillbirth.

Question 8

What are the investigations and management of obstetric cholestasis

Answer 8

Ix - LFTs (deranged with high bilirubin)
Rx - Ursodeoxycholic acid, emollients, antihistamines, soluble vitamin K and planned delivery at 37 weeks.

Question 9

What are the investigations of gestational diabetes

Answer 9

OGTT. Positive if:
Fasting glucose =/> 5.6
2 hours glucose =/> 7.8

Question 10

What is the management of gestational diabetes?

Answer 10

If fasting glucose < 7mmol/l then trial diet and exercise change. If no improvement add metformin, if still no improvement then ADD insulin.
If fasting glucose > 7mmol/l then start insulin.
If fasting glucose is 6-6.9 and evidence of complications (macrosomia) then offer insulin

Question 11

What is the management of pre-existing diabetes in pregnancy

Answer 11

If BMI > 27 then weight loss.
Stop oral hypoglycaemics (except metformin) and start insulin.
Folic acid from preconception to 12 weeks.
Retinopathy screening preformed after booking and 28 weeks gestation.

Question 12

What are the fetal risks of gestation diabetes?

Answer 12

Neonatal hypoglycaemia (baby is accustomed to large supple of glucose during pregnancy).
Polycythaemia,
Jaundice,
Congenital heart disease,
Cardiomyopathy

Question 13

What is the postnatal care for diabetes

Answer 13

If gestational then can stop diabetes meds immediately after birth but need follow up to test fast glucose after 6 weeks.
Women with existing diabetes should lower insulin dose and be wary of hypoglycaemia.

Question 14

Describe features of neonatal hypoglycaemia

Answer 14

Needs monitored with regular glucose checks and frequent feeds. Maintain blood sugars above 2mmol/l and if it falls then give IV dextrose or NG feeding.

Question 15

What is the normal fetal movements

Answer 15

Onset (quickening) occurs between 18-20 weeks and increases until 32 weeks where it then plateaus.
Fetal movement should be established by 24 weeks.

Question 16

What are the risk factors for reduced fetal movements

Answer 16

Postural changes - more movement when lying down and less sitting up.
Woman being distracted.

Placental position - may have less movement with anterior placentas.

Medications - Alcohol, opiates or benzodiazepines.

Fetal position - anterior fetal position means movement less noticble.

Body habitus - obese patients.

Amniotic fluid volume - both oligo and polyhydramnios

Fetal size - SGA fetus

Question 17

What are the investigations for reduced fetal movements

Answer 17

> 28 weeks then do handheld doppler to confirm fetal heartbeat. If no detectible heartbeat then do immediate ultrasound. If heartbeat is present then do CTG.
If between 24-28 weeks then do handheld doppler used to confirm doppler.
If < 24 weeks then use handheld doppler if previously had movements. If movements have never been felt then refer to maternity unit.

Question 18

What is foetal lie and the three types?

Answer 18

Fetal lie is the long axis of the foetus relative to the longitudinal axis of the uterus.
Longitudinal lie,
Transverse lie,
Oblique lie

Question 19

What are the risk factors for a transverse lie?

Answer 19

Previous pregnancies,
Fibroids and other pelvic tumours,
Multiple pregnancies,
Prematurity,
Polyhydramnios,
Foetal abnormalities

Question 20

How do you diagnose transverse lie?

Answer 20

Abdominal examination and ultrasound scan

Question 21

What is fetal presentation?

Answer 21

The first part of the baby which enters the maternal pelvis.

Question 22

What is fetal position?

Answer 22

The position of the fetal head as it exits the birth canal

Question 23

What are the complications and management of transverse lie?

Answer 23

Complications: PROM, cord prolapse or compound presentation.
Before 36 weeks no management required as likely to resolve.
After 36 weeks can do external cephalic version or elective C-section

Question 24

What is preterm labour with intact membranes and how is it diagnosed??

Answer 24

Regular painful contractions and cervical dilation.
If less than 30 weeks then clinical assessment is sufficient.
If over 30 weeks then transvaginal ultrasound is used to assess cervical length. If less than 15mm then offer treatment

Question 25

What is the management of preterm labour?

Answer 25

Fetal monitoring,
Tocolysis with nifedipine,
Maternal corticosteroids,
IV Magnesium sulphate,
Delayed cord clamping

Question 26

Describe features of tocolysis

Answer 26

Used to stop uterine contractions.
It can be used between 24 to 33 weeks gestation however can only be used for short term

Question 27

Describe features of magnesium sulphate for premature labor

Answer 27

It is given within 24 hours of delivery of premature babies less than 34 weeks gestation. Given as a bolus followed by an infusion for up to 24hr or until birth.
It is used to protect the fetal brain

Question 28

What observation is required for magnesium sulphate?

Answer 28

Monitor for toxicity every 4 hours. Signs are reduced respiratory rate, reduced BP and absent reflexes

Question 29

What is a prolonged pregnancy and the investigations??

Answer 29

Pregnancy which persists up to and beyond 42 weeks gestation.
Ix - ultrasound scan

Question 30

What are the clinical features of prolonged pregnancy?

Answer 30

Static growth/macrosomia,
Oligohydramnios,
Reduced fetal movements,
Presence of meconium,
Dry flaky skin with reduced vernix (white substance found coating the skin of newborns)

Question 31

What is the management of prolonged pregnancy?

Answer 31

Membrane sweeps - Offered from 40weeks in nulliparous women and 41 weeks in multiparous women.
Induction of labour - usually offered between 41 and 42 weeks. If declined then should have twice weekly CTG monitoning

Question 32

What are the risks of prolonged pregnancy?

Answer 32

Increased risk of still birth!
Umbilical cord compression, fetal acidaemia, meconium aspiration, hypoglycaemia

Question 33

What is red cell isoimmunisation?

Answer 33

Production of antibodies in response to isoantigens on erythrocytes. Mums immune system sensitized to antigens on fetal erythrocytes, resulting in IgG antibodies.
In subsequent pregnancies the antibodies cross placenta and attack fetal RBCs causing haemolysis (HDN). Most common in rhesus negative mums who have rhesus positive babies

Question 34

What are the indications for use of Anti-D immunoglobulin?

Answer 34

Considered following any sensitising event:
Invasive obstetric testing (amniocentesis or chorionic villus sampling).
Antepartum haemorrhage.
Ectopic pregnancy,
External cephalic version,
Fall or abdominal trauma,
Intrauterine death,
Miscarriage,
TOP,
Delivery

Question 35

What investigations should be preformed following a sensitisation event?

Answer 35

Maternal blood group and antibody screen.
Feto-maternal haemorrhage (FMH) test, also known as Kleihauer test.

Question 36

Name some medications which should be avoided in pregnancy

Answer 36

NSAIDs - Can delay labour and cause premature closure of ductus arteriosus.

Beta blockers - FGR, hypoglycaemia and bradycardia in neonate.

ACEi/ARBs - Oligohydramnios, miscarriage, hypocalvaria (incomplete closure of skull bones), renal failure or hypotension in neonate.

Opiates- Neonatal abstinence syndrome

Warfarin - Teratogenic (fetal loss, anomalies, haemorrhage)

Sodium valproate - Neural tube defects and developmental delay.

Lithium - Cardiac abnormalities - Ebstein’s anomaly (also aboid in breastfeeding).

SSRIs - heart defects, malformations, pulmonary hypertension and withdrawal.

Roacutane - miscarriage and defects