1
Q
Discuss folic acid
-Timing to take
-Dose to take
-Criteria for increased dose
-Efficacy
A
- Timing - 1 month prior to conception until 12 weeks
- Dose to take 800mcg (500mcg in Aus)
- Criteria for increased dose
-Take 5mg if: previously affected child with NTD, family hx of NTD, BMI >30, on anticonvulsants, pre-pregnancy diabetes, risk of malabsorption
-In multiple pregnancy or haemolytic anaemia then consider 5mg dose - Efficacy
-Decreases risk of NTD by 90% in those with no NDT hx
-Decreases risk of NTD by 70% in those with previous NTD
2
Q
Discuss supplementation with
-Iodine - dose & timing
-Vitamin B12 - criteria & dose
-Fe - Criteria and dose
-Calcium - criteria and dose
-Vitamin K
A
- Iodine
-150mcg for whole pregnancy and lactation - Vit B12
- If vegetarian, vegan or malabsorption issue
-2.6mcg/day in pregnancy
-2.8mcg/day during lactation - Fe
-Routine supplementation not required
-Treat if ferritin <30
-Give 100-200mg daily
-Intermittent PO as effective as daily
-If low Fe but not anaemic give low dose FE 20-80mg
-Give IV if no response to PO or need rapid Hb boost - Calcium
-Supplement if intake <1000mg/day with 1000mg/day
-If at risk for PET give 1000mg per day (RR 0.45 for PET) - Vitamin K
-Should be given to women with proven cholestasis late in pregnancy
3
Q
Discuss vitamin D supplementation in pregnancy
-Criteria for deficiency and insufficiency
-Findings regarding supplementation
-Recommendations for supplementation
-Recommendation for testing vit D levels
A
- Criteria
-Deficiency = <50nmol/L
-Insufficiency = <75nmol/L - Findings
-Deficiency associated with number of maternal and neonatal adverse outcomes. PET/GDM/CS/ IUGR/childhood asthma
-No evidence to suggest supplementation improves outcomes
-May improve childhood wheeze - Recommendations for supplementation
-All women should take 400IU as part of standard multi vit
-Exclusively breast fed infants should be given 400IU daily for first 6 months - Recommendation for testing vit D levels
-DON’T
4
Q
Discuss omega 3 fatty acid suplementation in pregnancy
-Impact to fetus
-Evidence of impact to pregnancy
-Recommendation for supplementation
A
- Impact to fetus
-Omega 3- fatty acids are important in fetal brain and retina development - Evidence for impact on pregnancy
-No conclusive evidence that supplementation helps but may improve neurodevelopment, reduce PTL - Recommendations for supplementation
-Consider supplementation if low sea food intake
5
Q
Discuss smoking in pregnancy
-Incidence
-Risk factors (6)
A
- Incidence
-1:8 women smoke in NZ
-44% are Maori - Risk factors
-Low SES
-Ethnicity
-Mulitparity
-Domestic violence
-Young age <21 = 30%
-Mental health disorders
6
Q
Discuss the effects of smoking on pregnancy
-Physiological effects (5)
-Risks in preconception (1)
-Antenatal risks (10)
-Postnatal risks (5)
A
- Physiological effects
-Disrupts implantation
-Interferes with transformation of spiral arteries
-Thickens villous membranes
-Nicotine impacts amino acid transport across placenta
-Carbon monoxide decreases oxygen carrying capacity of placenta - Pre-conception risks
-Reduces fertility - Antenatal risks
-Miscarriage (33%)
-Ectopic pregnancy
-Fetal anomalies
-IUGR (200%)
-Placental abruption (200%)
-PTL and PPROM (200%)
-Placenta praevia (33%)
-Worsens PET
-VTE
-Stillbirth (accounts for 10% of stillbirths) - Postnatal risks
-SIDs (300%)
-Respiratory disease
-ENT infections
-Childhood cancer
-Cognitive development
7
Q
How should women who smoke be managed in pregnancy (8)
A
- Screen for smoking/ recent quitting/passive smoking and other drug use
- Educate mother to quit
- Offer programmes which aid in quitting
- Offer NRT after discussing risks and benefits
-Better if not patch but gum or lozenge to avoid continuous nicotine exposure to fetus. Remove patches at night if chosen
-Cochrane shows no impact to health of mother or fetus with NRT
-Avoid Zyban or Champix - Support family and partner to quit
- Continue support in postnatal period - 50-70% resume smoking after a yr
- Support safe sleeping to reduce SIDS
- E cigarettes and vaping is not recommended. Nicotine causes perinatal damage
8
Q
Discuss neonatal abstinence syndrome
-Cause (2)
-Timing (3)
-Clinical features (5)
-Long term risks (3)
-Treatment (4)
A
- Cause
-Withdrawal to drugs that the fetus was exposed to in utero
-Worse with opiates and heroine but happens with all drugs - Timing
-Onset around 48hrs
-Can take up to 2 weeks to develop
-Cocaine and benzos can delay onset - Clinical features
-High pitched cry, GI dysfunction, tremors, irritable, poor feeding
-Usually resolves in a few days but can take up to 3 months - Long term risks
-SUDI
-Behavioural problems
-Delayed cognition - Treatment
-Avoid naloxone - makes worse
-Treat with morphine or methadone
-Treat seizures
-Less than 50% need treatment
9
Q
How should women with substance abuse disorders be managed in pregnancy
-Antenatal
-Intrapartum
-Postpartum
A
- Antenatal management
-MDT with social work, addiction services, neonatologists
-Support to attend appointments
-Nutritional support
-Hx of all substance use
-Review mental health and domestic violence
-Screen for blood borne viruses
-Anatomy scan
-Growth scans
-Check BP and urine - Intrapartum care
-Continue methadone if taking
-Continuous fetal monitoring
-May have higher anaesthetic requirement
-Paeds input - Postpartum management
-Observe for neonatal abstinence syndrome
-Encourage breast feeding
-Discuss contraception
-Social services input / OT for ? uplift / support
10
Q
Discuss alcohol use and pregnancy
-Incidence (3)
-Pregnancy risks (4)
-Risk factors for ongoing alcohol use in pregnancy (2)
A
- Incidence
-1% of women report using alcohol in pregnancy
-50% of women consume alcohol before knowing they are pregnant
-25% of women continue to use alcohol in pregnancy - Pregnancy risks
-Miscarriage 2-3 times higher
-Still birth
-LBW
-PTB - Risks for ongoing alcohol use
-Higher SES
-Higher education
11
Q
How should women with alcohol use disorder be managed in pregnancy
-Antenatal (10)
-Intrapartum (3)
-Postpartum (4)
A
- Antenatal
-Screen all women with T-ace screening tool
-Screen for other psychosocial risks (domestic violence, other drug use, mental health)
-Involve MDT
-Offer management of withdrawal
-Educate - no known safe level
-Screen for blood borne viruses and syphillis
-Consider 100mg thiamine in heavy drinkers
-Fetal anatomy scan
-Serial growth scans
-Update child protection and social work - Intrapartum
-May need higher doses of analgesia
-Be vigillent for withdrawal
-Continuous CTG - Postpartum
-Monitor for withdrawal - both mother and baby
-Contraception
-Encourage breastfeeding
-Ongoing social work support
12
Q
Discuss the impact of alcohol to the fetus
-General points about alcohol (4)
-Birth defects (4)
-Neonatal effects (1)
-Long term effects (5)
A
- General points
-Alcohol is teratogenic
-Alcohol reaches the fetus in similar amounts as is experienced by the mother
-Has a dose related effect
-There is no known safe limit in pregnancy or breast feeding - Birth defects
-Congenital heart disease - ASD/VSD
-Renal anomalies - hypoplasia, hydronephrosis, bladder diverticular
-Short stature and skeletal deformities
-Fetal alcohol spectrum disorder - Neonatal effects
-Withdrawal - Long term effects
-Increased neglect and abuse
-Attention and memory deficits
-Hyperactivity
-Learning impairment
-Behaviour and conduct problems
13
Q
Discuss fetal alcohol spectrum disorder
-Incidence (4)
-Diagnostic features
A
- Incidence
- 1-3% of births affected by the spectrum
- 0.1% have fetal alcohol syndrome
- 4% of heavy drinkers have babies with FAS - likely multifactorial
-Most common form of mental impairment - Diagnostic criteria
-Alcohol exposure + severe impairment in 3 domains
Domain 1: dysmorphic features - short palpebral fissures, thin upper lip, smooth phillrum, flat mid face
Domain 2: Growth restriction - SGA, failure to thrive
Domain 3: CNS involvement - reduced cranial size, structural brain abnormalities, neurological signs (motor function, poor gait, hearing loss)
14
Q
What is the impact of amphetamines
-Fetal impact (4)
-Pregnancy impact (4)
-Neonate impact
A
- Fetal impact
-Cardiac malformations
-Gastrochesis
-Cleft lip if prior to 7 weeks
-IUGR - Pregnancy impact
-PTL
-HTN
-Abruption
-PET - Neonate impact
-Neonatal abstinence syndrome
-Reduced growth
-Poor school performance
15
Q
What are the RANZCOG recommendations for substance use in pregnancy (5)
A
- Screen women to identify substance use
- Refer to MDT for management
- Refer to mental health services if indicated with mental health screening or previous Hx
- Screen with T-ace if harmful alcohol use is suspected and refer as necessary
- Re-screen for blood borne viruses
16
Q
Discuss influenza vaccination
-Type of vaccination (1)
-When to give (3)
-Benefits (5)
-Risks (1)
-Absolute contra-indications (1)
A
- Type of vaccination
-Killed virus - When to give
-Give each year
-If pregnancy span 2 flu seasons give vaccinations for both seasons
-Optimal time to give early in flu season but any time is fine - Benefits
-Protects mother against serious influenza complications
-Protects baby up to 6 months against neonatal influenza by 60%
-Reduces risk of still birth
-Reduces lab confirmed influenza by 50%
-Prevents 1-2 hospitalisations /1000 vaccinated women - Risks
-No risk of teratogenicity, growth or poor neurological outcomes - Absolute contra-indications
-Anaphylaxis to previous vaccine
17
Q
Discuss whooping cough vaccination
-Type of vaccine (1)
-How it works (2)
-Timing of vaccine (3)
A
- Type of vaccine
-Inactivated toxoid from bacteria - How it works
-Direct passive protection by transplacental transfer of antibodies
-Infants get vaccinated but antibodies not sufficient till after 3rd dose at 5 months - Timing of vaccine
-Optimal 28-32 weeks
-Can give from 16 weeks to 2 weeks before delivery
-Give at every pregnancy even if close together
18
Q
Discuss air travel in pregnancy
-Timing
-Impact to pregnancy
-VTE risk and management
-Radiation exposure
A
- Timing
- Not recommended if risk of PTL after 32/40
-Most carriers say not after 32/40
-Travel >4 hrs not recommended after 36/40
-Safest time to travel is second trimester - decreased risk miscarriage - Impact on pregnancy
-No evidence air travel increases pregnancy complications - VTE risk
-Increased risk lasts up to two weeks following travel
-Hydrate, mobilise, avoid tea and coffee
-Consider LMWH in those with increased baseline DVT
-TEDS if >4hrs - Radiation exposure
-Minimal with flying or with body scanner
19
Q
Discuss vaccination in pregnancy
-Absolutely contra-indicated in pregnancy
-OK if necessary
-Recommended
A
- Absolutely contra-indicated vaccines
-Live attenuated vaccines
-MMR, BCG, Typhoid, Rota virus, HPV, Varicella
-If receive accidently then reassure. Not a cause for abortion - OK if necessary
-Inactivated bacterial or viral vaccines
-Meningococcus, pneumococcus, Hep B - Recommended
-Boostrix, tetanus, influenza, COVID
20
Q
Discus preconception screening for infection and immunity
-What should be routinely screened for pre conception (7)
-What should not be screened for preconception (3)
A
- What should be routinely screened for
-Rubella - then vaccinate and wait 28 days prior to trying
-Hep B and C
-HIV and syphilis and STI
-Varicella IgG and offer vaccination if negative - What not to screen for
-CMV, Parvovirus, Toxoplasmosis
21
Q
Discuss exercise in pregnancy
-Contra-indications to exercise in pregnancy (2)
-Recommendation for exercise frequency (1)
-Recommendation for exercise duration (2)
-Recommendation for exercise intensity (3)
-Types of exercise to avoid (3)
A
- Contra-indication to exercise
-Cardiovascular disease, poorly controlled asthma or thyroid disease
-Placenta praevia, PET, gHTN, Increased risk of PTL, IUGR - Recommended frequency
-Most days - Duration
-300 mins per week or 30 mins per day.
-If inactive build up to 30mins per day - Recommended intensity
-Exercise to increase heart rate and breathing
-Don’t exercise so much can’t complete sentences
-If already very fit can continue on at usual intensity - Types of exercises to avoid
-Walking lunges - pelvic instability
-Team sports with risk of trauma or where balance is required
-Running, bouncing, jumping exercises - can damage pelvic floor
22
Q
Discuss exercise in pregnancy
-Benefits
-Risks
A
- Benefits
-Prevents excess weight gain
-May help with PET and GDM - Risks
-No evidence exercise is risky in pregnancy
23
Q
Discuss risks of obesity in pregnancy
-Maternal impact antenatally (9)
-Maternal impact intrapartum (6)
-Maternal impact postpartum (4)
A
- Maternal impact - antenatal
-Decreased fertility
-Increased miscarriage rate (2 x if BMI >40)
-Increased diabetes risk (7% GDM if BMI >40)
-HTN and PET
-VTE (x10 if BMI >40)
-Still birth BMI >30
-PTB
-OSA
-Maternal death - Maternal impact Intrapartum
-Labour dystocia
-Increase IOL rates and failed IOL
-Poor fetal monitoring
-Difficult labour analgesia
-Difficult fetal monitoring
-Increased risk of instrumental delivery
-Increased risk of shoulder dystocia
-Increased risk of CS (40% if BMI >40) - Maternal impact postpartum
-PPH
-Wound infection
-Postnatal depression
-VTE
24
Q
Discuss obesity in pregnancy
-Impact to fetus (8)
A
-Increased fetal anomalies - cardiac, NTD, abdominal wall
-Macrosomia
-SGA
-Prematurity
-Stillbirth and neonatal death
-NICU admission
-Obesity and metabolic issues in later life
-Cardiometabolic issues and neurodevelopmental issues
25
What are the risks of being underweight in pregnancy (3)
1. Decreased fertility
2. PTB
3. Low birth weight
26
What is the recommended weight gain in pregnancy
-BMI <18.5
-BMI 18.5-24.9
-BMI 25 - 29.9
-BMI >30
1. BMI <18.5 12.5 - 18kg
2. BMI 18.5 - 24.9 11.5-16kg
3. BMI 25-29.9 7-11.5kg
4. BMI >30 - 5-9kg
27
Discuss management of obesity in pregnancy
-Pre-conception (3)
-Antenatal (8)
-Intrapartum (6)
-Postpartum (3)
1. Pre-conception
-Folic acid 5mg
-Advise and support weight loss
-Discus risks and outcomes
-Avoid weight loss meds if trying to conceive
2. Antenatal
-Early dating scan as LMP often inaccurate
-Advise appropriate weight target
-Folic acid 5mg, Vit D 400IU
-Consider aspirin for PET prophylaxis
-NT and anatomy scan
-OGTT
-Anaesthetic review
-VTE prophylaxis if high risk through pregnancy
-Serial growth scans
3. Intrapartum
-Alert senior obstetrician and anaesthetics
-Early cannulation
-Early epidural
-Continuous fetal monitoring - consider FSE
-Confirm presentation with USS
-Active management third stage
4. Postpartum
-VTE prophylaxis according to risk
-Contraception - jadelle impacted by weight
-Review mental health
28
Discuss Caesarian section technique for raised BMI
-Incision types
-Pros of incision types
-Cons of incision types
-Other considerations
1. Incision types
Suprapubic transverse
-OK if wt <180kg
-Use manual retraction of pannus
-Con: Increased wound infection
-Pro: More familiar technique
Supra-umbillical
-If weight >180kg
Cons: Reduces exposure to lower segment
Pros: Lower wound infection rates, lower blood loss, decreased OT time, less OP pain
2. Other considerations
-Increased cephazolin dose 2g if >80kg, 3g if >120kg
-VTE prophylaxis 40mg if <90kg, 60mg if 90-130, 80mg if >130kg
29
Discuss caesarian section technique for raised BMI
-Closure type
-Use of drains
-Choice of dressing
1. Closure type
-If midline aim for mass closure
-Close adipose layer if >2cm
-Can close skin with subcut or staples
2. Use of drains
-Not advised
3. Use of dressing
-Negative pressure dressing
30
Discuss pregnancy post bariatric surgery
-Timing of pregnancy (1)
-Benefits of bariatric surgery for pregnancy (4)
-Risk of bariatric surgery to pregnancy (2)
-Antenatal considerations (3)
1. Timing
-Avoid pregnancy for 12-24 months post OP
-COC/POP may not be ass effective for contraception.
2. Benefits
-Improved fertility
-Reduced risk GDM
-Reduced PIH and PET
-Reduced macrosomia
3. Risks
-IUGR
-Stillbirth
4. Antenatal considerations
-Refer to dietician
-Consider additional vitamin supplements - esp. in gastric bypass
-Increase monitoring of minerals and vits during pregnancy
-Avoid OGTT do BSL for 4-7/7 as OGTT can cause dumping syndrome
-Consider Fe infusion for better absorption if required
31
What are the RANZCOG recommendations for exercise in pregnancy (6)
1. Women without contra-indications w=should participate in regular aerobic and strength exercises
2. Women should be advised that regular exercise is not detrimental
3. Assess women for possible contraindications for exercise in pregnancy
4. Consider frequency, mode, intensity of exercise
5. Consider baseline fitness and previous exercise experience
6. Exercise for pregnant women should take into consideration physiological adaptations
32
Discuss incarcerated uterus
-Definition
-Incidence
-Risk factors
1. retroflexed uterus fails to ascend into the abdomen as pregnancy progresses and is trapped under the sacral promontory
2. Incidence
1:3000
3. Risk factors
-Endometriosis
-Uterine abnormalities
-Posterior fibroids
-Adhesions
-Placenta accreta
33
Discuss incarcerated uterus
-Clinical presentation
-Examination findings
-USS features
1. Clinical presentation
-50% present with lower back pain
-PVB
-Urinary sx
-GI symptoms - constipation/ tenesmus
2. Examination findings
-Cervix is anterior and under the pubic symphysis
-Bulge in the posterior fornix
-Fundus palpable within the curvature of the sacrum
3. USS features
-Fetus positioned in POD
-Maternal bladder malpositioned
34
What are the RANZCOG recommendations for Obesity management in pregnancy (16)
1. Preconception BMI evaluation, optimisation of weight and information about risk factors for obesity in pregnancy should be undertaken
2. Women with a BMI >30 should take 5mg folic acid as they have an increased risk of NTD
3. Women who have undergone weight loss surgery require additional supplements and should avoid pregnancy at times of rapid weight loss
4. BMI should be assessed in the first trimester and retaken at least once a trimester
5. Pregnancy women should be offered advice about increased risks with obesity and plans to mitigate risks
6. Local protocols should be available for managing obesity in pregnancy
7. Provide advice around healthy weight gain and exercise in pregnancy. Refer to dietician if obese
8. Obese women should be offered early screening for GDM and be informed of increased risk of no result NIPT
9. Influenza and COVID vaccines are strongly recommended for pregnant women with obesity
10. Obese women esp. those more than BMI 40 should have an anaesthetic referral
11. Consider calcium and aspirin supplementation if other risk factors
12. Offer serial growth scans if obese but remember sens is low for detecting IUGR on scan in obese women
13. Inform obese women of the increased risk of complications and failure of VBAC
14. Women with BMI >50 should be offered delivery before their due date. No consensus on when tho. Aim 39/40
15. Obese women should be informed of their increased risk of EMCS
16. Intrapartum risks including PPH and shoulder dystocia should be planned for and mitigated as possible
RANZCOG 2024 - Antenatal Edward
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