Group D - Normal pregnancy, labour and puerperium Flashcards
Briefly outline the difference between gravidity and parity
Gravidity = number of times a woman has been pregnant (regardless of the outcome)
Parity = total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks)
Outline the weeks for the 3 trimesters
First trimester: start of pregnancy until 12 weeks
Second trimester: 13 weeks until 26 weeks
Third trimester: 27 weeks onwards
At what gestation do pregnant women typically start to feel fetal movements?
How does this vary for women who have had children previously
Start to feel fetal movements between:
16 to 24 weeks gestation (around 4-5 months)
If had children previously:
Feel later, often not until 20 weeks gestation
When does nausea and vomiting typically begin, peak and resolve in pregnancy?
Begin:
- 4th to 7th week
Peak:
- 9th to 16th week
Resolve:
- Around the 20th week
How is an accurate estimation of gestation and estimated date of delivery (EDD) achieved?
Outline some factors affecting accurate dating
During dating scan between 10-14 weeks: ultrasound scan to measure the crown-rump length (CRL). Before this date, Naegele rule can use LMP to predict
Factors affecting accurate dating:
- Uterine fibroids
- Maternal obesity
- Multiple pregnancy
Outline the booking screening blood tests offered to all women during pregnancy
Any additional measurements taken at a booking clinic
- FBC (anaemia)
- Electrophoresis for haemoglobinopathies (thalassaemia and sickle cell)
- Blood group test and antibody screening (rhesus and non-rhesus antibody status)
- Infection screen (hepatitis B, HIV and syphilis)
- Urine MSU (asymptomatic bacteraemia)
Additional measurements:
- Weight and height for BMI
- Blood pressure
haematuria, proteinuria and glycosuria
Outline topics covered in the booking visit
- What to expect during pregnancy
- Lifestyle advice
- Supplements
- Mental health
- Discuss screening tests
- Preference for birth
- Antenatal classes
- Breastfeeding classes
Outline how the following medical conditions can impact the baby / mother
- Diabetes (T1DM or T2DM)
- Hypothyroidism
- Epilepsy
- Previous VTE
- Blood bourne viruses
- Genetic diseases
Diabetes (type 1 or 2):
- Poor maternal health
- Fetal complications (e.g. macrosomia)
Hypothyroidism:
- If not well controlled, can lead to congenital hypothyroidism impacting neuro-development
Epilepsy:
- Seizures during pregnancy increase risk of miscarriage
- Also many anti-epileptic drugs are teratogenic
Previous VTE:
- Significantly increased risk of developing further VTEs without prophylactic treatment (e.g. LMWH)
Blood-borne viruses:
- Risk of vertical transmission during birth
Genetic disease:
- May influence the management of the patient and their pregnancy
List some drugs than are known to be teratogenic
- ACE inhibitors
- Sodium valproate
- NSAIDs
- Methotrexate
- Retinoids
- Trimethoprim
List some harmful substances that can cross the placenta
- Alcohol
- Thalidomide
- Drugs of abuse
Therapeutic drugs:
- Anti-epileptics e.g. Lithium
- Warfarin
- ACEi
- Tetracyclines
- Trimethoprim
Smoking - indirectly, affects development of the placenta
Outline the timeline for the following appointments in the pregnancy timeline
- Booking scan
- Dating scan
- Antenatal appointment
- Anomaly scan
Booking scan: before 10 weeks
Dating scan: 10 - 14 weeks (around 12)
Antenatal appointment: 16 weeks
Anomaly scan: 18 - 21 weeks
Briefly outline what happens during following appointments in the pregnancy timeline
- Booking scan
- Dating scan
- Antenatal appointment
- Anomaly scan
Booking scan: baseline assessment and plan the pregnancy
Dating scan: ultrasound scan to calculate gestational age from crown-rump length and identify multiple pregnancy
Antenatal appointment: discuss results and plan future appointments
Anomaly scan: ultrasound to identify any abnormalities e.g. heart conditions
Outline some things for pregnant women to avoid during pregnancy
- Alcohol
- Smoking
- Unpasteurised dairy / blue cheese
- Liver or pate
- Raw poultry / eggs / undercooked ready meals
- Contact sports
- Flying (increases risk of VTE)
Suggest some risk factors for which you would screen for gestational diabetes
- High BMI (>30)
- Previous macrosomia
- Previous gestational diabetes
- Family history of diabetes
- Ethnicity linked to diabetes e.g. South Asian or middle eastern
Suggest some risk factors for which you would screen for pre-eclampsia
- Previous pre-eclampsia
- Family history of pre-eclampsia
- Age > 40
- Increased BMI (>30)
- First pregnancy
- Twin pregnancy (multiples)
- Pre-existing HTN
- Pre-existing renal disease
Outline symptoms of preeclampsia
- Severe headache
- Vision changes e.g. blurring or flashing
- RUQ or epigastric pain
- Vomiting
- Swelling (hands, feet, face)
Start the management options offered to a post-term pregnancy (overdue at 41 weeks), what happens if this is unsuccessful and what if the induction is refused
At 41 weeks = offer membrane sweep (separation causes the release of prostaglandins which may stimulate spontaneous labour)
If the sweep is unsuccessful = offer administration of prostaglandins
If induction of labour is refused = expectant management involving regular foetal monitoring is required
Outline the 3 trisomy conditions tested for during nuchal translucency
1) Trisomy 13 = Patau
2) Trisomy 18 = Edwards
3) Trisomy 21 = Down’s
Outline the two antenatal screening combinations for trisomy conditions (Down’s, Patau and Edwards)
Combined test from 11-14 weeks
1. Ultrasound calculate nuchal translucency > 6mm
2. Maternal blood tests: beta-HCG (higher = risk) and PAPPA (lower = risk)
Quadruple test from 15-20 weeks, if missed dates for combined test
ONLY maternal blood tests
1. beta-HCG (higher = risk)
2. AFP (lower = risk)
3. Serum oestradiol (lower = risk)
4. Inhibin A (higher = risk)
Outline the significance of a thickened nuchal translucency on ultrasound scan
Presence of a thickened nuchal translucency is associated with chromosomal abnormalities and therefore requires further testing
A diagnosis can be made by amniocentesis or chorionic villus sampling
Outline the difference between amniocentesis and chorionic villus sampling, in terms of:
- What it samples
- What gestation it is typically done in
- Whether it can measure alpha-feto protein or not
Amniocentesis (better):
- Samples amniotic fluid containing fetal cells (which are then analysed)
- 14 weeks gestation (2nd trimester)
- CAN measure alpha-feto protein
Chorionic villus sampling:
- 8-10 weeks gestation (1st trimester)
- CAN’T measure alpha-feto protein
- Can cause absent limb defect
*Chorionic villus sampling can be done earlier, which means the pregnancy can be electively terminated earlier
Outline the purpose of screening tests for trisomies in pregnancy
- Reproductive choice for parents to decide whether to terminate
- Allows time for parents to prepare
- Allows planning of birth in specialist centre
- Allows for intrauterine therapy
Outline the difference between a monochorionic and dichorionic twin pregnancy and how regularly ultrasound tests should be done
Monochorionic = share the same placenta (risk of twin-to-twin transfusion syndrome
USS every 2 weeks
Dichorionic = have a placenta each
USS every 4 weeks
State the 2 vaccines that are offered to all pregnant women
- Whooping cough (from 16 weeks)
- Influenza (in autumn/winter)
LIVE vaccines are avoided in pregnancy
Outline 2 supplements that should be taken during pregnancy
- Folic acid 400mg (standard) from before pregnancy to 12 weeks - 500mg if high risk e.g. diabetic
- Vitamin D
Avoid vitamin A supplements - teratogenic at high doses
Outline the consequences of alcohol in early pregnancy
- Foetal alcohol syndrome
- Preterm delivery
- Small for dates
- Miscarriage
Outline the consequences of smoking in pregnancy
- Foetal growth restriction
- Preterm delivery
- Small for dates
- Miscarriage
- Placental abruption
- Preeclampsia
- Sudden infant death syndrome (SIDS)
- Cleft lip / palette
Outline the frequency of antenatal appointments for the following cases:
- Uncomplicated, nulliparous
- Uncomplicated parous
Uncomplicated, nulliparous: 7 appointments
Uncomplicated parous: 10 appointments (more if had children before)
Outline how the following antenatal conditions are managed
- Pregnancy past 41 weeks
- Breech presentation at term
- High risk for VTE
- High risk for preeclampsia
- Suspected foetal growth restriction
Pregnancy past 41 weeks:
- Offer a membrane sweep
- Offer induction of labour (after 41 weeks), if declined then regular CTG and USS monitoring
Breech presentation at term:
- Offer external cephalic version (after 37 weeks if no contraindications)
High risk for VTE:
- Offer LMWH prophylaxis
High risk for preeclampsia:
- Offer Aspirin from 12 weeks onwards, until 36 weeks
Suspected foetal growth restriction:
- Serial growth scans
State the 2 times during a pregnancy when a woman is screened for anaemia and provide the normal ranges
- Booking bloods at < 10 weeks
Range: > 110 g/l - At 28 weeks
Range: > 105 g/l
Outline how anaemia is managed during pregnancy
Iron replacement - ferrous sulphate 200mg tds
- If not tolerated or discovered late, may require a IV iron
- Further tests should be undertaken if there is no rise at 2 weeks
- Multiple pregnancy should have an additional FBC at 20–24 weeks
If folate deficiency, give 500mg folic acid (rather than 400mg)
Specialist haematological management if haemoglobinopathy e.g. sickle cell
Outline how acid reflux is managed during pregnancy
Investigations are usually not necessary
1st line: lifestyle advice e.g. eat smaller meals, avoid spicy food
2nd line: medication - antacids and alginates e.g. Gaviscon
- H2 receptor antagonists or PPIs only used if symptoms are severe
Pelvic girdle dysfunction - state the following:
- Pathophysiology
- Symptoms
- Investigations
- Management
Pathophysiology:
- Caused by the pelvic joints moving unevenly
Symptoms:
- Pelvic pain (pubic, lower back, hips, groin, thighs or knees)
- Clicking or grinding in pelvic area
- Pain made worse by movement
Investigations:
- Physiotherapy diagnosis
Management:
- Lifestyle modification to e.g. changing position frequently, equal weight on both legs and avoiding exacerbation e.g. heavy lifting
- Conservative e.g. exercises, hot baths
- Analgesia
- Crutches or wheelchair
- Can still have a natural birth
