Pre and Antenatal Care

Question 1

PRE-CONCEPTION VISIT
✔️ who
✔️ when
✔️ what / components

Answer 1

WHO: GP

WHEN: prior to conception

WHAT:

1. PMHx, PSHx and medications
2. Past obstetric history
   ✔️ previous pregnancies (including ectopic, miscarriages and abortions)
   ✔️ previous deliveries (including mode and indications)
   ✔️ current children
   ✔️ previous complications during pregnancy (e.g. gestation HTN, GDM, pre-eclampsia, APH)
3. Past gynaecological history
   ✔️ LMP
   ✔️ cycle length, regularity, bleeding patterns etc.
   ✔️ previous CST results
   ✔️ previous gynaecological problems (being and malignant)
   ✔️ sexual history (particularly previous STIs and PID)
4. Examination

5. General lifestyle advice
✔️ nutrition
✔️ physical activity
✔️ smoking and alcohol cessation
✔️ weight optimisation / BMI

6. TORCH infections --> information sheet provided!!
✔️ toxoplasma gondii
✔️ others
✔️ rubella 
✔️ CMV
✔️ HIV

7. Folic acid supplementation
8. Vaccinations
   ✔️ whooping cough (given during pregnancy)
   ✔️ influenza (given during pregnancy)

Question 2

FIRST ANTENATAL VISIT
✔️ who
✔️ when
✔️ what

Answer 2

WHO: GP

WHEN: within 12 weeks of pregnancy

WHAT:
1. LMP

2. Estimate EDD –> LMP + 280 days
3. Confirm with serum beta-hCG levels
4. Arrange pregnancy bloods (FBC, UECs, eLFTs, coags, maternal blood group, HIV, HepB, HepC and syphillus serology
5. Arrange follow up tests:
   ✔️ NTT (11 to 13 weeks)
   ✔️ morphology scan (18 to 20 weeks)
6. Discuss ongoing care
   ✔️ midwives / GP shared care
   ✔️ private obstetrician
   ✔️ public obstetrician
7. Arrange influenza vaccine
8. Discuss normal changes associated with pregnancy
   ✔️ weight gain (4.5 to 13kg over the entire pregnancy)
   ✔️ increased nutritional requirements (300kCal / day in second and third trimester)
   ✔️ cardiovascular changes (hypotension leading to dizziness and headache)
   ✔️ swelling in ankles (later)
   ✔️ morning sickness (hyperemesis gravardium)
   ✔️ haematological changes (IDA)
   ✔️ gastrointestinal changes (GORD)
   ✔️ MSK changes (lower back pain, carpal tunnel disease)
9. Answer any questions.

Question 3

MIDWIFE BOOKING IN APPOINTMENT
✔️ who
✔️ when
✔️ what

Answer 3

WHO: midwives

WHEN: 12 to 18 weeks

WHAT:
1. Ask about symptoms of pregnancy
✔️ nausea and vomiting
✔️ weight gain
✔️ appetite 
✔️ headache and blurred vision
✔️ swelling of ankles
✔️ foetal movements

3. Measure:
   ✔️ maternal BP
   ✔️ foetal HR
   ✔️ maternal urine dipstick
4. Review blood tests
5. Review NTT
6. Order Maternal Serum Alpha Feto Protein (MS-AFP)

Question 4

ONG BOOKING IN APPOINTMENT
✔️ who
✔️ when
✔️ what

Answer 4

WHO: obstetrician

WHEN: 20 weeks

WHAT:
1. Ask about symptoms of pregnancy
✔️ nausea and vomiting
✔️ weight gain
✔️ appetite 
✔️ headache and blurred vision
✔️ swelling of ankles
✔️ foetal movements

2. Measure:
   ✔️ maternal BP
   ✔️ foetal HR
   ✔️ maternal urine dipstick
3. Review morphology results
4. Review maternal serum alpha foetal protein
5. Order OGTT (for 24 to 28 weeks)
6. Order Quadruple tests (AFP, ostrodial, inhibin, Beta-HCG)

Question 5

24-WEEK APPOINTMENT

✔️ what

Answer 5

1. Discuss: 
✔️ foetal movements
✔️ headache and dizziness
✔️ visual changes
✔️ swelling

2. Measure:
   ✔️ fundal height
   ✔️ maternal HR and BP
   ✔️ foetal BP
3. Discuss OGTT results
   ✔️ fasting < 5.1 mmol / L
   ✔️ post 1 hour < 10.0 mmol / L
   ✔️ post 2 hour < 8.5 mmol / L

Question 6

28-WEEK APPOINTMENT

✔️ what

Answer 6

1. Discuss: 
✔️ foetal movements
✔️ headache and dizziness
✔️ visual changes
✔️ swelling

2. Measure:
   ✔️ fundal height
   ✔️ maternal HR and BP
   ✔️ foetal BP
3. Discuss OGTT results
   ✔️ fasting < 5.1 mmol / L
   ✔️ post 1 hour < 10.0 mmol / L
   ✔️ post 2 hour < 8.5 mmol / L
4. Arrange dTPA vaccination.
5. Give anti-D if required.

Question 7

32 WEEK APPOINTMENT

Answer 7

1. Discuss: 
✔️ foetal movements
✔️ headache and dizziness
✔️ visual changes
✔️ swelling

2. Measure:
   ✔️ fundal height
   ✔️ maternal HR and BP
   ✔️ foetal BP
3. Give anti-D if required (second dose).
4. Begin discussing maternal wishes for delivery.

Question 8

36 WEEK APPOINTMENT

Answer 8

1. Discuss: 
✔️ foetal movements
✔️ headache and dizziness
✔️ visual changes
✔️ swelling

2. Measure:
   ✔️ fundal height
   ✔️ maternal HR and BP
   ✔️ foetal BP
3. Test GBS status.
4. Continue discussing maternal wishes for delivery.

Question 9

40 WEEK APPOINTMENT

Answer 9

1. Discuss: 
✔️ foetal movements
✔️ headache and dizziness
✔️ visual changes
✔️ swelling

2. Measure:
   ✔️ fundal height
   ✔️ maternal HR and BP
   ✔️ foetal BP
3. Foetal position and lie, head engagement etc.
4. Induce labour at 40 + 1.

Question 10

What is the most appropriate regime for antenatal visits?

Answer 10

Pre-conception counselling

Initial GP Visit < 12 weeks

Midwife Booking In Appointment 12 to 18 weeks

ONG Booking In Appointment 20 Weeks

20 to 32 Weeks: every 4 weeks

32 to 36 Weeks: every 2 weeks

36 to 40 Weeks: every one week

Question 11

When is RhD given (if required)?

Answer 11

28 and 34 weeks.

Indications:
✔️ maternal RhD -ve
✔️ unknown RhD status

Question 12

When is GBS tested for?

Answer 12

36 weeks.

Question 13

Define HYPEREMESIS GRAVIDARUM.

Answer 13

Severe form of morning sickness characterised by ketosis and > 5 % weight loss.

Question 14

Describe some management strategies for HYPEREMESIS.

Answer 14

✔️ anti-emetic (e.g. metoclopramide, ondansetron)
✔️ IV fluids
✔️ electrolyte and vitamin replacement (thiamine, Vitamin B, Vitamin C, Vitamin E)
✔️ monitoring baby

Question 15

Define INTRAUTERINE GROWTH RESTRICTION.

Answer 15

IUGR is defined as a foetus measuring <10th centile for its age.

It may also be considered when fundal height is greater than 4cm less than expected (e.g. 28 cm at 32 weeks).

Question 16

Identify some causes for IUGR.

Answer 16

✔️ placental insufficiency
✔️ pre-eclampasia
✔️ maternal cardiovascular or renal disease
✔️ maternal diabetes (pre-existing or GDM)
✔️ placenta previa and other disorders of abnormal placentation
✔️ maternal infection (e.g. CVM, rubella, herpes etc)
✔️ maternal substance use (e.g. drugs, smoking)