13 - Antenatal Care Flashcards
What is the difference between gravida and para?
Gravida is number of times a woman has been pregnant
Para is the number of live births after 24 weeks gestation
e.g pregnant woman with 4 kids is G5, P4
What is classified as first, second and third trimester?
First: 0-12 weeks
Second: 13 - 26 weeks
Third: 27 weeks to birth
Fetal movements start around 20 weeks
How many antenatal appointments does a woman have?
10 for nulliparous
7 for multiparous
When should a booking appointment take place and what happens at this?
Before 10 weeks
Full history needed included previous mental health, ask about domestic violence if alone
Examination: height, weight, BMI, urinalysis for proteinuria, blood pressure, FBC for blood type and rhesus
Offer screening (can decline): HIV, Syphilis, Rhesus D, Sickle Cell, Thalassemia, Fetal Anomaly
Provide general information about pregnancy
What information about pregnancy is given to a mother in a booking appointment?
• changes during pregnancy
• staying healthy during pregnancy: flu and whooping cough vaccine, infections that can impact baby, safe use of medicines, mental health
• lifestyle: diet, exercise, smoking, alcohol, recreational drug use
• antenatal care: why different appointments and screening
• contact details for midwifery team if issues e.g bleeding
A nulliparous woman has 10 antenatal appointments, when do these take place and what happens at these?
- Booking scan
- Dating scan
- Antenatal Appointment
- Anomaly scan
- Antenatal appointments
A multiparous woman only has 7 antenatal appointments, which ones do they not have?
- 25 weeks
- 31 weeks
- 40 weeks
At a booking appointment what should you do if a woman is smoking?
Offer smoking cessation for both her and her partner as passive smoke is just as bad for the baby
What are two sensitive issues that need to be established about a woman preferably at the booking scan?
- History of FGM
- Any domestic violence
What are some screening programmes offered to women who are pregnant?
- Infectious screening e.g HIV, Hep, Syphillis
- Sickle Cell and Thalassemia screening
- Fetal anomaly screening
Woman can decline any of these
When should you offer anti-D prophylaxis to rhesus negative women who are pregnant?
28 weeks
When should you take symphis fundal height?
From 24 weeks at every antenatal scan unless had done in last 2 weeks or if having growth scan
Only do for singleton pregnancy
If large or small for age send for US to assess fetal growth and wellbeing. Base urgency on fetal movements and mothers BP.
Don’t usually US after 28 weeks unless issue with this height
Breech presentation is looked at at the 36 week mark, what should you do if you suspect a baby is breech?
Send for US
If confirmed on US discuss the options e.g external cephalic version, elective C-section, breech vaginal birth
What are some things done at every antenatal appointment past 25 weeks?
- Discuss plans for the remainder of the pregnancy and delivery
- Symphysis–fundal height from 24 weeks
- Fetal presentation assessment from 36 weeks onwards
- Urine dipstick for protein for pre-eclampsia
- Blood pressure for pre-eclampsia
- Urine for MS+C for asymptomatic bacteriuria
What are some additional appointments that a nulliparous woman may need on top of her 10 appointments scheduled routinely during pregnancy?
- Additional appointments for higher risk
- Oral glucose tolerance test in women at risk of gestational diabetes (between 24 – 28 weeks)
- Anti-D injections in rhesus negative women (at 28 and 34 weeks)
- Ultrasound scan at 32 weeks for women with placenta praevia on the anomaly scan
- Serial growth scans are offered to women at increased risk of fetal growth restriction
What vaccines are offered to pregnant women?
Avoid live vaccines like MMR
- Flu if winter
- Whooping cough/Pertussis from 16 weeks gestation
What is some general lifestyle advice to give a mother at a booking appointment?
- Folic Acid 400mcg before pregnancy to 12 weeks
- Vitamin D supplement
- Avoid vitamin A supplements and eating liver or pate (vitamin A is teratogenic at high doses)
- Don’t drink alcohol (risk of fetal alcohol syndrome)
- Don’t smoke
- Avoid unpasteurised dairy or blue cheese (risk of listeriosis)
- Avoid undercooked or raw poultry (risk of salmonella)
- Continue moderate exercise but avoid contact sports
- Sex is safe
- Flying increases the risk of VTE
- Place car seatbelts above and below the bump (not across it)
What are some of the issues with drinking alcohol during pregnancy?
Worse complications if in the first three months
- Miscarriage
- Preterm labour
- Fetal Alcohol syndrome
- Small for dates
What are some of the risks with smoking during pregnancy?
- Fetal growth restriction (FGR)
- Miscarriage
- Stillbirth
- Preterm labour and delivery
- Placental abruption
- Pre-eclampsia
- Cleft lip or palate
- Sudden infant death syndrome (SIDS)
Can you fly during pregnancy?
Can fly up to
- 37 weeks in a uncomplicated single pregnancy
- 32 weeks in a uncomplicated twin pregnancy
After 28 weeks gestation, most airlines need a note from a midwife, GP or obstetrician
What is the structure of what happens at a booking appointment?
(image important)
- Education
- Booking bloods
- Screening for infectious disease, anomolies
- Measurements
- Risk assessment
What booking bloods and measurements are taking at a booking appointment?
Bloods
- FBC for anaemia
- Blood group, Rhesus D
- Thalassemia and Sickle Cell screening if agreed
- Infectious disease screening if agreed
Measurements
- Height, weight, BMI
- Urinalysis for proteinuria and asymptomatic bacteria
- Blood pressure
Who should be offered antenatal classes and what do these classes do?
Nulliparous women or multiparous women with large gaps between pregnancies
What are some of the conditions screened for in the fetal anomaly scan?
What are some of the ways that Down syndrome is screened for and when are these done?
- Combined Test (most accurate): 11 to 14 weeks
- Triple Test: 14 to 20 weeks
- Quadruple Test: 14 to 20 weeks
What happens in a combined test for Down’s syndrome and what results would indicate a high risk of Down’s?
US
- Look at nuchal thickness
- If >9mm higher risk
Maternal Bloods
- b-hCG, higher results higher risk
- Pregnancy Associated Plasma Protein A (PAPPA), lower result higher risk
If a woman presents after 13 weeks gestation, a triple or quadruple test may be done to screen for Down’s syndrome. What do these involve and what results indicate a high risk of Down’s?
All based on maternal bloods
Triple Test
- b-hCG: higher means high risk
- AFP: lower indicates high risk
- Serum estriol: lower indicates high risk
Quadruple Test
- Above plus
- Inhibin A: higher indicates high risk
If a woman is identified as high risk for Down’s syndrome, what diagnostic testing can she be offered?
If risk score is greater than 1 in 150 (5%) offered aminocentesis or CVS
Chorionic Villus Sampling
US guided biopsy of placental tissue, done before 15 weeks
Aminocentesis
US guided aspiration of amniotic fluid. Used later in pregnancy once more amniotic fluid so safer to take a sample
What is another test that can be offered before invasive diagnostic testing if a woman has a high risk score for Down’s syndrome?
Non-invasive prenatal testing
Blood test from mother taken which will contain fragments of fetal DNA that can be analysed
What are the risks associated with aminocentesis and chorionic villus sampling?
Aminocentesis
- 1% risk of miscarriage, higher is <14+0
- False reassurance
- Risk of infection
- Pain
- Rhesus sensitisation
- Increased risk of club foot
Chorionic Villus Sampling
- Miscarriage (higher risk than above)
- Vaginal bleeding
- Other maternal complications include: pain, infection, amniotic fluid leakage and resus sensitisation
- Mosaic result: Amniocentesis may then be offered to establish whether the baby has a mosaic karyotype or if mosaicism is just confined to the placenta
What is red blood cell isoimmunisation?
When a Rhesus negative mother has a Rhesus positive child, their RBCs get into mother’s blood stream and mother produced IgG antibodies against Rhesus
This is called sensitisation, no issues in first pregnancy but issues in next pregnancies as antibodies can cross placenta and cause haemolysis of fetal blood cells, haemolytic disease of newborn
What is the management for rhesus incompatibility?
- Anti-D IM prophylaxis: Given at 28 weeks gestation and then at birth. Prevents sensitisation as once sensitised cannot be reversed
What are some sensitisation events?
- Antepartum haemorraghe
- Aminocentesis
- Abdominal trauma
Must give Anti-D within 72 hours to prevent sensitisation then do Kleihauer test
What is the Kleihauer Test?
After 20 weeks
Checks how much fetal blood passed to mother during a sensitisation event to assess whether further doses of Anti-D needed
Add acid to sample of mother’s blood, fetal cells will persist but mothers will die, calculate amount of Hb left behind
What is the definition of the following terms related to multiple pregnancies and what is the best case scenario for a multiple pregnancy:
- Monozygotic
- Dizygotic
- Monoamniotic
- Diamniotic
- Monochorionic
- Dichorionic
Diamniotic Dichorionic is the best!
How is multiple pregnancy diagnosed?
On US! (also look at gestational age, risk of Down’s and calculate number of placentas and sacs)
- Dichorionic diamniotic: membrane between the twins, with a lambda sign or twin peak sign
- Monochorionic diamniotic : membrane between the twins, with a T sign
- Monochorionic monoamniotic: have no membrane separating the twins
What are the complications with multiple pregnancies?
Risks to the mother:
- Anaemia
- Polyhydramnios
- Hypertension
- Malpresentation
- Spontaneous preterm birth
- Instrumental delivery or caesarean
- Postpartum haemorrhage
Risks to the fetuses and neonates:
- Miscarriage
- Stillbirth
- Fetal growth restriction
- Prematurity
- Twin-twin transfusion syndrome
- Twin anaemia polycythaemia sequence
- Congenital abnormalities
What is twin to twin transfusion syndrome?
When fetuses share a placenta and one fetus receives the majority of the blood
Recipient can become fluid overloaded with heart failure and polyhydraminos
Donor has growth restriction, anaemia and oligohydramnios.
There will be a discrepancy between the size of the fetuses
In severe cases may need laser treatment to separate the blood supplies
What is twin anaemia polycythemia sequence?
Similar to twin-twin transfusion syndrome, but less acute
One twin becomes anaemic whilst the other develops polycythaemia
What are some differences in antenatal care provided for women with a multiple pregnancy compare to a singleton pregnancy?
Additional monitoring for anaemia, with a full blood count at:
- Booking clinic
- 20 weeks gestation
- 28 weeks gestation
Additional ultrasound scans are required in multiple pregnancy to monitor for fetal growth restriction, unequal growth and twin-twin transfusion syndrome:
- 2 weekly scans from 16 weeks for monochorionic twins
- 4 weekly scans from 20 weeks for dichorionic twins
Planned birth is offered between:
- 32 and 33 + 6 weeks for uncomplicated monochorionic monoamniotic twins
- 36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins
- 37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins
- Before 35 + 6 weeks for triplets
Corticosteroids are given before delivery to help mature the lungs.
How can twins be delivered?
Monoamniotic twins
Elective caesarean section between 32 and 33 + 6 weeks.
Diamniotic twins _(_aim to deliver between 37 and 37 + 6 weeks):
- Vaginal delivery is possible when first baby has a cephalic presentation
- Caesarean section may be required for the second baby after successful birth of the first baby
- Elective caesarean is advised when the presenting twin is not cephalic presentation
What is polymorphic eruption of pregnancy and how is it managed?
Ichy rash that starts in third trimester, begin on abdomen, particularly associated with stretch marks
- Urticarial papules
- Wheals
- Plaques
Management
- Topical emollients
- Topical steroids
- Oral antihistamines
- Oral steroids may be used in severe cases
What is atopic eruption of pregnancy and how is it managed?
Eczema flares during first and second trimester
E type: eczematous inflamed red itchy skin
P (Prurigo) type: intensely itchy papules on abdomen back and limbs
Management
- Emollients
- Topical steroids
- UVB Phototherapy and Oral steroids in severe cases
What is melasma and how is it managed?
Increased pigmentation to patches of skin on the face. Thought to be due to increase in female sex hormones during pregnancy, COCP, HRT
Linked to sun exposure, thyroid disease and FHx
Managment
- Avoid sun exposure and wear sun cream
- Camouflage make up
- Skin lightening cream after pregnancy
- Chemical peels
What is pemphigoid gestationis?
Autoimmune condition where antibodies created to damage connection between dermis and epidermis, in response to placental tissue
Occurs in second or third trimester with itchy red blistering rash around umbilicus that then spreads to other parts of the body and large fluid filled blisters form
Usually resolves after delivery and heals with no scarring
How is pemphigoid gestationis managed and what are the risks to the unborn baby with this condition?
Management
- Topical emollients
- Topical steroids
- Oral steroids
- Immunosuppressants
- Abx if secondary infection
Risks
- Fetal growth restriction
- Preterm delivery
- Blistering rash after delivery as maternal antibodies pass to baby
What is still birth and some causes of this?
Birth of a dead fetus after 24 weeks gestation
What are some factors that can increase the risk of a stillbirth?
- Fetal growth restriction
- Smoking
- Alcohol
- Increased maternal age
- Obesity
- Twins
- Sleeping on back
How is a still birth prevented?
- Risk assess for fetal growth restriction: if at risk then serial growth scans can closely monitor and early delivery if growth is static
- Risk assess for pre-eclampsia: If risk five aspirin
- Lower other risk factors: avoid alcohol, stop smoking, control diabetes, sleep on side
What are three key symptoms that should always be asked when seeing a pregnant woman?
- Normal fetal movements?
- Any abdominal pain?
- Any vaginal bleeding?
How is a still birth diagnosed?
US to look for fetal heart beat
Passive fetal movements can still occur after IUFD so do repeat US
How is a confirmed stillbirth managed?
- 1st Line: Vaginal birth. Choice of induction of labour with mifepristone/misoprostolol or expectant management
- Anti-D prophylaxis if Rh-ve: use Kleihauer test to quantify dose
- Dopamine agonists: e.g Cabergoline to suppress lactation after still birth
- Identify the cause with parental consent
- Offer counselling and support with wishes e.g naming baby, funeral arrangements
What are the reversible causes of adult cardiac arrest?
4 T’s and 4 H’s
4 T’s
- Thrombosis (MI/PE)
- Tension pneumothorax
- Toxins
- Tamponade (Cardiac)
4 H’s
- Hypoxia
- Hypovolemia
- Hypothermia
- HyperK, Hypoglycaemia
What are the three major causes of cardiac arrest in pregnancy?
- Obstetric haemorrhage
- PE
- Sepsis leading to metabolic acidosis and shock
Obstetric haemorrhage causes hypovolemia, what are some causes of obstetric haemorrhage?
- Ectopic
- Placental abruption
- Placenta praevia
- Placenta accreta
- Uterine rupture
Why should a pregnant woman not lie on her back?
After 20 weeks gestation uterus is large and can compress inferior vena cava and aorta on lying down
Compression of IVC reduces venous return, therefore reducing cardiac output so hypotension and can lead to loss of cardiac output and cardiac arrest
Lie woman in left lateral position to lay pregnant uterus away from IVC which is on the right
Why is resuscitation during a cardiac arrest in a pregnant woman more difficult than a normal cardiac arrest?
- Aortocaval compression
- Increased oxygen requirements
- Splinting of the diaphragm by pregnant abdomen
- Risk of aspiration
- Ongoing obstetric haemorrhage
What are the principles of CPR that are different in a pregnant person to a non-pregnant person?
- 15 degree tilt to the left side for CPR
- Early intubation
- Early supplementary oxygen
- Aggressive fluid resuscitation
- Delivery of baby after 4 minutes and within 5 minutes of starting CPR
How is a baby delivered if a pregnant woman is having a cardiac arrest?
Immediate C-section at site of arrest if doing CPR for 4 minutes
Aim is to deliver baby within 5 minutes of CPR commencing
Improves survival of mother as delivery improves venous return to heart, improves cardiac output and reduces oxygen consumption. Also helps ventilation and chest compressions
If a woman has PPROM (<37 weeks), what medication needs to be given to them?
- IM corticosteroids for lung maturation
- Prophylactic Erythromycin for 10 days or until delivery
- Magnesium Sulphate for neuroprotection of baby
What are the risks of PPROM and prematurity?
- Respiratory distress syndrome
- Pulmonary Hypoplasia
- Necrotizing enterocolitis
- Intraventricular hemorrhage
- Retinopathy of prematurity
- Cerebral palsy
- Blindness
- Deafness
- Infection: chorioamnionitis, sepsis, HIE
What did the ORACLE trial show?
- Erythromycin prolonged pregnancy and reduced need for surfactant with PPROM
- Use of Co-Amoxiclav for prophylaxis with PPROM was associated with NEC
How is pemphigoid gestationis managed and what are the risks to the unborn baby with this condition?
Management
- Topical emollients
- Topical steroids
- Oral steroids
- Immunosuppressants
- Abx if secondary infection
Risks
- Fetal growth restriction
- Preterm delivery
- Blistering rash after delivery as maternal antibodies pass to baby
When should you start measuring symphis fundal height?
25 weeks
Then take at every antenatal appointment unless been measured in the last 2 weeks or if having growth scans
