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TN Obstetrics > 3. Antepartum Care > Flashcards

3. Antepartum Care Flashcards

1
Q

Describe preconception supplementation (2)

A
  • folic acid: encourage diet rich in folic acid and consider supplementation from 8-12 wk pre- conception until end of T1 to prevent neural tube defects
    • 0.4-1 mg daily in all women; 5 mg if previous NTD, antiepileptic medications, DM, or BMI >35 kg/m2
  • iron supplementation (in cases of iron deficiency anemia), prenatal vitamins
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2
Q

How to estimate the due date? (3)

A
  • Naegele’s rule: 1st day of LMP + 1 year + 7d – 3 mo
  • e.g. LMP = 1 Apr 2014, EDD = 8 Jan 2015 (modify if cycle >28 d by adding number of d >28)
  • EDD by LMP not reliable if irregular menstrual cycle, or if patient unsure of the LMP
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3
Q

Describe non-pharmacological management of nausea and vomiting (6)

A
  • frequent small meals (bland, dry, salty are better tolerated), encourage any safe appealing foods
  • electrolyte oral solutions (Pedialyte®, Gatorade®)
  • stop prenatal vitamins and if T1, substitute with folic acid or adult/children’s vitamins that are low in iron
  • increase sleep/rest
  • ginger (maximum 1000 mg/d)
  • acupuncture, acupressure, and mindfulness-based cognitive therapy
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4
Q

Describe pharmacological management of nausea and vomiting (4)

A
  • first line: pyridoxine (B6) monotherapy or doxylamine/pyridoxine (Diclectin) combination 4 tablets PO daily (1 q am, 1 q lunch and 2 qhs) up to maximum of 8 tablets/d
  • H1 receptor antagonists should be considered for acute or chronic episodes of N/V in pregnancy
  • metoclopramide and phenothiazines can be used as an adjunctive therapy for severe N/V in pregnancy
  • Ondansetron if severe N/V and other anti-emetics have failed
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5
Q

Describe: Hyperemesis Gravidarum (3)

A
  • intractable N/V
  • usually presents in T1 then diminishes; occasionally persists throughout pregnancy
  • Wikipedia: is a pregnancy complication that is characterized by severe nausea, vomiting, weight loss, and possibly dehydration. Feeling faint may also occur.
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6
Q

Describe etiology: Hyperemesis Gravidarum (2)

A
  • multifactorial with hormonal, immunologic, and psychological components
  • rapidly rising β-hCG ± estrogen levels may be implicated
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7
Q

Describe investigations: Hyperemesis Gravidarum (2)

A
  • rule out systemic causes: GI, pyelonephritis, thyrotoxicosis
  • rule out other obstetrical causes: multiple gestation, gestational trophoblastic neoplasia (GTN), HELLP syndrome
  • CBC, electrolytes, BUN, creatinine, liver function test (LFTs), urinalysis
  • U/S
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8
Q

Describe manamgenet: Hyperemesis Gravidarum (7)

A
  • thiamine supplementation may be indicated
  • non-pharmacological
  • pharmacological options
    • doxylamine/pyridoxine
    • dimenhydrinate can be safely used as an adjunct to Diclectin® (1 suppository bid or 25 mg PO qid)
    • other adjuncts: hydroxyzine, pyridoxine, phenothiazine, metoclopramide
    • also consider: ondansetron or methylprednisolone (avoid steroids in T1 due to increased risk of oral clefting)
    • if severe: admit to hospital, NPO initially then small frequent meals; correct hypovolemia, electrolyte disturbance, and ketosis; total parenteral nutrition TPN (if very severe) to reverse catabolic state
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9
Q

Describe complications MATERNAL: Hyperemesis Gravidarum (4)

A
  • dehydration, electrolyte, and acid-base disturbances
  • Mallory-Weiss tear
  • Wernicke’s encephalopathy, if protracted course
  • death
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10
Q

Describe complications FETAL: Hyperemesis Gravidarum (2)

A
  • usually none
  • intrauterine growth restriction is 15x more common in women losing >5% of pre-pregnancy weight
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11
Q

Describe frequency of prenatal visits (4)

A
  • usually within 8-12 wk of the 1st day of LMP or earlier if <20 or >35 yr old, bleeding, very nauseous, or other risk factors present
  • after, for uncomplicated pregnancies, SOGC recommends
    • q4-6 wk until 30 wk
    • q2-3 wk from 30 wk,
    • and q1-2 wk from 36 wk until delivery
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12
Q

When to perform Leopold’s Maneuvers? (1)

A
  • performed after 30-32 wk gestation
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13
Q

Describe Leopold’s Maneuvers (4)

A
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14
Q

Describe: Ultrasound screening (9)

A
  • 8-12 wk GA: dating U/S (most accurate form of pregnancy dating)
  • measurement of crown-rump length (margin of error: ± 5 d)
  • EDD should be based on T1 U/S if available
  • 11-14 wk GA: nuchal translucency ultrasound (NTUS)
  • measures the amount of fluid behind the neck of the fetus
  • early screen for Trisomy 21 (may also detect cardiac and other aneuploidies like Turner syndrome)
  • NT measurement is necessary for the FTS and IPS Part 1
  • 18-20 wk GA: growth and anatomy U/S (margin of error: ± 10 d)
  • earlier or subsequent U/S performed when medically indicated
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15
Q

Describe: NON-INVASIVE PRENATAL TESTING (NIPT) (2)

A
  • analyses maternal blood for circulating cell-free fetal DNA (ccffDNA) at 9-10 wk GA onwards.
  • Requires dating U/S for accuracy
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16
Q

Name indications: NON-INVASIVE PRENATAL TESTING (NIPT) (3)

A
  • age >35 yr (increased risk of chromosomal anomalies)
    • risk factors in current pregnancy
    • abnormal U/S
  • abnormal prenatal screen (IPS, eFTS, or MSS)
  • past history/family history of:
    • chromosomal anomaly or genetic disease
    • either parent a known carrier of a genetic disorder or balanced translocation
    • consanguinity
    • >3 spontaneous abortions
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17
Q

Describe: Amniocentesis (1)

A

U/S-guided transabdominal extraction of amniotic fluid performed as early as 15 weeks GA

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18
Q

Name indications: Amniocentesis (4)

A
  • identification of genetic and chromosomal anomalies (15-16 wk gestation) as per indications above
  • confirmation of positive non-invasive prenatal testing NIPT testing
  • positive eFTS/IPS/MSS
  • assessment of fetal lung maturity (T3) via the L/S ratio (lecithin:sphingomyelin)
    • if >2:1, RDS is less likely to occur
19
Q

Describe: CHORIONIC VILLUS SAMPLING (1)

A

biopsy of fetal-derived chorion using a transabdominal needle or transcervical catheter at 10-12 wk

20
Q

Name risk Factors for Neural Tube Defects (5)

A

GRIMM

  • Genetics: family history of NTD (risk of having second child with NTD is increased to 2-5%), consanguinity, chromosomal (characteristic of Trisomy 13, 18, and 21)
  • Race: European Caucasians > African Americans, 3-fold higher in Hispanics
  • Insufficient vitamins: zinc and folate
  • Maternal chronic disease (e.g. DM)
  • Maternal use of antiepileptic drugs
21
Q

Describe: ISOIMMUNIZATION SCREENING (1)

A

isoimmunization: antibodies (Ab) produced against a specific RBC antigen (Ag) as a result of antigenic stimulation with RBC of another individual

22
Q

Describe etiology: Isoimmunization (4)

A
  • maternal-fetal circulation normally separated by placental barrier, but sensitization can occur and can affect the current pregnancy, or more commonly, future pregnancies
  • anti-Rh Ab produced by a sensitized Rh-negative mother can lead to fetal hemolytic anemia
  • risk of isoimmunization of an Rh-negative mother with an Rh-positive ABO-compatible infant is 16%
  • sensitization routes
    • incompatible blood transfusions
    • previous fetal-maternal transplacental hemorrhage (e.g. ectopic pregnancy, abruption)
    • invasive procedures in pregnancy (e.g. prenatal diagnosis, cerclage, D&C)
    • any type of abortion
    • labour and delivery
    • trauma (e.g. car accident, fall, etc.)
23
Q

Describe investigations: isoimmunization (5)

A
  • screening with indirect Coombs test at first visit for blood group, Rh status, and antibodies
  • Kleihauer-Betke test used to determine extent of fetomaternal hemorrhage by estimating volume of fetal blood volume that entered maternal circulation
  • detailed U/S for hydrops fetalis
  • middle cerebral artery Dopplers are done to assess degree of fetal anemia; if not available, bilirubin is measured by serial amniocentesis to assess the severity of hemolysis
  • cordocentesis for fetal Hb should be used cautiously (not first-line)
24
Q

Describe prophylaxis: Isoimmunization (1)

A

exogenous Rh IgG (Rhogam® or WinRho®) binds to Rh antigens of fetal cells and prevents them from contacting maternal immune system

25
Q

Rhogam® (120-300 µg) given to all Rh negative and antibody screen negative women in the following scenarios (7)

A
  • routinely at 28 wk GA (provides protection for ~12 wk)
  • within 72 h of the birth of a Rh positive fetus
  • with any invasive procedure in pregnancy (CVS, amniocentesis)
  • as part of management of ectopic pregnancy
  • with miscarriage or therapeutic abortion
  • with an antepartum hemorrhage
  • with trauma
26
Q

Describe treatment: isoimmunization (3)

A
  • falling biliary pigment warrants no intervention (usually indicative of either unaffected or mildly affected fetus)
  • intrauterine transfusion between 18-35 wk GA of O-negative packed RBCs may be required for severely affected fetus
  • early delivery of the fetus for exchange transfusion following 35 wk GA
27
Q

Describe complications: isoimmunization (2)

A
  • anti-Rh IgG can cross the placenta and cause fetal RBC hemolysis resulting in fetal anemia, CHF, edema, ascites
  • severe cases can lead to hydrops fetalis (edema in at least two fetal compartments due to fetal heart failure secondary to anemia) or erythroblastosis fetalis (moderate to severe immune-mediated hemolytic anemia)
28
Q

Patients will generally first notice fetal movement (“quickening”) when? (3)

A
  • at 18-20 wk in primigravidas
  • can occur 1-2 wk earlier in multigravidas
  • can occur 1-2 wk later if placenta is implanted on the anterior wall of uterus
29
Q

If the patient is concerned about decreased fetal movement, she is counselled to do what? (1)

A

to choose a time when the fetus is normally active to count movements (usually recommended after 26 wk)

30
Q

All high-risk women should be told to do fetal movement FM counts when? (3)

A
  • ≥6 movements in 2 h expected
  • If there is a subjective decrease in fetal movement, time how long it takes to feel 10 discreet movements, laying on the left in a quiet setting may facilitate feeling subtle movements
  • if 10 movements take more than 2 h, further assessment is indicated, and patient should present to labour and delivery triage for non-stress test
31
Q

Name DDx of Decreased Fetal Movements (4)

A
  • Death of fetus
  • Amniotic fluid decreased
  • Sleep cycle of fetus
  • Hunger/Thirst
32
Q

Describe: NON-STRESS TEST (2)

A
  • FHR tracing ≥20 min using an external Doppler to assess FHR and its relationship to fetal movement
  • Indication: any suggestion of uteroplacental insufficiency or suspected compromise in fetal well-being
33
Q

Describe: Normal NST (3)

A
  • 2 accels
  • >15 bpm from baseline
  • lasting >15 s in 20 min
34
Q

Describe normal/atypical/abnormal tracing: Baseline

A
  • Normal: 110-160 bpm
  • Atypical:
    • 100-110 bpm or >160 bpm for <30 min
    • Rising baseline
  • Abnormal:
    • Bradycardia <100 bpm
    • Tachycardia >160 for >30 min
    • Erratic baseline
35
Q

Describe normal/atypical/abnormal tracing: Variability

A
  • Normal:
    • 6-25 bpm (moderate)
    • ≤5 (absent or minimal) for <40 min
  • Atypical:
    • 5 (absent or minimal) for 40-80 min
  • Abnormal:
    • ≤5 for 80 min
    • Sinusoidal
    • 25 bpm for >10 min
36
Q

Describe normal/atypical/abnormal tracing: Decelerations

A
  • Normal: None or occasional variable <30 s
  • Atypical: Variable decelerations, 30-60 s duration
  • Abnormal:
    • Variable decelerations >60 s
    • Late deceleration(s)
37
Q

Describe normal/atypical/abnormal tracing: Accelerations in Term Fetus

A
  • Normal:
    • 2 accelerations with acme of ≥15 bpm, lasting 15 s over

<40 min of testing

  • Atypical:
    • 2 accelerations with acme of ≥15 bpm, lasting 15 s in

40-80 min

  • Abnormal: <2 accelerations with acme (peak) of contraction of ≥15 bpm, lasting 15s in >80 min
38
Q

Describe normal/atypical/abnormal tracing: Accelerations in Preterm Fetus (<32 wk)

A
  • Normal: >2 accelerations with acme of >10 bpm, lasting 10 s in <40 min
  • Atypical:

<2 accelerations with acme of >10 bpm, lasting 10 s in 40-80 min

  • Abnormal: <2 accelerations with acme of >10 bpm, lasting 10 s in >80 min
39
Q

Describe normal/atypical/abnormal tracing: Action

A
  • Normal: FURTHER ASSESSMENT OPTIONAL, based on total clinical picture
  • Atypical: FURTHER ASSESSMENT REQUIRED
  • Abnormal: URGENT ACTION REQUIRED An overall assessment of the situation and further investigation with U/S or BPP is required; some situations will require delivery
40
Q

Define: BIOPHYSICAL PROFILE (1)

A

U/S assessment of the fetus ± NST

41
Q

Name indications: BIOPHYSICAL PROFILE (BPP) (4)

A
  • post-term pregnancy
  • decreased fetal movement
  • intrauterine growth restriction IUGR
  • any other suggestion of fetal distress or uteroplacental insufficiency
42
Q

Describe: Scoring of the BPP

A
43
Q

Describe interpretation of BPP score (3)

A
  • Reassuring BPP (8/8) LAMB. 8: perinatal mortality rate 1:1000; repeat BPP as clinically indicated
    • Limb extension + flexion
    • AFV 2 cm x 2 cm
    • Movement (3 discrete)
    • Breathing (one episode x 30 s)
  • 6: perinatal mortality 31:1000; repeat BPP in 24 h
  • 0-4: perinatal mortality rate 200:1000; deliver fetus if benefits of delivery outweigh risks

TN Obstetrics (16 decks)

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