[9] Antenatal Care - Normal Pregnancy Flashcards
What is preconceptual care?
An opportunity for the mother to improve their health before they start trying for a baby
What should all women ideally do before conceiving?
Present to their GP for pre-pregnancy care and counselling
What can a GP do for a woman prior to conception?
Undertake screening tests and provide advice regarding conception and early pregnancy care
What should be assessed in a woman prior to conception in order to maximise preconceptual care?
- Plans for timing of pregnancy
- Previous obstetric history
- Dietary habits and BMI
- Use of folic acid
- Cervical smear status
- Smoking status
- Amount of alcohol consumed
- Use of illicit drugs and hep B risk
- Vaccination status
- Use of medications
- Chronic health problems
Why is previous obstetric history important when counselling a woman looking to conceive?
- Inter-pregnancy interval may affect perinatal outcomes
- Previous complications may need to be considered
- Timing of pregnancy attempt after previous miscarriage
What inter-pregnancy interval has been shown to be safer in terms of perinatal outcomes?
18-59 months
What will a decision to try again after miscarriage be influenced by?
- When woman and partner feel ready
- Speed of recovery
- Pending test results or follow up of surgery, ectopic or molar pregnancy
What advice should be given to women prior to conception regarding diet and BMI?
- Health, balanced diet
- Attain and maintain healthy weight
Why is attaining and maintaining a healthy weight prior to pregnancy important?
It reduces the risk of pregnancy complications
What are the risks of being obese during pregnancy and conception?
- Reduced fertility
- Increased risk of miscarriage
- Gestational diabetes
- Gestational hypertension/pre-eclampsia
- Macrosomia and shoulder dystocia
- Preterm delivery
- Birth trauma
- Caesarean delivery
- Post-partum complications
- Congenital anomalies
What post-partum complications are more likely in obese mothers?
- Haemorrhage
- Thrombosis
- Infection
What congenital anomalies are more likely in babies of obese mothers?
- Neural tube defects
- CVS abnormalities
- Cleft palate
- Limb reduction
- Anorectal atresia
- Hydrocephaly
What are the risks of being underweight in conception and pregnancy?
- Reduced fertility
- First trimester miscarriage
- Pre-term birth
- Low birth weight
- Gastroschisis
When assessing a hopeful mothers use of folic acid what should be considered?
The dose being taken in relation to her risk of neural tube defects
What is the recommended dose and regime of folic acid for all women?
400 μg daily for at least 1 month pre- and 3 months post-conception
What is folic acid used for?
Reducing the incidence of neural tube defects
If patients are considered a higher risk for neural tube defects what dose of folic acid is used?
5mg daily
What might make a woman high risk for neural tube defects?
- Those on anti-epileptics
- Obese women
- Diabetic women
- Women with history of neural tube defects
Why is checking cervical smear status important in the pre-conceptual history?
To undertake routine cervical cytology if due
What advice should women wanting to get pregnant be given regarding smoking?
Stop smoking and initially try to do so without nicotine replacement
Where can a patient who smokes before conception be referred if needed?
Smoking cessation services
What vaccinations may be needed in women looking to get pregnant (if not already)?
- Rubella
- Varicella
- Pertussis
What might a patient need if history of vaccinations and associated infections is uncertain?
Serology
What are women who require vaccines prior to conceiving advised to do?
Defer conception for 28 days after
Why should women defer conception for 28 days after vaccination?
Live attenuated viral vaccines can be dangerous to foetus
Why are seasonal influenza vaccines recommended in pregnant women?
There is increased risk of serious morbidity in pregnancy in flu
Use of what types of medications should be considered when taking a pre-conceptual history?
- Prescription medications
- OTC medicines
- Herbal medicines
What chronic health problems should be considered in a pre-conceptual history?
- Mental health issues
- Epilepsy
- DM
- Thyroid disease
- Chronic hypertension
- Chronic cardiac disease
- Renal disease
- Asthma
- Previous thromboembolism
- Rheumatological conditions
- IBD
- Haemoglobinopathies
What lifestyle factors should be considered when pregnant?
- Alcohol cessation
- Exercise
- Foods
- Medicines and complementary therapy use
- Nutritional supplements
- Work
- Travel
What advise should pregnant women be given regarding exercise?
- Moderate exercise is not associated with adverse outcomes
- Some activities can be dangerous
- Sexual intercourse is not associated with adverse outcomes
What physical activities can be dangerous during pregnancy?
- Contact sports
- High impact sports
- Vigorous racquet sports
- Scuba diving
What effect can scuba diving have on the fetus?
May cause fetal birth defects and fetal decompression disease
What conditions are important to avoid during pregnancy in terms of food consumption?
- Listeriosis
- Salmonella
How can the risk of listeriosis be reduced in pregnancy?
- Only drink pasteurised or UHT milk
- Don’t eat ripened soft cheese
- Don’t eat pâté
- Don’t eat uncooked or under-cooked ready meals
How can the risk of salmonella be reduced?
- Avoid raw or partially cooked eggs or food that contains them e.g. mayonnaise
- Avoid raw or partially cooked meat especially poultry
What is true of medicines (including prescription, OTC and complimentary therapies) in pregnancy?
Few have been established to be safe and should be taken as little as possible
When are medicines generally considered ok to use in pregnancy despite risks?
When the benefit outweighs the risk
What nutritional supplements are routinely advised in pregnancy?
- Folic acid
- Vitamin D
What is the dose of vitamin D supplement in pregnancy?
10mg/day
Why is vitamin D supplement important in pregnancy?
Improves maternal health and baby’s health in pregnancy and breastfeeding
Who is particularly helped by vitamin D supplement in pregnancy?
Women with darker skin
What supplement is not offered routinely in pregnancy?
Iron
What supplement can be teratogenic and should be avoided?
Vitamin A
What should women be informed of with regards to work in pregnancy?
Their maternity rights and benefits
Why is an occupation history important in pregnancy?
To identify women with high occupational risk
What is important to inform pregnant women with regards to travel?
Seatbelt should go above and below the bump
What are the important aspects of previous obstetric history in pregnancy?
- Number of all previous pregnancies
- Duration of previous gestations
- Previous antenatal complications
- Details of induction of labour
- Duration of labour
- Presentation and methods of delivery
- Birth weight and gender of each infant
- Mode of delivery
- Conditions of each infant at birth and need for care in a special baby unit
- Complications of puerperium
What should be included in number of pregnancies in an obstetric history?
- Miscarriages
- Terminations
What are the types of modes of delivery?
- Spontaneous
- Assisted
- Caesarean sections
What are some possible complications of puerperium?
- Post-Partum haemorrhage
- Extensive perineal trauma or wound breakdown
- Infections of genital tract
- DVT
- Difficulties with breastfeeding
What types of medications should be listed and given to doctor/midwife?
- Prescription medications
- OTC
- Nutritional supplements
- Herbal remedies
What other forms of substance use should be reported by the patient in pregnancy?
- Smoking
- Drinking
- Use of illegal drugs
In what ways can medications and other substances harm the foetus?
- Interfere with normal development
- Damage baby’s organs
- Damage the placenta
- Increase the risk of miscarriage
- Bring on premature labour
What can affect the harm medications and other substances can have on a foetus?
- Type taken
- How taken
- Size of dose
- How often taken
- Whether used alone or in combination
- Individual response of the baby
- Gestational age of baby
- Maternal health and diet
Give some examples of medications that can cause birth defects in the developing foetus?
- ACE inhibitors and angiotensin II antagonists
- Isotretinoin
- Lithium
- Some antibiotics
- Some anti-epileptics
- Some chemotherapies
- Some thyroid medications
- Warfarin
What antibiotics are not safe in pregnancy?
- Aminoglycosides
- Chloramphenicol
- Co-trimoxazole
- Tetracyclines
What effect can aminoglycosides have in pregnancy?
Risk of fetal ototoxicity
What effect can co-trimoxazole have in pregnancy?
May displace bilirubin and cause kernicterus in the foetus
What effect can tetracyclines have on a developing foetus?
Dental discolouration
What antibiotics are thought to be safe in pregnancy?
- Erythromycin
- Penicillins
- Metronidazole
- Cephalosporins
What are the risks of warfarin in pregnancy?
- Congenital malformations
- Placental, fetal or neonatal haemorrhage especially in last few weeks of pregnancy and delivery
What are the periods of pregnancy in which warfarin use should be particularly avoided?
1st and 3rd trimester
When is it difficult to stop warfarin in pregnancy?
In women with prosthetic heart valves, AF or recurrent VTE or PE
What analgesic is generally advised to be avoided in pregnancy?
Ibuprofen
When should ibuprofen be only taken in benefits outweigh the risks in pregnancy?
Before 30 weeks
When should ibuprofen be absolutely not used in pregnancy?
After 30 weeks
What is the risk of ibuprofen use before 30 weeks?
Increased risk of complications including miscarriage
What is the risk of ibuprofen in pregnancy after 30 weeks?
Increased risk of complications including heart problems and reduced amniotic fluid
Why should women stop smoking in pregnancy?
Tobacco smoke contains chemicals that can pass into the blood stream and cross the placenta
What does smoking in pregnancy increase the risk of?
- Miscarriage
- Ectopic pregnancy
- Low birth weight
- Premature labour
- Placental abruption
- Still birth
- Fetal abnormalities e.g. cleft lip or palate
What are children who’s parents smoke after pregnancy at increased risk of?
- Glue ear
- Chest infections and asthma
- Cot death
- Behavioural problems e.g. ADHD
Is nicotine replacement used in pregnancy?
It can be, but may have some effects on the baby (safer than smoking)
What medications can be used to help stop smoking BEFORE pregnancy?
- Bupropion
- Varenicline
Are e-cigs safe in pregnancy?
Advised not to use as not enough evidence
What is the risk of drinking alcohol during pregnancy?
Development of fetal alcohol syndrome
What is fetal alcohol syndrome?
A range of disabilities and abnormalities a child is born with as a result of drinking during pregnancy
What is fetal alcohol syndrome a part of?
A group of fetal alcohol spectrum disorders
What is included under fetal alcohol spectrum disorders?
- Alcohol-related birth defects
- Partial fetal alcohol syndrome
- Alcohol related neurodevelopmental disorders
What other factors influence the development of fetal alcohol syndrome (as well as drinking)?
- Genetic factors
- Health of mother
- Mother’s diet
- Maternal stress
- Maternal age
- Maternal smoking
What are the groups of abnormalities in fetal alcohol syndrome?
- Typical shape of face
- Stunted growth
- Mental and behavioural difficulties
What are the typical facial features of fetal alcohol syndrome?
- Small head
- Flattened philtrum
- Thin upper lip
- Flat bridge of nose
- Ptosis
- Epicanthic folds
What is meant by stunted growth in fetal alcohol syndrome?
Babies tend to be small and grow up to be shorter than average
What mental and behavioural difficulties can be present in fetal alcohol syndrome?
- Lower than average IQ
- Hyperactivity
- Attention deficit
- Memory problems
- Poor judgement
- Poor impulse control
- Speech and language delay
What other problems can present as part of the fetal alcohol spectrum disorders?
- Poor vision and hearing
- Heart valve problems
- Kidney problems or genital abnormalities
- Bone and joint problems
How can fetal alcohol syndrome be treated?
It can’t
How can fetal alcohol syndrome be prevented?
Don’t drink alcohol in pregnancy
What illegal substances have known effects on pregnancy?
- Amphetamines
- Cannabis
- Cocaine
- Heroin
- Inhalants
What are the known effects of amphetamines in pregnancy?
- Low birth weight
- Birth defects
- Prematurity
What are the known effects of cannabis in pregnancy?
- Growth restriction
- Sleep problems
- Behavioural problems
What are the known effects of cocaine in pregnancy?
- Miscarriage
- Pre-term birth
- Growth restriction
- Stillbirth
- Birth defects
What can be affected by birth defects caused by cocaine use in pregnancy?
- Brain
- Heart
- Genitals
- Urinary system
What are the known effects of heroin in pregnancy?
- Low birth weight
- Prematurity
- Fetal distress
- Still birth
- Blood-borne viral disease e.g. hepatitis
- Infant withdrawal after birth
What are the known effects of inhalants in pregnancy?
- Miscarriage
- Low birth weight
- Birth defects
- Sudden unexplained death in infancy
How can mothers who take illegal drugs be helped?
- Offer treatment plans
- Provide counselling and information
- Provide harm-reduction strategies e.g. needle exchange schemes
What treatment can be provided to pregnant women who are heroin or opioid dependent?
Methadone and buprenorphine can help treat dependency and is safer than heroin
Why is maternal age important in pregnancy?
It can be a determinant of outcomes with increased risk at both extremes of age
What has happened to the median age of pregnancy in developing countries in recent years?
Rise to around 30 years
What has happened to the rate of pregnancy over 35 and 40?
Risen
What has happened to the rate of teenage pregnancy?
Decline
What reasons are behind the rising median maternal age in developing countries?
- Social, economic and educational factors
- Access to assisted reproductive technology
What has happened to rates of multiple pregnancies?
Increasing
Why is there an increase in the number of multiple pregnancies?
- Increase in ART
- Increasing maternal age
Is the absolute number of babies born to each woman generally high or low?
Low
What percentage of expectant mothers are going to give birth to their first or second baby?
75%
What is done at the booking visit?
- Identify need for additional care
- Measure woman’s height, weight and BMI
- Measure BP and test urine for protein
- Offer GDM and pre-eclampsia screening
- Check ABO and rhesus D groups
- Offer screening for maternal condition
- Offer early USS for gestational age assessment
- Offer USS screening for gestational abnormalities
- Identify women with FGM
- Ask about past or present mental illness and current mood to identify depression
- Ask about occupation to identify risks
When is the gestational age assessed in the early USS?
10 weeks - 13 weeks 6 days
How is the gestational age assessed using the early USS?
Crown-rump length (if <84mm)
Head circumference (if CRL >84mm)
What tests are performed in women who opt for screening?
- Blood tests
- Urine tests
- Down’s screening
What do blood tests look for in antenatal screening?
- Blood group and Rh D
- Haemoglobinopathies
- Anaemia
- Red cell alloantibodies
- Hep B
- HIV
- Syphillis
What do urine tests look for in antenatal screening?
- Proteinuria
- Asymptomatic bacteruria
Antenatal screening for what conditions is offered to all women in the UK?
- Anencephaly
- Open spins bifida
- Cleft lip
- Diaphragmatic hernia
- Gastroschisis
- Exomphalos
- Serious cardiac abnormalities
- Bilateral renal agenesis
- Edward’s syndrome
- Patau’s syndrome
- Down’s syndrome
When does the physical abnormality ultrasound scan take place?
18-20+6 weeks
How many tests are performed initially to screen for Down’s, Edward’s and Patau’s syndromes?
One combined test
What is the combined test to assess for Down’s and other syndromes?
Measure the fluid at the back of the fetus’ neck using nuchal translucency and taking a blood sample
When is the combined test for Down’s, Edward’s and Patau’s performed?
10-14+1 weeks
What test is available for Down’s syndrome if the mother presents late between 14+2 and 20+0 weeks?
The quadruple blood test
What is the quadruple blood test for Down’s?
A blood sample from the mother is taken to determine the levels of 4 biochemical markers that are used alongside maternal age to determine risk
Which test is more effective at screening for Down’s syndrome?
The combined test
What is offered if a mother has high risk based on either syndrome screening tests?
Chorionic villus sampling or amniocentesis
When is chorionic villus sampling performed?
11 - 14 weeks
What is involved in chorionic villus sampling?
Fine needle put through mothers abdomen and taking sample of tissue from the placenta
When is amniocentesis usually performed?
After 15 weeks
What is involved in amniocentesis?
Fine needle passed through abdomen to collect amniotic fluid
What are the important sates in the schedule of antenatal care?
- Booking visit
- 16 weeks
- 18 - 20 weeks
- 25 weeks (nulliparous women)
- 28 weeks
- 31 weeks
- 34 weeks
- 36 weeks
- 40 weeks (nulliparous women)
- 41 weeks (if not given birth)
What takes place at around 16 weeks in antenatal care?
- Review and discuss results of screening tests
- Measure BP and test for proteinuria
- Give information
- Discuss issues
- Answer questions
- Discuss routine anomaly scan
What takes place between 18 - 20 weeks in antenatal care?
- USS for structural anomalies (if opted for)
- Offering of 32 week scan if placenta extends across os
What do nulliparous women receive at 25 weeks in antenatal care?
- Measure and plot symphysis-fundal height
- Measure BP
- Test for proteinuria
- Discussion
What happens at 28 weeks in antenatal care?
- Offer second screening for anaemia and atypical red cell alloantibodies
- Offer anti-D prophylaxis to Rh -ve
- Measure BP
- Test for proteinuria
- Give information
What happens at 31 weeks in nulliparous women in antenatal care?
- Measure BP
- Test for proteinuria
- Measure and plot symphysis-fundal height
- Give information
- Discuss results of 28 weeks screening tests
What happens at 34 weeks in antenatal care?
- Offer second anti-D dose to Rh -ve women
- Measure BP
- Test for proteinuria
- Plot symphysis-fundal height
- Give information
- Review and discuss results of screening tests from 28 weeks
What happens at 36 weeks in antenatal care?
- Measure BP
- Test for proteinuria
- Check position of baby
- Offer ECV for babies in breech position
What is ECV?
External cephalic version
What happens at 38 weeks in antenatal care?
- Measure BP
- Test for proteinuria
- Plot symphysis-fundal height
What happens at 40 weeks for nulliparous women in antenatal care?
- Measure BP
- Test for proteinuria
- Plot symphysis-fundal height
What happen at 41 weeks in antenatal care if the women has not given birth yet?
- Offer membrane sweep and induction of labour
- Measure BP
- Test for proteinuria
- Plot symphysis-fundal height
What percentage of Caucasian women are Rh -ve?
Around 15%
What are Rh -ve women at risk of developing?
Anti-D antibodies during or immediately after pregnancy
Where does a baby inherit it’s blood type from?
Both parents
What is the result of a baby inheriting its blood group from either parent?
An Rh-ve mother can carry a baby who is Rh +ve
How can fetal blood enter the mothers circulation?
During FMH (fetal-maternal haemorrhage)
What happens if RhD +ve blood enters the circulation of an RhD -ve woman?
Mounting of an immune response via sensitisation
When does sensitisation to RhD antigens occur?
Any time in pregnancy but most commonly in the 3rd trimester or during birth
What medical interventions can lead to sensitisation to RhD antigens in the mother?
- Chorionic villus sampling
- Amniocentesis
- External cephalic version
What types of pregnancy termination can lead to sensitisation to RhD antigens in the mother?
- Late miscarriages
- Antepartum Haemorrhage
- Abdominal trauma
Is RhD sensitisation reversible?
No
Why can RhD sensitisation in a RhD -ve mother pose a risk to the RhD +ve fetus?
Antibodies can cross the placenta and attack the blood cells of the fetus
What can happen as a result of anti-RhD antibodies attacking blood cells fo the fetus?
- Anaemia
- Hydrops
- Neonatal anaemia
- Jaundice and kernicterus
- Fetal death in utero
What can reduce the risk of RhD sensitisation?
Administration of anti-D immunoglobulin Post-Partum or when sensitisation may occur
When should anti-D immunoglobulin be administers routinely?
In the third trimester, at 28 and 34 weeks
What legal rights do working pregnant women have?
- Maternity leave
- Time off for antenatal appointments
- Sick pay
- Health and safety
When are working women entitled to maternity leave?
If they are an ‘employee’
How long are women entitled to maternity leave for?
Up to 1 year
When is a working woman not usually entitled to maternity leave?
If they are a ‘worker’ e.g:
- Works for an agency
- Is a casual worker
- Is on 0 hour contract
Are all women entitled to maternity pay if they are entitled to maternity leave?
No, and not necessarily for the entire period, so they should check with the employer
Who else may be entitled to leave due to childbirth?
Partner of the pregnant woman
What must a pregnant woman to in order to be entitled to maternity leave?
Inform the employer at least 15 weeks before due date that:
- They are pregnant
- When the baby is due
- They want maternity leave
- When they want to start and end (these dates are flexible)
When can maternity leave be started?
Any day from 11 weeks before due date
When can maternity leave start earlier than 11 weeks before due date?
- If the baby comes earlier
- If the mother has a pregnancy related illness 4 weeks before due date
When can a pregnant woman receive paid time off for antenatal appointments?
- If the appointments are advised by doctor, midwife or nurse
- If entitled to maternity leave
- If employed by an agency and worked or at least 12 weeks in a row
What antenatal appointments may a woman receive paid leave to attend?
- Parenting classes
- Relaxation classes
- Medical appointments
How might maternity pay be affected if the woman takes sick leave whilst pregnant?
Can decrease as maternity pay is 90% of average pay during 8 week qualifying period
What must an employer do once they have been informed of pregnancy?
A risk assessment for mother and baby at the work place
If the employer finds the work isn’t safe for the mother and baby what must be done?
- Change if possible
- Give different work
- Let them stay at home and pay in full
