Anetnatal care Flashcards
MILESTONES IN PREGNANCY
i) when is booking clinic attended? when is dating scan done? what is gestational age calculated from?
ii) when is the anomaly scan done? when is oral glucose tolerance test done for women at risk of GD?
iii) when is US done for women with placenta previa on anomaly scan? who are serial growth scans offered to?
iv) which two vaccines re offered to all pregnant women? which vaccines are avoided in pregnancy? name three booking bloods that are done
v) when is first second and third trimester? when do fetal movements start?
i) booking before 12 weeks
dating between 10 and 13+6
gestational age calc from crown rump length
ii) anomaly between 18 and 20+6
oral gluc tol between 24-28 weeks
iii) US for placental praevia at 32 weeks
serial growth scans if at risk of fetal growth restric
iv) pertussis and influenza
avoid live vaccs eg mmr
booking bloods - blood groupm, antibodies, rhesus D, FBC for anemiaa, screen for thalassemia and SCA
v) first - up to 12 weeks
second - 13 to 26 weeks
third 27 weeks until birth
ANTENATAL SCREEN FOR DOWNS SYNDROME
i) what is the first line test? when is it performed? what two things does it involve?
ii) what is meaasured on the fetus? what may indicate DS? which two bloods are done?
iii) which test is done between 14 and 20 weeks? what does it involve? (3)
iv) when is the quadruple test done? what does it test for in addition to others?
v) what is done if screening provides a high risk score? what counts as high risk?
vi) name a new test that can be done to detect fetal DNA in mothers blood
i) combined test is first line - done between 11-14 weeks - US and materrnal bloods
ii) US measures nuchal translucency (thickness of back of neck) >6mm may indicate DS
iii) 14-20 weeks = triple test only involves maternal blood
beta HCG (high), AFP (low), serum oestriol (low)
iv) quadruple done between 14-20 weeks
also tests maternal inhibin A (high)
v) if high risk (greater than 1in 150) then refer for amniocentesis or chronic villus sampling
CVS - US guided biopsy of placenta (done before 15 weeks)
amnio - US aspiration of amniotic fluid (later on)
vi) NIPT
CHRONIC CONDITIONS IN PREGNANCY
i) how does levothyroxine for hypothyroid need to be changed in pregnancy?
ii) name three anti hypertensives that are not suitable in pregnancy? name three that are safe
iii) what should women with epilepsy take before conception? name three safe anti epileptics? name two to be avoided
iv) what is first line for RA in pregnancy? what should not be used?
i) increase levothyroxine levels
ii) ACEi, ARBs and thiazide diuretics not suitable
change to labetalol, CCBs, alpha blockers
iii) take folic acid
leviteracetam, lamotrigine and carbamaz are ok
CI - valproate and phenytoin
iv) treat RA with hydroxychloroquinine or sulfasalazine
MTX not suitable
MEDICATIONS IN PREGNANCY
i) are NSAIDs generally used in preg? in which trimester is this important? name two things they can cause
ii) what is first line for high blood pressure caused by pre eclampsia? name two side effects this drug can cause
iii) how can ACEi and ARBs affect the fetus? how may it affect the bones? name three things they can cause in pregnancy
iv) what can opiate use in pregnancy cause after birth? how quick does this present? what does it px with?
v) can warfarin be used? name three effets in preg?
i) NSAIDs not usually used as they block PGs (Which maint ductus arteriosis) also soften cervix and stim contractions
espec dont use in third trimester as premature closure of DA and delay labour
ii) labetalol is first line for high BP > SE fetal growth restric, hypogly and bradycardia in neonate
iii) cross placenta and affect kidney/reduce urine production and amniotic fluid
also cause hypocalvaria = incomplete formation of skull bones
can cause oligohydramnios (little fluid), misscarriage, hypocalvaria, renal fail and hypoten in neonate
iv) opiate use can result in neonatal abstinence syndrome px 3-72hrs after birth with irritability, tachypnoea, high temp and poor feeding
v) crosses placenta and is teratogenic
can cause fetal loss, congen malforms eg craniofacial, bleeding during preg
MEDICATIONS IN PREG CONT
i) name two things sodium valproate in pregnancy can cause? what is the programme called to ensure this doesnt happen?
ii) what is lithium used for? when should it particularly be avoided? what can it lead to? what happens if it needs to be used? should the mother breastfeed?
iii) are SSRIs used in pregnancy? what is it linked to in the first trimester? which drug in particular? what is it linked to in the third trimester?
iv) can isotretinoin be used in pregnancy?
i) valproate > neural tube defects and dev delay
prevent programme
ii) lithium is mood stab in bipolar, mania, recurrent depress
avoid in preg women unless no other option - espec in first trimester as linked to congenital cardiac abnorms > ebsteins anomaly = tricuspid valve is lower on right therefore bigger RA and smaller RV
if needs to be use then close monitor every 4 weeks and dont bf as passess through breast milk
iii) SSRIs cross placenta and risk vs benefit
first trimester = congenital heart defects espec paroxetine
third = persisent pulm HTN
iv) isotret is high teratogenic - reliable contracep before during and 1 month after taking
RHESUS INCOMPATIBILITY
i) what happens when a mother becomes sensitised? when does htis usually cause problems? what does it result in?
ii) how is sensitisation prevented? when is this done? (2)
iii) name three other sensitisation events? how long after the event is tx given?
iv) what test is done after 20 weeks when there is a sensitisation event? what does this involve?
i) sens when mother is rhesus negative and baby is rh positive > baby cells cross to mother and mother makes ABs against cells
causes problems in subsequent pregnancies if antibodies cross placenta and attack baby cells anca cause haemolutic disease of the newborn
ii) prevent with IM anti D injections to rh negative women
give at 28 weeks and at birth if baby is rh positive
iii) antepartum haemm, amniocentesis, abdo trauma
give anti D within 72 hours of sens event
iv) after 20 weeks - do kelinhauer test
checks how much fetal blood has passed to mum in a sens event and whether more anti D is required
add acid > fetal cells persist > how many are there
SMALL FOR GESTATIONAL AGE
i) what is it defined as? what two meas on US are used for fetal size? what is severe SGA? what is low birth weight?
ii) what are the two categories of SGA? what happens in each?
iii) what are the two categories of fetal growth restriction? name three causes of each? name three other signs of fetal growth restric?
iv) name three short term complicats of FGR? what do growth restric babies have a higher risk of? (3)
v) name five RF for SGA?
i) SGA is below 10th centile for gestational age
US - estimated fetal weight and fetal abdo circumference
severe SGA is below 3rd centile
LBW is birth < 2500g
ii) SGA - constitutionally small (matching mother and other family members and growing along growth chart)
fetal growth restric = IUGR
iii) FGR - placenta mediated or non placeta mediated (small due to genetic or struc abnorm)
placenta mediated - idiopathic, pre eclampsia, maternal smoking, ETOH, anaemia, malnut, infec
non plac med - genetic abnorm, struc abnorm, fetal infec, error of metab
other signs - reduced amniotic fluid vol, abnormal doppler, reduced foetal movement
iv) ST complications - fetal death, birth asphyxia, neonate hypothermia and hypogly
higher risk of CV disease, T2DM, obesity, mood disorders
v) RF - previous SGA baby, obesity, smoking, diabtets, high BP, pre eclampsia, mum over 35, multiple preg
SGA MONITORING AND MX
i) what is monitored in low risk women? when does this start from? when are women booked for serial growth scans? (3)
ii) name three things serial growth scans measure?
iii) what should be given if there is pre eclampsia? what is done if growth is static?
iv) name three ix that may be done to ident the cause of SGA
v) what dis done when there is static growth? what does this reduce the risk of? what medication is given?
i) monitor symphysis fundal height at every antenatal appt from 24 weeks
book for serial growth scans if SDH is less than 10th centile, 3+ minor RFs, 1+ major RF - umbillical artery doppler
ii) measure estimated fetal weight and abdo cirucmference to meas growth velocity, umbilical artery pulsatility index (flow thro UA), amniotic fluid volume
iii) aspirin if pre eclampsia
growth is static = early delivery
iv) ident cause - blood pressure and urine dip for pre eclampsia
uterine artery doppler scan
fetal anomaly scan
karyotyping, test for infections
v) static growth - early delivery to reduce the risk of stillbirth
corticosteroids given when early delivery is planned
LARGE FOR GESTATIONAL AGE
i) how is it defined? what is estimated fetal weight?
ii) name five causes of macrosomia?
iii) name three risks to mother and three risks to baby?
iv) what are the two investigations for LGA baby?
v) what is the main risk at delivery? name three ways this can be reduced
i) weight > 4.5kg at birth or estim fetal weight above 90th centile
ii) consitutional, maternal diabetes, prev macrosomia, materal obesity, overdue, male baby
iii) risks to mum - shoulder dystocia, fail to progress, perineal tears, instrumentation, post part haemm, uterine rupture
risks to baby - birth injury - erbs palsy, clavic fracture, neonatal hypogly, obesity in childhood, T2DM in adulthood
iv) US to exclude polyhydramnios and to estimate fetal weight
oral gluc tol test for diabetes
v) main risk is shoulder dystocia - deliver with consultant, active mx of third stage, paeds, early decision for CS
MULTIPLE PREGNANCY
i) name three things US is used to determine in MP? what sign indicates dichorionic? what sign indicates monochorionic?
ii) name three risks to mother? name three risks to baby?
iii) what is twin twin transfusion syndrome? what happens to each baby? how may it be tx? what is twin anaemia polycythaemia sequence?
iv) when may women be monitored for anaemia? (3)
v) what delivery do monoamniotic twins require? when? how must first baby be for vaginal delivery of diamniotic twins? what happens if twin isnt?
i) US to determine gestational age, number of placenta/sacs, risk of downs syndrome
ii) risks to mum - anaemia, polyhydramnios, hypertnesion, spont preterm birth, instrumental delivery, post partum haemm
risk to baby - miscarriage, stillbirth, FGR, TTS, congen abnorm
iii) TTTS - connection in blood supply of two fetsus and one twin gets more and one gets less
recipient - fluid overload, HF, polyhydram
donor - growth restric, anaemia, oligohydram
may do laser tx to destroy connection
TAPS - less acte TTTS - one twin is anaemic and other is polycythaemic
iv) anaemia check at booking, 20 weeks and 28 weeks
v) mono need elective CS between 32 and 33+6 weeks
di can have vaginal deliver is first baby is cephalic
elective CS if not cephalic
may need to do CS for second baby after first baby is delivered
UTI IN PREGNANCY
i) what does it increase the risk of? what is asymptomatic bacteriuria? when are women tested for this?
ii) name three ways lower UI may px? name three ways pyelonephritis may px?
iii) what is seen on urine dip if bac infection? (2) which is more accurate? what is the most common causative? name two other causes
iv) how are they mx? name three abx that may be given?
v) which abx should be avouded in third trimester? why? what needs to be avoided in first trimester? why?
i) inc risk of preterm delivery, low birth weight and pre eclamp
asymp bac is when there is bac but no signs of inefection - test for routinely in pregnancy > MC&S
ii) lower - dysuria, suprapubic pauin, inc freq and urgency, incont
upper - fever, loin, subrapubic, back pain, vom, haematuria
iii) nitrites and leucocytes (leuco esterase) nitrites are more accurate
e coli most common causative also klebs pnuemoniae, enteroccus, pseudomoas
iv) mx with 7 days of abx - nitro, amox, cefalexin
v) avoid nitro in 3rd trimester due to risk fo neonatal haemolysis
avoid trimethoprim in first trim as folate antag > congen malforms eg neural tube defects
ANAEMIA IN PREGNANCY
i) which two times are women screened? what happens to hb in pregnancy?
ii) what are normal ranges for hb in pregnancy? (3) what two other things are women screened for?
iii) what is given to women who are anaemic? who are not anaemic but have low ferritin?
iv) what are the two tx for low B12? how much folic acid should women be taking daily?
i) screen at booking and 28 weeks
hb lowers due to high plas volume
ii) booking > 110
28 weeks > 105
post partum > 100
also screen for thtalassemia and SCA (if at higher risk)
iii) ferrous sulphate 200mg tds
low ferritin - start on supplementary iron
iv) IM hydroxocobalamin
oral cyanocobalamin tablets
take 400mcg per day
VTE IN PREGNANCY
i) when is the risk the highest? name five RFs? when should prophylaxis be started if there are three RF? if four or more?
ii) name three other scenarios prophylaxis may be started? when is VTE risk assessed? what medication is given? when should this be stopped?
iii) name two types of mechanical prophylaxis? how is VTE measured on examination? what is the investigation of choice? name two other things needed?
iv) what medication is given? when should it be started? how long for?
v) is the wells score used? why?
i) highest risk is postpartum
RF - smoking, multiparity, age > 35, BMI > 30, multiple preg, pre eclampsia, varicose veins, immobility, F, IVF
start at 28 weeks if three RF
start in first trimester if four or more
ii) also start if hosp admin, surgery, previous VTE, high risk thrombophilia, ovarian hyperstim syndrome
risk assess at booking > give LMWH and stop during labour but start again after delivery
iii) intermittent pneumatic compression and anti embolic stockings
measure circumference of calf below tibial tub > 3 cm diff = significant
ix is doppler ultrasound
also need CXR and ECG
iv) give LMWH continue for pregnancy once VTW dx then for six weeks postnatal or 3 months total
v) wells score is not used and D dimers are not helpful as preg elevates D Dimer
