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OnG > Antenatal > Flashcards

Antenatal Flashcards

1
Q

What is the rapid test to detect PPROM + alternative

A

“Actim PROM kit”

  • Binds to IGF binding protein-1 presence in amniotic fluid
  • Use vaginal swab sample
  • Blood/ secretion/ urine/ lubricant do not affect the test result

Alternative: Litmus test (red to blue, amniotic fluid pH is 7.1-7.3), examine under microscopy (ferning of dried amniotic fluid due to high salt content)

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2
Q

Management for PPROM

A

<34 weeks POA

  • T. erythromycin 400mg BD for 10 days
  • IM Dexamethasone 12mg x 2 doses, 12 hourly
  • Tocolytic: if in labor for dexamethasone to complete
  • Allow labor if steroid complete
  • Expectant management up to 34 weeks if does not go into labor
  • If infection develops -> parenteral antibiotics and deliver fetus regardless of maturity

> 34 weeks POA

  • Recommend delivery
  • Dexamethasone should be completed
  • Use of tocolytics to complete dexamethasone is not justifiable
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3
Q

How to monitor PPROM <34 weeks POA

A
  • FBC and CRP on admission
  • Maternal vital sign 4 hourly
  • Strict pad chart: changes in liquor color (meconium/ foul staining)
  • Fetal kick chart
  • Daily CTG: uterine contraction
  • Fetal heart rate 4 hourly
  • S&S of chorioamnionitis
  • FBC weekly (WBC)
  • Low vaginal swab weekly (for C&S)
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4
Q

Criteria to suspect chorioamnionitis

A

> Fever >37.5’C, plus 2 of:

  • Maternal tachycardia
  • Fetal tachycardia
  • Leukocytosis
  • Uterine tenderness
  • Foul smelling amniotic fluid
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5
Q

Component of Modified Bishop score

A
  • Dilatation of cervix
  • Consistency of cervix
  • Length of cervical canal
  • Position of cervix
  • Station of presenting part
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6
Q

Definition of preterm labor

A
  • Labor occurring between 24+0 and 36+6 weeks
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7
Q

How to perform fetal kick chart

A
  • Monitoring baby movement from 9am each day
  • Tick every time baby kick
  • Fill in the time at 10th kick
  • If <10 by 9pm, refer to clinic
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8
Q

Causes of reduce CTG variability

A
  • Fetal sleeping (should be <40 min)
  • Fetal acidosis
  • Fetal tachycardia
  • Drugs: opiates
  • Prematurity
  • Congenital heart abnormalities
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9
Q

Definition of CTG: contraction, baseline rate, baseline variability, acceleration, deceleration

A
  • Contraction: number of contraction in 10 minutes
  • Baseline rate: average heart rate in 10 minutes
  • Baseline variability: refers to variation of fetal heart rate from one beat to the next
  • Acceleration/ Deceleration: abrupt increase/ decrease greater than 15bpm greater than 15 seconds
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10
Q

Tocolytic agents used in preterm labor

A
  • Nifedipine: preferable, CCB
  • Salbutamol/ terbutaline: B2 agonist -> smooth muscle inhibition
  • Magnesium sulphate
  • Atosiban: oxytocin antagonist
  • Ritodrine
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11
Q

Definition of pregnancy induced hypertension

A
  • > = 140/90 mmHg on at least 2 separate occasion and at least 4 hours apart arising de novo
  • After 20 weeks of gestation in a previously normotensive woman
  • Resolving completely by the 6th postpartum week
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12
Q

Definition of pre-eclampsia

A

Hpt >20 weeks + one or more:

  • Proteinuria (24 hour urine albumin: >=300mg)
  • Other maternal organ dysfunction
  • Uteroplacental dysfunction
  • Others: pulmonary edema, placental abruption, oliguria, epigastric pain
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13
Q

Complication of pre-eclampsia

A

> Maternal

  • Risk of cerebrovascular accident
  • Renal/ Liver failure
  • DIVC
  • Placental abruption
  • Eclampsia

> Fetus

  • IUGR
  • Respiratory distress syndrome
  • Prematurity
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14
Q

Pathophysiology of pre-eclampsia

A
  • Failure of trophoblast invasion of the myometrial segments of spiral arteries -> impaired perfusion of fetoplacental unit -> placenta ischemia -> release inflammatory cytokines -> dysfunction of vascular endothelial cells -> decrease release of nitric oxide and other vasodilators -> vasoconstriction -> HPT
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15
Q

Risk factor for pre-eclampsia

A

> Major

  • HPT in previous pregnancies
  • Chronic renal disease
  • Autoimmune disease (eg: SLE, anti-phospholipid)
  • DM
  • Chronic HPT

> Minor

  • Primigravida
  • Birth interval >10 years
  • Multiple pregnancies
  • Family hx of pre-eclampsia
  • Age >40 years
  • BMI >30 kg/m2
  • 1 major/ 2 minor = Aspirin (12-36 weeks) + calcium carbonate (from 20 weeks)
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16
Q

Component of PE profile

A
  • FBC: Hb, plt (Anemia and Thrombocytopenia seen in HELLP)
  • Renal profile: creatinine
  • LFT: AST, ALT (Elevated liver enzyme in HELLP)
  • Serum uric acid
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17
Q

Dosage of MgSO4 for PE

A

> Intravenous - 1 ampoule = 2.47g/ 5ml

  • Loading: 4gm (8ml) MgSO4 + 12ml NS slow bolus over 15 mins
  • Maintenance: 24.7gm (50ml) + 450ml NS to run at 21ml/H

> Intramuscular

  • Loading: 5gm (10ml) given at each buttock
  • Maintenance: 5gm (10ml) in alternate buttock every 4 hours
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18
Q

How to monitor for MgSO4 toxicity

A
  • Patellar reflex present
  • RR >16bpm every 15 mins
  • Urine output >30ml/hour
  • Serum MgSO4 within 1.7-3.5 mmol/L
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19
Q

Mode and timing of delivery for hypertensive in pregnancy

A
  • Severe PIH: 37 weeks
  • PET: 34-37 weeks
  • PIH on anti-HPT: 38 weeks
  • PIH not on anti-HPT: 40 weeks
  • PE end up with Cx: deliver ASAP
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20
Q

Prevention of pre-eclampsia

A
  • Aspirin 150mg ON (100mg if <40kg); 12-36 weeks of gestation
  • CI: asthma, allergy
    • Calcium carbonate 1g BD; from 20 weeks of gestation
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21
Q

Indication for magnesium sulphate

A

> Eclampsia (as a treatment to stop seizure)
Severe HPT associated with
- Significant proteinuria >= 2+
- Symptoms of impending eclampsia (headache, BOV, epigastric pain, NV)
- Complication from severe pre-eclampsia: HELLP syndrome, acute pulmonary edema, placenta abruption

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22
Q

Management of HPT in pregnancy

A
  • Assess symptoms of IE, check urine albumin
  • Control of BP
  • Prevent seizure (MgSO4)
  • Fluid management
  • Maternal and fetal monitoring (eg: PET chart, vital sign, MgSO4 chart, continuous CTG)
  • If stable, monitor as outpatient (with anti-HPT, BP + serial growth scan + umbilical artery Doppler 2 weekly) until 37 weeks and delivered
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23
Q

Management of eclampsia

A
  • Call for help!
  • DR ABC, left lateral position
  • Secure 2 IV line
  • IV/ IM MgSO4 loading dose followed by maintenance dose
  • Start anti-HPT (if >160/110 mmHg)
  • Total fluid 2L/24 hours
  • Monitor in HCU (PET chart, RR, urine output)
  • Plan for delivery
24
Q

Indication for MOGTT

A

“MOMMA”

  • Maternal age >25
  • Obesity
  • Macrosomia
  • Multiple pregnancy
  • A history (Previous ep/ Family)
  • Once at 16-18 weeks/ booking + at 24-28 weeks
25
Q

Pre-pregnancy counselling in pre-existing DM

A
  • Achievement of optimal control
  • Assessment of severity of DM
  • Education: effect of hyperglycemia, risk of congenital abnormalities, need of tight control
  • Stop smoking, optimize weight
  • Folic acid: 5mg OD given 12 weeks prior to conception
  • Contraception until good control
26
Q

Monitoring of GDM in clinic

A
  • Urine dipstick & BP each visit
  • Random/ 2h post prandial capillary glucose
  • HbA1C (1st trimester only)

> Fetal assessment

  • Fetal growth: serial growth scan every 2 weeks after 24 weeks; detail ultrasound at 18-24 weeks
  • Fetal well being: from 28 weeks onward (Normal >10 kicks/day)
  • Cardiotocography
27
Q

Timing and mode of delivery GDM

A

> Timing

  • Uncomplicated/ Good control: 40 - 40+6 weeks
  • Pre-existing/ Overt DM/ On-treatment without complication: 37 - 38+6 weeks
  • Poor control/ maternal or fetal complication: prior to 37 weeks

> Mode of delivery

  • C-section: if suspect fetal macrosomia - fear of shoulder dystocia
  • SVD if no contraindication & IOL
28
Q

Intrapartum care of GDM

A

> T1DM

  • Insulin infusion and IV dextrose from onset of labor
  • +- Potassium

> T2DM, GDM

  • Insulin infusion sliding scale when >7 mmol/l
  • Fine tune to achieve between 4-7 mmol/l
29
Q

Complication of GDM

A

> Maternal

  • Miscarriage
  • Pre-eclampsia
  • Preterm labour
  • PROM
  • Recurrent infection

> Fetus

  • Congenital abnormalities
  • Macrosomia
  • Polyhydramnios
  • Respiratory distress syndrome
  • IUD
30
Q

Effect of pregnancy on pre-existing DM

A
  • Risk of deterioration of established nephro/neuro/retinopathy
  • Increase in insulin dose requirement
  • Greater importance of tight glucose control
31
Q

Definition of anemia in pregnancy

A
  • Hb <11g/dL (WHO) or <10g/dl (hospital)
32
Q

Causes of anemia in pregnancy

A
  • Physiological
  • Nutritional: IDA/ Folate
  • Hemolytic: thalassemia
  • Myeloproliferative: leukemia
33
Q

Types of iron preparation

A
  • Iberet (500mg/tab): 105 mg ferrous sulphate
  • Ferrous fumarate (200mg/tab): 60 mg ferrous fumarate
  • New obimin: 30mg ferrous sulphate
34
Q

Ferrous fumarate vs sulphate

A

> Fumarate

  • Absorption: less readily
  • SE: NV, constipation
  • Cheaper
  • Polypharmacy: Yes

> Sulphate

  • Readily absorb
  • No NV, constipation
  • Expensive
  • Polypharmacy: No
35
Q

Complication of postdate pregnancy

A
  • Oligohydramnios
  • Meconium aspiration
  • Macrosomia
  • Placental insufficiency (due to aging -> IUGR/ IUD)
  • Fetal dysmaturity syndrome
36
Q

Classification of multiple pregnancy based on what

A
  • Fetus
  • Fertilized eggs (zygosity)
  • Placenta (chrionicity)
  • Amniotic cavities (amniocity)
37
Q

Antenatal monitoring of multiple pregnancy

A

> Antenatal

  1. 1st trimester scan - determine chrionicity
    - ‘T’ sign: monochorionicity
    - ‘lamda sign’: dichorionicity
  2. Monitoring of fetal growth -> Serial growth scan (fetal parameter, fetal activity, lies and DVP)
    Monitoring of fetal wellbeing -> Doppler and CTG
    - DCDA: 4 weekly
    - MCDA: 2 weekly
38
Q

Timing of delivery for multiple pregnancy

A
  • DCDA: 37-38 weeks
  • MCDA: 36-37 weeks
  • MCMA: 32-34 weeks
39
Q

Mode of delivery for multiple pregnancy

A

> C-section

  • Non-cephalic first twin
  • Previous LSCS scar
  • MCMA/ MCDA twin

> SVD
- First twin cephalic

40
Q

Complication of multiple pregnancy

A

> Maternal

  • Anemia
  • Preterm delivery
  • PIH, GDM
  • APH, PPH
  • Increase risk of operative delivery

> Fetal

  • TTTS
  • IUGR
  • Polyhydramnios
  • Congenital anomalies
  • Cord accident
41
Q

DVT sign and symptoms

A
  • Swelling
  • Pain/ tenderness
  • Warmth in skin
  • Red/ discolored skin
  • Leg fatigue
42
Q

Differential diagnosis for small for gestational age

A
  • Inborn error of metabolism
  • Substance abuse
  • Cigarette smoking
  • Pre-eclampsia
  • Chronic renal disease
  • Anemia
  • Antepartum hemorrhage
  • Multiple gestation
43
Q

What to look for in umbilical artery doppler

A
  • S/D ratio (abnormal if >95th percentile for gestational age)
  • Absent diastolic flow is an important sign as it may lead to intrauterine fetal death
44
Q

Alternative medication than MgSO4 to abort seizure

A
  • Diazepam 10mg
45
Q

Mechanism of Aspirin and in preventing pre-eclampsia

A

> Aspirin

  • Low dose aspirin diminished platelet thromboxane synthesis while maintaining vascular wall prostacyclin synthesis
  • Prostacyclin helps to inhibits platelet activation and is an effective vasodilator
46
Q

Differential for uterus larger than date

A
  • Multiple gestation
  • Macrosomic
  • Molar pregnancy
  • Polyhydramnios
  • Uterine fibroid
  • Wrong date
47
Q

Contraindication for parenteral iron

A
  • Hx of anaphylaxis
  • 1st trimester
  • Chronic livery disease
  • Acute/ Chronic infection
48
Q

How to distinguish thalassemia and IDA

A

> IDA

  • Reduced serum ferritin, iron, transferrin saturation
  • Increase total iron binding capacity
  • Hb electrophoresis: normal or reduced HbA2

> Thalassemia
- Hb electrophoresis: increased HbA2

49
Q

Management of thalassemia carrier in pregnancy

A

> Serum ferritin <30 ng/ml
- Hematinic supplement

> Serum ferritin >30 ng/ml
- Only folic acid 5mg/day

  • Screen partner for thalassemia and counsel accordingly
50
Q

Investigation done during booking visit

A

> Blood

  • FBC (Hb level)
  • Blood group and type
  • Rh antibodies
  • Rubella titre, VDRL, HBsAg routine, HIV serology

> Urine examination

  • Dipstick for protein, glucose
  • R/o UTI
51
Q

Contraindication of external cephalic version

A
  • Independent indication requiring LSCS (eg: placenta praevia, major uterine abnormality)
  • Ruptured membranes
  • Recent APH (within 7 days)
  • Multiple pregnancy (except 2nd twin)
  • Abnormal CTG
52
Q

Complication of ECV

A
  • Placental abruptio
  • Transplacental haemorrhage
  • Cord entanglement
  • PROM
  • Foetal bradycardia
  • Uterine rupture/ scar dehiscence
53
Q

Pre-requisites for ECV

A
  • 37 weeks POG
  • Recent ultrasound to confirm presentation, normal foetus, and liquor volume
  • Reactive CTG before the procedure for 20 mins
  • Facilities for LSCS
  • Check rhesus status
54
Q

Complication of malpresentation/ malposition

A
  • High head at term
  • Ineffective contraction
  • Obstructed labour
  • Increased incidence of instrumental/ operative delivery
55
Q

Diagnosis of polyhydramnios

A
  • DVP >= 8cm/ AFI >= 24cm
  • Pressure symptoms
  • Uterus large for dates
  • Difficulty palpating foetal parts/ hearing foetal heart sound
56
Q

Management of polyhydramnios

A
  • Complete ultrasound evaluation to look for fetal anomalies (eg: esophageal atresia, cardiac septal defect, cleft platelet)
  • Screen for maternal diabetes
  • If severe -> therapeutic amniocentesis

> Timing of delivery

  • Mild to moderate: 39-40 weeks
  • Severe: 37 weeks (minimized risk of abruption in cause of SPROM)
57
Q

For REDD, first u/s should performed before how many weeks for it to be reliable?

A
  • < 22 weeks POG

- Serial ultrasound should be performed: suboptimal interval growth = suggest SGA; accelerated = suggest LGA

OnG (14 decks)

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