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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
Pre-pregnancy counselling in pre-existing DM
- 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
Monitoring of GDM in clinic
- 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
Timing and mode of delivery GDM
> 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
Intrapartum care of GDM
> 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
Complication of GDM
> Maternal - Miscarriage - Pre-eclampsia - Preterm labour - PROM - Recurrent infection > Fetus - Congenital abnormalities - Macrosomia - Polyhydramnios - Respiratory distress syndrome - IUD
30
Effect of pregnancy on pre-existing DM
- Risk of deterioration of established nephro/neuro/retinopathy - Increase in insulin dose requirement - Greater importance of tight glucose control
31
Definition of anemia in pregnancy
- Hb <11g/dL (WHO) or <10g/dl (hospital)
32
Causes of anemia in pregnancy
- Physiological - Nutritional: IDA/ Folate - Hemolytic: thalassemia - Myeloproliferative: leukemia
33
Types of iron preparation
- Iberet (500mg/tab): 105 mg ferrous sulphate - Ferrous fumarate (200mg/tab): 60 mg ferrous fumarate - New obimin: 30mg ferrous sulphate
34
Ferrous fumarate vs sulphate
> Fumarate - Absorption: less readily - SE: NV, constipation - Cheaper - Polypharmacy: Yes > Sulphate - Readily absorb - No NV, constipation - Expensive - Polypharmacy: No
35
Complication of postdate pregnancy
- Oligohydramnios - Meconium aspiration - Macrosomia - Placental insufficiency (due to aging -> IUGR/ IUD) - Fetal dysmaturity syndrome
36
Classification of multiple pregnancy based on what
- Fetus - Fertilized eggs (zygosity) - Placenta (chrionicity) - Amniotic cavities (amniocity)
37
Antenatal monitoring of multiple pregnancy
> 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
Timing of delivery for multiple pregnancy
- DCDA: 37-38 weeks - MCDA: 36-37 weeks - MCMA: 32-34 weeks
39
Mode of delivery for multiple pregnancy
> C-section - Non-cephalic first twin - Previous LSCS scar - MCMA/ MCDA twin > SVD - First twin cephalic
40
Complication of multiple pregnancy
> Maternal - Anemia - Preterm delivery - PIH, GDM - APH, PPH - Increase risk of operative delivery > Fetal - TTTS - IUGR - Polyhydramnios - Congenital anomalies - Cord accident
41
DVT sign and symptoms
- Swelling - Pain/ tenderness - Warmth in skin - Red/ discolored skin - Leg fatigue
42
Differential diagnosis for small for gestational age
- Inborn error of metabolism - Substance abuse - Cigarette smoking - Pre-eclampsia - Chronic renal disease - Anemia - Antepartum hemorrhage - Multiple gestation
43
What to look for in umbilical artery doppler
- 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
Alternative medication than MgSO4 to abort seizure
- Diazepam 10mg
45
Mechanism of Aspirin and in preventing pre-eclampsia
> 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
Differential for uterus larger than date
- Multiple gestation - Macrosomic - Molar pregnancy - Polyhydramnios - Uterine fibroid - Wrong date
47
Contraindication for parenteral iron
- Hx of anaphylaxis - 1st trimester - Chronic livery disease - Acute/ Chronic infection
48
How to distinguish thalassemia and IDA
> IDA - Reduced serum ferritin, iron, transferrin saturation - Increase total iron binding capacity - Hb electrophoresis: normal or reduced HbA2 > Thalassemia - Hb electrophoresis: increased HbA2
49
Management of thalassemia carrier in pregnancy
> 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
Investigation done during booking visit
> 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
Contraindication of external cephalic version
- 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
Complication of ECV
- Placental abruptio - Transplacental haemorrhage - Cord entanglement - PROM - Foetal bradycardia - Uterine rupture/ scar dehiscence
53
Pre-requisites for ECV
- 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
Complication of malpresentation/ malposition
- High head at term - Ineffective contraction - Obstructed labour - Increased incidence of instrumental/ operative delivery
55
Diagnosis of polyhydramnios
- DVP >= 8cm/ AFI >= 24cm - Pressure symptoms - Uterus large for dates - Difficulty palpating foetal parts/ hearing foetal heart sound
56
Management of polyhydramnios
- 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
For REDD, first u/s should performed before how many weeks for it to be reliable?
- < 22 weeks POG | - Serial ultrasound should be performed: suboptimal interval growth = suggest SGA; accelerated = suggest LGA

OnG (14 decks)

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