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3a Women's health > Antenatal > Flashcards

Antenatal Flashcards

1
Q

What is gestational diabetes

A

Reduced insulin sensitivity ( carbohydrate intolerance) during pregnancy which may or may not resolve after birth

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2
Q

Give 5 RFs for gestational diabetes

A
  • Previous gestational diabetes
  • Previous macrosomic baby (≥ 4.5kg)
  • BMI > 30
  • black Caribbean, Middle Eastern and South Asian origin
  • Polyhydramnios
  • First gen FHx of diabetes
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3
Q

What is the screening test of choice for gestational diabetes

A

oral glucose tolerance test

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4
Q

What time of day should an Oral Glucose Tolerance Test (OGTT) be performed?

A

In the morning after a fast (patient can drink plain water).

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5
Q

When should individuals with risk factors for gestational diabetes be screened?

A

With an oral glucose tolerance test (OGTT) at 24–28 weeks gestation

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6
Q

When do women with a history of previous gestational diabetes have an OGTT?

A

as soon as possible after the booking clinic and subsequently at 24-28 weeks

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7
Q

Describe the oral glucose tolerance test

A
  • patient drinks a 75g glucose drink at the start
  • blood sugar level is measured before the sugar drink (fasting) and then at 2 hours
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8
Q

What are the diagnostic thresholds on an OGTT for gestational diabetes

A
  • fasting glucose >= 5.6mmol/L
  • 2 hour glucose >= 7.8mmol/L
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9
Q

How is gestational diabetes managed

A
  • joint diabetes and antenatal clinics
  • education - self monitoring of glucose, exercise, diet
  • Fasting glucose <7 mmol/l: trial of diet and exercise for 1-2 weeks
  • fasting glucose >7 mmol/l: start short acting insulin ± metformin
  • Fasting glucose >6 mmol/l plus macrosomia (or other Cx): start insulin ± metformin
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10
Q

How is gestational diabetes managed in a woman with a fasting glucose <7mmol/L

A
  • trial of exercise for 1-2w
  • if glucose targets not met within 1-2w then start metformin
  • if glucose targets still not met, add short acting insulin
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11
Q

What medication is suggested for women who decline insulin or cannot tolerate metformin in the management of gestational diabetes?

A

Glibenclamide - sulfonylurea

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12
Q

How is gestational diabetes followed up postnatally

A

test fasting glucose at 6 weeks

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13
Q

How are pregnant women with pre-existing diabetes managed

A
  • folic acid 5 mg/day from pre-conception to 12 weeks gestation
  • aspirin 75-150mg daily from 12 weeks gestation until the birth
  • retinopathy screening
  • stop oral hypoglycaemic agents, apart from metformin, and commence insulin
  • planned delivery between 37 and 38+6 w
  • tight glycaemic control
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14
Q

What are the self-monitoring blood sugar targets for pregnant women with gestational and pre-existing diabetes?

A
  • Fasting: 5.3 mmol/l
  • 1 hour post-meal: 7.8 mmol/l
  • 2 hours post-meal: 6.4 mmol/l
  • Avoid levels of 4 mmol/l or below.
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15
Q

What are the risks to babies of mothers with diabetes?

A
  • Neonatal hypoglycaemia
  • Polycythaemia (raised haemoglobin)
  • Jaundice (raised bilirubin)
  • Congenital heart disease
  • macrosomia -> birth trauma
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16
Q

When are women routinely screened for anaemia during pregnancy?

A

At the booking clinic and again at 28 weeks gestation

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17
Q

What causes anaemia in pregnancy

A

During pregnancy, the plasma volume increases. This results in a reduction in the haemoglobin concentration. The blood is diluted due to the higher plasma volume.

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18
Q

What are the normal ranges for haemoglobin during pregnancy

A
  • First trimester: > 110 g/l
  • Second/third trimester: > 105 g/l
  • Post partum: > 100 g/l
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19
Q

What screening for haemoglobinopathy is offered to women at the booking clinic?

A
  • Thalassaemia screening for all women.
  • Sickle cell disease screening for women at higher risk.
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20
Q

Give 3 maternal complications of sickle cell in a pregnant woman

A
  • crisis
  • thrombosis
  • pre-eclampsia
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21
Q

Give 2 fetal complications of sickle cell in their mother

A
  • intrauterine growth retardation
  • increased perinatal mortality
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22
Q

How is sickle cell managed in pregnancy

A
  • folic acid 5mg
  • aspirin
  • penicillin V
  • LMWH
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23
Q

In a pregnant woman with hypertension, which 3 antihypertensive medications should be stopped due to teratogenicity

A
  • ACE inhibitors (e.g. ramipril)
  • Angiotensin receptor blockers (e.g. losartan)
  • Thiazide and thiazide-like diuretics (e.g. indapamide)
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24
Q

Give 3 antihypertensive drugs that are safe to use in pregnant women with existing hypertension

A
  • Labetalol (a beta-blocker )
  • Calcium channel blockers (e.g. nifedipine)
  • Alpha-blockers (e.g. doxazosin)
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25
Q

Give some RFs of VTE in pregnancy and state their risk level

A
  • Prev VTE - high
  • thrombophilia - high/med
  • prolonged hospitalisation - med
  • co-morbidities - med
  • surgery - med
  • age >35
  • BMI >30
  • Parity >3
  • smoking
  • multiple pregnancy
  • gross varicose veins
  • immobility
  • current pre-eclampsia
  • FHx
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26
Q

When should VTE prophylaxis be initiated in pregnant women

A
  • 3 RFs: From 28 weeks till 6w postnatal
  • ≥ 4 RFs: immediate treatment continued until 6 weeks postnatal
  • if there’s a single high/ medium risk factor - as above
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27
Q

What is the pharmacological prophylaxis for VTE in pregnancy

A

Low molecular weight heparin (LMWH) unless contraindicated.
Eg. enoxaparin, dalteparin and tinzaparin

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28
Q

What is the protocol for VTE prophylaxis during and after labour?

A

Prophylaxis is temporarily stopped when the woman goes into labor and can be started immediately after delivery (except with PPH, spinal anaesthesia, and epidurals.

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29
Q

What is the recommendation for anticoagulation treatment if a DVT is diagnosed shortly before delivery?

A

Continue anticoagulation treatment for at least 3 months.

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30
Q

What are the options for mechanical VTE prophylaxis in pregnant women with contraindications to LMWH?

A
  • Intermittent pneumatic compression (equipment that inflates and deflates to massage the legs).
  • Anti-embolic compression stockings.
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31
Q

What is intrahepatic cholestasis of pregnancy

A

characterised by the reduced outflow of bile acids from the liver in a pregnant woman
(aka obstetric cholestasis)

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32
Q

When does obstetric cholestasis typically present?

A

Later in pregnancy, particularly in the third trimester.

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33
Q

Give 3 features of obstetric cholestasis

A
  • pruritis - typically worse on palms, soles and abdomen
  • jaundice (uncommon)
  • excoriations without a rash
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34
Q

What fetal complication is associated with obstetric cholestasis?

A

increased risk of stillbirth.

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35
Q

How is obstetric cholestasis investigated

A
  • LFTs - abnormally raised
  • raised bile acids
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36
Q

How is obstetric cholestasis managed

A
  • topical emollients - soothe skin
  • antihistamine (e.g. chlorphenamine) - help sleep
  • monitoring LFTs and bile acids
  • ursodeoxycholic acid - reduce severity of pruritis
  • vitamin k supplements
  • induction of labour at 37-38w if [bile acids] >100micromol/L
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37
Q

Define gravidity

A

the total number of pregnancies a woman has had

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38
Q

Define parity

A

the number of times the woman has given birth after 24 weeks gestation, regardless of whether the fetus was alive or stillborn

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39
Q

Define gestational age

A

refers to the duration of the pregnancy starting from the first day of the last menstrual period

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40
Q

What are the 3 trimesters of pregnancy

A
  • first - from the start of pregnancy until 12 weeks gestation
  • second trimester - from 13 weeks until 26 weeks gestation
  • third trimester - from 27 weeks gestation until birth
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41
Q

At what gestation do fetal movements typically start

A

20 weeks

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42
Q

In pregnancy, what is the dating scan and when should it be done

A
  • ultrasound to determine accurate gestational age using crown-rump length, also detects multiple pregnancies
  • between 10 and 13+6 weeks
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43
Q

What is the basic antenatal schedule recommended for women with uncomplicated pregnancies

A
  • 16w - Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron. Routine care: BP and urine dipstick
  • 18 - 20+6w - anomaly scan
  • 25, 28, 31, 34, 36, 38, 40 and 41w - routine care
  • scans at 25, 31 and 40 weeks are only done for nulliparous women
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44
Q

What are the key assessments and discussions during routine antenatal appointments?

A
  • Discuss plans for the remainder of the pregnancy and delivery
  • Symphysis–fundal height measurement from 24 weeks onwards
  • Fetal presentation assessment from 36 weeks onwards
  • Blood pressure
  • Urine dip
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45
Q

What screening programmes are offered to all pregnant women

A
  • Infectious diseases in Pregnancy Screening Programme (hep B, syphilis, HIV)
  • Sickle Cell and Thalassaemia Screening
  • Fetal Anomaly Screening Programme (Down’s syndrome, Edwards’ syndrome and Patau’s syndrome)
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46
Q

Name a haemoglobinopathy screened for in high risk pregnant women

A

sickle cell disease

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47
Q

What is the advice on vitamin supplementation in pregnant women

A
  • folic acid 400mcg from before conception till 12w
  • avoid vitamin A as can be teratogenic in high doses
  • 10mcg Vit D daily
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48
Q

What conditions are risk assessed in women during antenatal appointments, and what plans are made for high-risk conditions?

A
  • Rhesus negative (book anti-D prophylaxis)
  • Gestational diabetes (book oral glucose tolerance test)
  • Fetal growth restriction (book additional growth scans)
  • VTE (provide prophylactic LMWH if high risk)
  • Pre-eclampsia (provide aspirin if high risk)
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49
Q

What is the standard screening test for down’s syndrome antenatally

A
  • combined test
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50
Q

when should the combined test be done when screening for down’s syndrome

A

between 11 - 13+6 weeks

51
Q

Describe how the combined test is done

A
  • ultrasound to measure nuchal translucency
    maternal blood test to measure:
  • Beta‑human chorionic gonadotrophin (beta-HCG)
  • Pregnancy‑associated plasma protein‑A (PAPPA)
52
Q

What results would suggest down’s syndrome on the combined test

A
  • high bHCG
  • low Pregnancy‑associated plasma protein‑A (PAPPA)
  • nuchal translucency thickness > 3.5mm
53
Q

What screening test is done for down’s syndrome if the woman books too late for the combined test.

A

quadruple test done between 14-20w

54
Q

What is measured in the quadruple screening test in regards to chromosomal abnormalities and what results would indicate down syndrome

A
  • bHCG (high)
  • alpha-fetoprotein (low in trisomy 21)
  • inhibin (high in trisomy 21)
  • oestriol (low)
55
Q

Screening tests provide a risk score for the fetus having down-syndrome. What score is considered high risk

A

1 in 150 chance or less (eg 1 in 100)

56
Q

What is offered to pregnant women with a high risk score after down-syndrome screening

A
  • non-invasive prenatal screening test (NIPT)
  • diagnostic tests: amniocentesis (after 15w) or chorionic villus sampling (before 15w)
57
Q

Give 2 examples of neural tube defects

A
  • spina bifida
  • anencephaly (incompatible with life)
58
Q

What protein is raised in a fetus with a neural tube defect

A

alpha-fetoprotein

59
Q

Give 3 RFs for congenital heart anomalies

A

mother:
* with congenital heart disease
* with diabetes
* taking antiepileptic meds

60
Q

What is exomphalos

A

abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum

61
Q

Give 2 conditions associated with exomphalos

A
  • down’s syndrome
  • cardiac and kidney malformations
62
Q

How is exomphalos managed

A
  • C-section due to risk of sac rupture
  • staged repair
63
Q

What is gastroschisis

A

congenital defect characterised by free loops of bowel in the amniotic cavity

64
Q

How is gastroschisis managed

A

postnatal surgery within 4 hours of birth

65
Q

What is the most important antigen of the rhesus system

A

D antigen

66
Q

Explain how rhesus incompatibility in pregnancy can be an issue

A
  • if a Rh -ve mother has a Rh +ve child a leak of fetal red blood cells may occur
  • this causes anti-D IgG antibodies to form in mother as she has become sensitised to rhesus-D antigens
  • in later pregnancies these antibodies can cross placenta and cause haemolysis in rhesus +ve fetus
  • this is haemolytic disease of the newborn
67
Q

How is rhesus incompatibility in pregnancy managed

A
  • test for D antibodies in all Rh -ve mothers at booking
  • prevention of sensitisation (prophylaxis): IM anti-D to non-sensitised rhesus -ve mothers at 28w (or 28 + 34w)
68
Q

What situations in a pregnancy of a RH -ve mother necessitate the administration of Anti-D immunoglobulin as soon as possible

A
  • delivery of Rh +ve infant
  • antepartum haemorrhage
  • amniocentesis, chorionic villus sampling, fetal blood sampling
  • abdominal trauma
  • miscarriage if gestation is > 12 weeks
  • ectopic if managed surgically
  • any termination of pregnancy (>10w)
    anti-D within 72h
69
Q

What tests should be done to assess rhesus incompatibility and sensitisation

A
  • all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test
  • Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
  • Kleihauer test (>20w) : determines proportion of fetal RBCs present
70
Q

What is the purpose of the Kleilhauer test

A

checks how much fetal blood has passed into the mother’s blood during a sensitisation event

71
Q

What are dizygotic twins

A

non-identical
* develop from fertilisation of two different oocytes by two different sperms at the same time

72
Q

What are monozygotic twins

A

identical twins
* from mitotic division of a single zygote

73
Q

Are dizygotic or monozygotic twins more common?

A

dizygotic

74
Q

What are dichrorionic diamniotic (DCDA) twin pregnancies

A

two separate placentas and two separate amniotics sacs

75
Q

What are monochrionic diamniotic (MCDA) twin pregnancies

A

shared placenta but separate amniotic sacs
(most common)

76
Q

What are monochorionic monoamniotic (MCMA) twin pregnancies

A

shared placenta and single amniotic sac

77
Q

Give 4 predisposing factors for dizygotic twin pregnancies

A
  • previous twins
  • IVF
  • FHx
  • increasing maternal age
78
Q

Give 3 maternal complications of multiple pregnancies

A
  • anaemia
  • gestational HTN
  • postpartum haemorrhage
79
Q

Give 5 fetal complications of multiple pregnancies

A
  • miscarriage
  • prematurity
  • twin-twin transfusion syndrome
  • fetal growth restriction
  • congenital abnormalities
80
Q

Explain twin-twin transfusion syndrome

A
  • occurs when the fetuses share a placenta
  • caused by unequal blood distribution through vascular anastomosis of the shared placenta
81
Q

What are the effects of twin-twin transfusion syndrome on the ‘donor’

A
  • volume depleted
  • oligohydramnios
  • growth restriction
  • anaemic
82
Q

What are the effects of twin-twin transfusion syndrome on the ‘recipient’

A
  • fluid overloaded
  • polyhydramnios
  • heart failure
  • polycythaemia
83
Q

How is twin-twin transfusion syndrome managed

A

laser ablation of interconnecting vessels

84
Q

How are multiple pregnancies managed antenatally

A
  • FBC at booking, 20w and 28w
  • 2 weekly scans from 16w for monochorionic twins
  • 4 weekly scans from 20w for dichorionic twins
85
Q

When is delivery advised in different types of multiple pregnancies

A
  • 37 - 37+6w for uncomplicated dichorionic diamniotic twins
  • 36 - 36+6w for uncomplicated monochorionic diamniotic twin
  • 32+0 - 33+6 weeks for uncomplicated monochorionic monoamniotic twins
  • before 35+6w for triplets
86
Q

What are the delivery options for diamniotic twins

A
  • vaginal delivery if the first baby has a cephalic presentation
  • may need emergency csection to deliver the second twin after vaginal birth of the first twin
  • elective caesarean if the first twin is not cephalic at the time of planned birth
87
Q

What are the delivery options for monoamniotic twins

A

elective C section between 32 - 33+6w

88
Q

What is a breech presentation

A

when the presenting part of the fetus is the legs and bottom

89
Q

State and define the 3 types of breech presentation

A
  • extended (frank) breech - both hips flexed and knees fully extended
  • footling breech - one or both feet present below the buttocks
  • Flexed (complete) breech - both legs flexed at the hips and knees
90
Q

What is the most common breech presentation

A

Extended/frank breech - 70%

91
Q

Give 5 RFs for breech presentations

A
  • prematurity
  • fetal abnormality
  • placenta praevia
  • pelvic tumours/ fibroids
  • polyhydramnios or oligohydramnios
92
Q

How are breech presentations managed

A
  • <36w - no intervention as baby may turn spontaneously
  • > 37w - External cephalic version.offer at 36 if nulliparous
  • If ECV fails then choice between planned vaginal delivery and elective caesarean
93
Q

What are the benefits of an elective caesarean compared to a vaginal delivery when delivering a breech baby

A

caesarean carries a reduced perinatal mortalitiy and early neonatal morbidity

94
Q

Describe how external cephalic version is done

A
  • tocolysis to relax uterus - SC terbutaline
  • attempt to turn fetus using pressure applied on abdomen
  • performed under ultrasound guidance
  • Anti-D prophylaxis given to rhesus-D negative women
95
Q

Give 5 contraindications to external cephalic version

A
  • if vaginal delivery is contraindicated
  • ruptured membranes
  • multiple pregnancy
  • antepartum haemorrhage
  • compromised fetus
96
Q

What is fetal lie

A

the relationship of the fetus to the long axis of the uterus

97
Q

What are the 3 types of fetal lie

A
  • longitudinal (mc) - cephalic or breech
  • transverse lie - head in one flank
  • oblique - head in one iliac fossa
98
Q

Give 4 risk factors for abnormal fetal lie

A
  • polyhydramnios
  • high parity
  • multiple pregnancy
  • fibroids and other pelvic tumours
99
Q

Give 3 complications of abnormal fetal lie

A
  • pre-term rupture of membranes
  • cord-prolapse
  • uterine rupture if obstruction neglected
100
Q

How are transverse and oblique lie managed

A
  • <36w - no action required unless in labour
  • > 37w - admit to hospital. ECV if membranes haven’t ruptured and women would like a vaginal delivery
  • elective caesarian - patient choice or ECV failed/ CI
101
Q

What is fetal hydrops

A

occurs when extra fluid accumulates in two or more fetal compartments

101
Q

What is an unstable fetal lie

A

when a fetus’s position and presentation frequently change in late pregnancy, usually after 37 weeks

102
Q

Give 4 causes of fetal hydrops

A
  • Immune: anaemia and haemolysis secondary to rhesus disease
  • Non-immune:
  • chromosomal abnormalities
  • structural abnormalities (pleural effusion)
  • cardiac abnormalities
  • anaemia causing heart failure (parvovirus, fetal a-thalassaemia major)
103
Q

How is obesity in pregnancy defined

A

BMI > 30 kg/m2

104
Q

Give 5 maternal risks of obesity in pregnancy

A
  • pre-eclampsia
  • venous thromboembolism
  • gestational diabetes
  • postpartum haemorrhage
  • wound infections
105
Q

Give 5 risks to the fetus due to maternal obesity in pregnancy

A
  • congenital anomaly
  • perinatal mortality
  • prematurity
  • macrosomia
  • stillbirth
106
Q

How is obesity in pregnancy managed

A
  • women avoid dieting and instead maintain weight during pregnancy due to malnutrition risk
  • 5mg folic acid
  • gestational diabetes screening
  • BMI >40 - anaesthetic risk assessment and antenatal thromboprophylaxis
107
Q

Define small for gestational age

A

a fetus that measures below the 10th centile for their gestational age

108
Q

What 2 measurements on ultrasound are used to assess fetal size

A
  • Estimated fetal weight (EFW)
  • Fetal abdominal circumference (AC)
109
Q

What are the two categories of causes for Small for Gestational Age

A
  • Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart
  • Fetal growth restriction (FGR), aka intrauterine growth restriction (IUGR)
110
Q

Define intrauterine growth restriction

A

when there is a small fetus (or a fetus that is not growing as expected) due to a pathology

111
Q

What are the two categories of causes for intrauterine growth restriction?

A
  • Placenta-mediated growth restriction.
  • Non-placenta-mediated growth restriction
112
Q

What conditions can lead to placenta-mediated fetal growth restriction

A
  • Pre-eclampsia
  • Maternal smoking
  • Maternal alcohol/ drug use
  • Anaemia
  • Booking BMI
  • Infection (e.g. CMV)
  • Maternal health conditions (e.g. autoimmune, HTN)
113
Q

What are some causes of non-placenta-mediated growth restriction in the fetus?

A
  • Genetic abnormalities
  • Structural abnormalities
  • Fetal infection
  • Errors of metabolism
114
Q

Apart from small for gestational age, give 4 signs that indicate fetal growth restriction

A
  • Reduced amniotic fluid volume
  • Abnormal Doppler studies
  • Reduced fetal movements
  • Abnormal CTGs
115
Q

Give 3 complications of fetal growth restriction

A
  • stillbirth
  • fetal distress
  • preterm delivery
116
Q

Give 5 RFs for small for gestational age

A
  • heavy daily exercise
  • smoking
  • cocaine usage
  • prev SGA baby or stillbirth
  • multiple pregnancy
117
Q

What parameters are monitored in a fetus at risk or with Small for Gestational Age (SGA) using serial ultrasound scans?

A
  • Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity
  • Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery
  • Amniotic fluid volume
118
Q

How is intrauterine growth restriction managed

A
  • serial growth scans
  • early delivery by caesarean or induction if fetal compromise
119
Q

What is placenta accreta

A

when the placenta implants deeper, to the myometrium instead of endometrium, making it difficult to separate the placenta after delivery of the baby

120
Q

Give 2 RFs for placenta accreta

A
  • previous caesarean section
  • placenta praevia
121
Q

What is the risk of placenta accreta

A

As the placenta does not properly separate during labour there is a risk of postpartum haemorrhage

122
Q

Describe the 3 types of placenta accreta

A
  • superficial accreta: placenta implants in the surface of the myometrium, but not beyond
  • increta: placenta attaches deeply into the myometrium
  • percreta: placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder
123
Q

Recommended treatment for delayed placental delivery in patients with placenta accreta

A

Hysterectomy

3a Women's health (12 decks)

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