Antenatal Flashcards
1
Q
When does antenatal care begin?
A
Preconception Folic acid 3 months prior Stabilise medical conditions Stop smoking, alcohol Weight in healthy range Avoid teratogenic drugs (AECi) Switch antihypertensives to labetolol and methydopa Pre-pregnancy counselling on antiepileptics, warfarin, lithium
2
Q
In an uncomplicated pregnancy, how many contacts with the midwife/healthcare workers do you have?
A
Booking by 10 weeks gestation
10 appointments for nulliparous women
7 appointments for multiparous women
3
Q
What is done in a booking appointment?
A
Vitamin D 10mcg Discussion: Food hygiene Lifestyle advice Screening tests The Pregnancy Book Antenatal classes and breastfeeding workshops
4
Q
What is screened for in pregnancy?
A
HIV, HepB, syphilis, chlamydia for young women, NOT rubella
Group and save blood test (rhesus disease, in case of blood products later)
FBC (anaemia)
Haemoglobinopathy screen
MSU (asymptomatic infection)
20 weeks: placenta location scan, fetal anomaly scan
Glucose tolerance test if higher risk for gestational diabetes mellitus.
5
Q
What is anti-D?
What else is done after trauma?
A
Anti-D immunoglobulin is given to women at risky events (eg road traffic accident, amniocentesis, any haemorrhage) and all women at 12 weeks.
Kleihauer test or Acid elution test, is a blood test used to measure the amount of fetal haemoglobin transferred from a fetus to a mother’s bloodstream. Used in women with Hx of trauma.
6
Q
What increases maternal mortality significantly and women are asked to terminate their pregnancy?
A
Pulmonary hypertension
7
Q
What intervention is offered to pregnant women with a high BMI?
A
Referred to slimming world
“pregnancy diet”
8
Q
What needs to be considered in pregnant migrant women?
A
FGM?
Undiagnosed rheumatic fever?
9
Q
What is cervical incompetence? Possible treatments?
A
- Screening for cervical opening/funnelling
- Cervical cerclage (stitch in cervix)
- Aram pessary
10
Q
When is a C-section recommended?
A
Twins (depending on presentation and mother’s thoughts)
Breech presentation
Failure to progress in labour/complication
Mothers with epilepsy
Mothers with cardiovascular disease
11
Q
If a mother has had a c-section in her last pregnancy, what is recommended?
A
Vaginal delivery
Unless due to a comorbidity
12
Q
What is parvo virus?
Why is it different in pregnancy?
A
- Slapped cheek virus
- If primary infection during pregnancy, can cause fetal anaemia due to bone marrow suppression
- Anaemia tested for via MCA dopplers to assess relative brain arterial vasodilation
- Can be treated with blood transfer into umbilical artery or fetal peritoneum
13
Q
What is antepartum haemorrhage?
A
Bleeding from genital tract or into genital tract after 24 weeks of pregnancy
3-5% of pregnancies
14
Q
What is bleeding from/into genital tract called before 23 weeks gestation?
A
Threatened miscarriage
15
Q
Name 7 causes of antepartum haemorrhage
A
- Placental abruption
- Placenta praevia
- Trauma (including sexual assault)
- Cervical ectropion/polyp/cervicitis
- Cancer
- Blood stained show (blood stained mucus from the cervical mucus plug)
- Membrane sweep from midwife at 40/41 weeks to release prostaglandins (finger inside cervix)
16
Q
Define placental abruption
A
Premature separation of the placenta from the uterus
Blood dissects under the placenta
17
Q
Types of placental abruption
A
Visible versus concealed
Visible: Bleeding
Symptoms: bleeding, uterine contractions and fetal distress
18
Q
14 risk factors of placental abruption
A
- Previous abruption in previous pregnancy
- Pre-eclampsia
- Fetal growth restriction
- Malpresentation (and ECV)
- Polyhydramnos
- Advanced maternal age (over 40)
- Multiparity
- Low BMI
- IVF
- Chorioamonitis
- PROM
- Abdominal trauma
- Smoking
- Cocaine and amphetamines
19
Q
Define placenta praevia
2 categories
A
- Placenta in lower segment of uterus (where peritoneum is not fused to uterine wall)
- Minor (does not cover internal os, more than 2cm away)
- Major (covers os, can’t delivery vaginally)
20
Q
Define vasa praevia
A
Vessels of umbilical cord rupture near cervix
Small bleed of fetal blood
Rapid deterioration on CTG
21
Q
Define placenta accreta
A
Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium. 3 grades according to the depth of invasion:
Accreta – chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis.
Increta – chorionic villi invade into the myometrium.
Percreta – chorionic villi invade through the perimetrium (uterine serosa).
22
Q
Investigations if pt is not compromised with antepartum haemorrhage
A
• Pain, contractions • Quantity of bleeding • Post-coital bleeding • 20 week scan • Placental site assessment • Examine (hard wood like abdomen suggests abruption, ectropion? • CTG Blood tests: Hb, group&save, rhesus status, coagulation profile, Kleihauer test
23
Q
When do you admit a pregnant lady with antepartum haemorrhage?
A
If more than 50ml blood
24
Q
Treatment of antepartum haemorrhage
A
Don’t ignore someone with blood on her feet
If above 50ml, admit (? Deliver)
If above 500ml, admit, resuscitate, deliver
If above 1000ml, resuscitate, deliver C section under GA
Aim for vaginal delivery even if fetus has died
25
Maternal complications of antepartum haemorrhage
* Anaemia
* Shock
* Renal failure
* DIC
* Postpartum haemorrhage
* Hysterectomy (rare)
* Psychological effects
26
Fetal complications of antepartum haemorrhage?
* Acute fetal distress
* Anaemia
* Fetal death
* Fetal growth restriction
* Prematurity (iatrogenic/pathological)
27
Explain the need for anti-D
If mother does not have copy of Rh-D antigen gene they are Rh negative
if Rh negative pt has partner who is Rh positive, their offspring may be Rh positive.
if fetal blood enters maternal circulation, antibodies will develop to D-antigen
In subsequent pregnancies these Ab may cross placenta and attack fetal red cells and cause anaemia (+- stillbirth)
Anti-D immunoglobulin can prevent this and is given routinely at 28 weeks
28
If a patient has had 1 child born at 38 weeks, one miscarriage at 9 weeks and is pregnant, what is her GP?
G3 P1+1
29
When does nausea and vomiting during pregany usually resolve by?
16-20weeks
30
What foods should be avoided in pregnancy?
soft cheeses, unpasteurised milk, raw fish (listeria)
unwashed salad, fruit, veg, raw meat (toxoplasmosis)
shellfish, raw eggs (food poisoning)
Caffeine (limit to 300mg/day)
31
Dose of folic acid?
400ug OD in 1st 12 weeks
| 5mg if taking anti-epileptics or T1DM
32
Why is aspirin given to hypertensive/PET mothers in pregnancy?
To aid placental blood flow
33
What can be diagnosed with USS screening?
```
Anencephaly (cranium not formed)
Congenital heart disease
Ventirculomegaly
Cleft lip
Omphalocele/exomphalmos (midline abdominal wall defect with herniation of abdominal contents into base of umbilical cord, commonly contains liver and small bowel)
Talipes
```
34
Define talipes
Talipes is a condition that can affect one or both of a baby's feet from birth. In most cases, the front half of the foot turns inwards and downwards. This is called congenital talipes equinovarus (CTE). It is also known as club foot.
35
Define screening
Any testing procedure designed to separate people or objects according to a fixed characteristic or property, with the intention of detecting early evidence of disease.
36
What proportion of births are twins/multiple pregnancies?
3%
37
Mechanism of mono and dizygotic twins
* Division of a single fertilised ovum into 2 embryos (monozygotic identical twins)
* Fertilisation of two separate ova (dizygotic fraternal twins)
38
Risks of multiple pregnancy?
* Early labour and preterm delivery
* Growth restriction (suboptimal perfusion, velamentous cord insertions along edge of placenta with lack of Warton’s jelly for protection of cord)
39
Monozygotic twins risk
* Miscarriage & stillbirth & perinatal mortality
* Placental problems (twin-twin transfusion syndrome)
* Cord entanglement in MZ monoamniotic monochorionic twins
* Chromosomal abnormalities (screening by CRL, nuchal translucency, ßHCG, PEPA, feticide by intracardiac K+)
* Congenital malformation (neural tube, cardiac and gastrointestinal atresia
40
Describe the amnion versus chorion
The inner membrane, the amnion, encloses the amniotic cavity, containing the amniotic fluid and the fetus. The outer membrane, the chorion, contains the amnion and is part of the placenta (the fetal part of the placenta, chorionic villi)
41
Describe the chorion and amnion possibilities of twins
If morula is cleaved on days 1-3-> dichorionic, diamniotic
If blastocyst is cleaved on days 4-8-> monochorionic, diamniotic
If implanted blastocyst is cleaved on days 8-13-> monochorionic, monoamniotic
If formed embryonic disc is cleaved on days 13-15-> conjoined twins
42
Risk factors of dizygotic twinning
Infertility treatments, maternal age over 40, increased parity
43
How common are mono vs dizygotic twins?
Monozygotic twinning: 1pair/250 live births
| Dizygotic twinning: UK 8pairs/1000 births.
44
Which infertility treatments increase chances of dizygotic twins?
aromatase inhibitors, clomiphene, gonadotropins, IVF
45
How is chorionicity assessed?
Assessed with USS at 11-14 weeks
Dichorionicity: widely separated sacs/placentae, membrane insertion showing lambda sign, fetuses different sexes
Monochorionicity: T sign
46
How is antenatal care different for multiple pregnancies?
* High risk so consultant led
* Signs: fundus felt before 12 weeks, hyperemesis
* Consider delivery at 38weeks by induction or caesarean depending on orientation of leading twin
* If monochorionic: fetal medicine team
* Gestational age is worked out by CRL of largest baby
* Label babies (1&2, R&L, up&down)
47
What are the risks to the mother in multiple pregnancies?
* Hyperemesis gravidarum (due to more ßHCG as more placenta)
* Anaemia (FBC at 20-24 weeks)
* PET
* Gestational DM
* Polyhydramnios
* Placenta praevia
* Post partum haemorrhage (due to larger uterus, give syntocin infusion)
* Operative delivery
48
Define TTTS
Twin-to-twin transfusion syndrome
Caused by abnormal connecting blood vessels in the twins' placenta. This results in an imbalanced blood flow from one twin (known as the donor) to the other (recipient), leaving one baby with a greater blood volume than the other.
49
Risks of TTTS to twins
* Donor twin (anaemia, hypovolaemia, oligohydramnios, growth restriction)
* Recipient twin (polycythaemia, hypervolaemia, polyhramnios, large bladder, fetal hydrops including ascites, pleural and pericardial effusions)
50
Management/treatment of TTTS
* USS fortnightly from 12 weeks
* Treatment: laser ablation of anastomoses, serial amnioreductions, septostomy, selective feticide by occlusion of cord (last resort)
51
Define IUGR in twins
* USS assessed
| * 10% for gestational age or 25% difference between twins
52
Difference in management of preterm labour in multiple pregnancies
* Can’t use cervical length, fetal fibronectin, cervical cerlage, progesterone or tocolytics
* Tocolytics can be used if steroids need time to be effective or transfer to a special care centre is needed
* Twins are induced at 38 weeks if not spontaneous, triplets at 35 weeks
53
What is the maternal death rate?
8.5/100000 maternities
| 2 of those cardiac-> pulmonary oedema
54
What are the risks of maternal diabetes?
* Miscarriage/stillbirth
* Hypertension and PET
* Congenital malformation
* Large baby and shoulder dystocia/obstructed birth
* Birth injury
* Hypoglycaemia
* Respiratory distress
* Jaundice
* Death
55
What should BP be kept under in pregnancy?
140/90
56
Define pregnancy induced hypertension
Hypertension with no proteinuria from 20weeks of pregnancy
57
Define PET
Multisystem disorder with hypertension after 20 weeks gestation, proteinuria and oedema
More than 300mg protein/24hrs
Protein creatinine ration>30
Placental problem, oxidative stress
58
Define eclampsia
Seizure/convulsive episode caused by PET
59
Categories of hypertension in pregnancy
Mild: 140-149/90-99
Moderate: 150-159/100-109
Severe:160/110
60
Causes of maternal death in PET
Intracranial haemorrhage, cerebral oedema, pulmonary oedema, hepatic rupture/necrosis
Long term associations with CV disease and future hypertension and stroke
61
Risk factors for PET
* Essential hypertension
* 1st baby (10% risk)
* Hypertension in previous pregnancy
* Chronic renal disease
* Diabetes
* Hydatidiform mole
* Acquired clotting disorders
62
When should a mother be on aspirin?
• 1st pregnancy
• Multiple pregnancy
• BMI>35
If 2 or more-> aspirin 75mg at 12 weeks gestation
63
Symptoms of PET
```
Headache
Visual disturbances
Oedematous
Epigastric and RUQ pain (liver changes)
Feeling jittery
Vomiting
```
64
What investigations should be done in PET?
FBC: no acute haemolysis, platelets, U&Es, LFTs (ALT), Urate
Blood pressure
Urine dip
Oedema
Reflexes (knee jerk and ankle clonus)
Fundoscopy
Fetal:
• Movements
• USS: growth, liquor volume, umbilical artery dopplers
• Symphysiofundal height (fetal growth restriction is strongly associated)
65
What antihypertensives can be used in pregnancy?
* Labetalol (1st line alpha+beta blocker)
* Methyldopa (alpha-blocker)
* Nifedipine (amlodipine is fine, Ca2+ channel blocker))
* NOT ACEi, ARB
* Long term B-blockers can cause IUGR
* IV labetalol/hydralazine
66
Treatment of severe pre-eclampsia
* MgSO4 (reduces risk of eclamptic seizure)
* Fluid balance (limit intake to 85ml/hr to avoid pulmonary oedema)
* If preterm, corticosteroids
* Consider delivery (ultimate treatment!)
67
Define HELLP
Haemolysis, elevated liver enzymes, low platelets
↑ Thromboxane (vasoconstricting prostaglandin)
↑ in anti-angiogenic factors (cytotrophoblasts fail to invade)
68
Where is progesterone produced?
Synthesised by the corpus luteum until day 35 and then by the placenta
69
Actions of oestradiol in pregnancy
Breast and nipple growth, pigmentation of the areola, promotes uterine blood flow, myometrial growth and cervical softening
70
Actions of human placental lactogen
Similar to growth hormone, modifies the maternal metabolism to increase the energy supply to the fetus
HPL increases insulin secretion but decreases insulin’s peripheral effect, therefore liberating maternal FA and sparing glucose for the fetus.
71
Describe the haemodynamic changes of pregnancy
* Plasma volume (increases by 30-50%, total gain roughly 1.5L)
* Red cell volume (rises by 18%)
* Total WCC (increases due to polymorphonuclear leucocytes. Neutrophilia during labour. However, depressed immune function)
* Platelets (decrease slightly, function is unchanged)
* Clotting factors (hypercoaguble state, most clotting factors increase, especially fibrinogen)
72
Describe cardiovascular changes in pregnancy
* Cardiac output (increases due to increased stroke volume and pulse rate)
* Contractions increase CO due to blood from placental spaces entering circulation
* Heart enlarges due to hypertrophy
* Blood pressure (decreases mid pregnancy due to vasodilatory prostaglandins decreases peripheral resistance)
* Profound hypotension can occur in late pregnancy when lying supine due to compression of the IVC
73
Describe resp changes in pregnancy
* Level of the diaphragm raises, breathing becomes more diaphragmatic than costal
* Tidal volume increases (inspiratory capacity increases)
* Breathlessness is common due to the maternal PCO2 is set lower to allow fetus to offload CO2
74
Uterine changes in pregnancy
* 10 fold increase in weight (1kg at term, muscle hypertrophy)
* Uterine blood flow increases (x10 ml/min)
* Cervix (reduction in collagen towards term, cervical mucus plug as barrier to infection, increases ectopy-> vaginal discharge)
75
How do the breasts change in pregnancy
* Lactiferous ducts and alveoli develop and grow under oestrogen, progesterone and prolactin
* Colostrum can be expressed from breast after 3-4months
* Prolactin stimulates breast milk production (blocked during pregnancy by oestrogen and progesterone)
* Suckling stimulates prolactin and oxytocin-> ejection of milk
76
Risk factors for placenta praevia
```
Previous placenta praevia
Advanced materna; age
Multiparity
Multiple pregnancy
Presence of succenturiate placental lobe
Smoking
```
77
How is placenta praevia diagnosed?
If 20 week scan shows low lying placenta, scan is done in 3rd trimester so diagnose
May present with painless unprovoked vaginal bleeding
78
Signs and symptoms of placental abruption
Antepartum haemorrhage
Constant, unprovoked abdominal pain
Shock?
Tonic contraction of uterus (wood-like uertus)
79
Differential diagnosis of eclampsia
```
Epileptic seizure
Meningitis
Cerebral thrombosis
Intracerebral bleed
Intracerebral tumour
```
80
Who is screened for gestational diabetes?
```
BMI above 30
Previous macrosomic baby (>4.5kg)
Previous gestational diabetes
1st degree relative w/diabetes
South asian, black caribbean, middle eastern origin
```
81
Treatment of obstetric cholestasis
Chlrophenamine
Aqueous creams
Ursodeoxycholic acid
LFT monitored weekly & CTG
82
What can cause a uterus to be small for dates?
```
Maternal disease-> IUGR (renal, htn, congenital heart disease, severe anaemia, sickle-cell, SLE, CF, HIV)
PET/HTN
Chromosomal anomaly
Fetal malformation
Fetal infection
Constitutional
Placental issues
```
83
What can cause a uterus to be large for dates?
Gestational diabetes
Gestational trophoblastic disease
Increased liquor volume (fetal abnormality, gestational diabetes, intrauterine infection)
84
Obese ladies in pregnancy may need:
Glucose tolerance test for GDM
Anaesthetic referral to see if suitable for C-section, IV access difficult, neck fat immobile
Need extra vitamins due to malnutrition
Clexane for 10 days post partum (VTE risk)
85
Name 3 causes of oligohydramnios
Issue with fetal kidney function
Placental insufficiency
Fetal TTTS
86
What bloods would show acute fatty liver of pregnancy?
Raised ALT
Raised uric acid
Low blood glucose
87
When can amniocentesis be carried out? Risk?
15-22weeks
| 1% risk of miscarriage
88
A 40yr old primiparous woman attends antenatal clinic at 12 weeks gestation. She has a history of essential hypertension, with a FH of multiple pregnancy. She is allergic to penicillin. Which factor in her history is the most important in the antenatal risk assessment?
Essential hypertension
| In conjunction with elderly primip, strong risks for PET
