Antenatal Flashcards
What is the purpose of the booking visit?
To determine the mother’s level of risk (low, intermediate, high)
- her status can change at any time
- make sure we can optimise mother’s health
Two types of maternal death
DIRECT (haemorrhage, birthing complications)
INDIRECT (ongoing maternal medical conditions)
Leading cause of indirect maternal death
Cardiac conditions - myopathies in the postpartum period particularly overlooked
Leading cause of direct maternal death
VTE (PE), followed by amniotic embolus then suicide
Worldwide the leading cause is PPH (major obstetric bleeding is >2500mL)
Normal sequence of midwife care in pregnancy
Booking (10 weeks)
If Nulliparous - 16, 25, 28, 31, 34, 36, 38, 40, 41 (10 appts)
If multiparous and low risk - 16, 28, 34, 36, 38, 40, 41 (8 appts)
What should be checked during each antenatal appt?
BP, Urinalysis, Maternal wellbeing, Fetal movements, FHR (auscultate with doppler or pinard’s), Plot the symphysis-fundal height
What scans will every woman receive and when?
Every woman will have at least two scans:
- DATING SCAN: any time between 11+2 and 14+1
- ANOMALY SCAN: any time between 18+0 and 20+6
Define antenatal anaemia and suggest treatment
This is something that is commonly screened for in pregnancy. Hb levels lower in pregnancy physiologically (number of RBCs increase but plasma increases even more so relative conc is lower) but if they drop <100g/dL then consider FERROUS SULPHATE
Antenatal polyhydramnios: what is it?
Liquor volume commonly monitored in pregnancy
In 2nd and 3rd trimesters baby’s kidneys produce amniotic fluid - so abnormal levels of fluid might suggest renal abnormality or gastro-intestinal abnormality (inability to swallow amniotic fluid)
Polyhydramnios presentation
Tight, non-compressible uterus (cannot palpate fetal structures)
High symphysis-fundal height
Polyhydramnios: investigations
USS: pool >8cm, amniotic fluid index >90centile
Offer regular growth scans and GTT (associated with diabetes)
Polyhydramnios risks
Placental abruption, malpresentation, cord prolapse, large for gestation child, C-section, perinatal death
What is routine screening in ante-natal period?
- Fetal anomalies (scan)
- Infectious diseases (HIV, syphilis, hepatitis B)
- Rhesus negative
- Haemoglobinopathies
What is tested for in the DATING SCAN?
Occurs at 11+2-14+1 weeks. Confirm the pregnancy and give a reliable EDD
Also offer COMBINED SCREENING
- CRL (crown-rump length)
- NUCHAL TRANSLUCENCY (abnormal if >3.5mm)
- Maternal blood tests for BhCG and PAPPA (pregnancy associated plasma protein A)
***these will then produce a risk category for Down’s (high risk = >1/150) - 2% of women. NOT DIAGNOSTIC
If combined screening suggests woman is HIGH RISK what is the next stage?
Should be offered either CVS (from 11w) or amniocentesis (from 15w)
- This is a DEFINITIVE test for DOWN, EDWARDs and PATAUS
What if the woman misses combined screening?
If the woman attends for her dating scan later than 14+0 then it is possible she might miss the window for combined screening, in these circumstances she can be offered QUADRUPLE TESTING
can be done between 14+2 and 20+0 and involves a blood test only
80% detection rate and 4.1% chance of false positive
Are there other options for antenatal screening beyond those offered?
There is a test known as NON-INVASIVE PRENATAL TESTING (NIPT) that is a blood test that has a very very good detection rate - not offered on the NHS
When does the ANOMALY scan take place and what sort of things does it look for?
Between 18+0 and 20+6 Structural abnormalities including: -Gastroschisis -Heart defects -Trisomies
What infectious diseases are screened for in pregnancy?
Syphilis, HIV and Hepatitis B (done at booking)
HIV in pregnancy - when tested for and what is the risk of transmission?
If woman found, at booking visit, to be HIV +ve then we can act quickly to reduce risk of spread
- follow BHIVA guidance for anti-virals
- if woman has low viral load risk of transmission is 0.3%, goes up to 3% if breastfeed
Hepatitis B in pregnancy - when tested for and how do we determine risk profile?
Booking bloods
Notifiable disease - refer to public health
Woman with HepBe antibody + antigen are LOW RISK
Women with HepBe antibody - antigen are HIGH RISK
Offer antivirals
Breastfeeding is fine
Syphilis in pregnancy - when tested for and whats the risk?
Booking bloods
Will usually be in late-latent phase
Refer to GUM
They need to receive 4 weeks of therapy otherwise the baby will need to receive IV treatment
Other than infectious diseases, what other blood tests are done during booking visit?
Rhesus testing and haemoglobinopathies
Why do we test for Rhesus status?
If the mother is Rh-ve then she could produce antibodies to a rhesus positive baby meaning all future pregnancies with a Rh+ve baby will be attacked and result in a termination of the pregnancy
Management of a Rh-ve mother
Offer ANTI-D at 28 weeks and then again at 34 weeks if not sensitised (IM injection)
When the baby is born the cord bloods are also tested - if the baby is found to be Rh+ve then the mother will receive another anti-D
In what other situations is anti-D given?
TOP Miscarriage >12w Ectopic pregnancy managed surgically ECV APH Amniocentesis
What haemoglobinopathies do we test mothers for?
Sickle cell and thalassaemia
- mother will usually be asked to fill out a family origin questionnaire to work out if she is high risk
What is done if the woman is found to have a sickle cell or thalassaemia trait?
Her partner will be tested
When the baby is born it will have HEEL-PRICK test and haemoglobinopathies are tested for in this
What are some of the early clinical signs and symptoms of pregnancy?
Nausea and vomiting
Breast engorgement and tenderness
What are some of the early investigations we can do for pregnancy?
B-hCG - pregnancy test - can be measured for via urine dip
USS
What are the two types of USS most often used in pregnancy?
Transvaginal and transabdominal
Transvaginal might be more appropriate in women with higher BMIs
What structures appear when during the first trimester or pregnancy?
4-5 weeks - only gestation sac visible. About 6mm long
5-6 weeks - the yolk sac will become visible
6 weeks - the fetal pole should become visible (thickened margin of the yolk sac)
FETUS NOW DOUBLES IN SIZE EVERY WEEK UNTIL 12 WEEKS
6-7 weeks - this should be when you can first hear fetal heart beat although specialist equipment will likely be needed
8 weeks - at this point limb buds will start forming and there will be some fetal movement (women won’t feel it until 18weeks though)
What is mainly happening in the first 12 weeks of pregnancy?
During this period is when ORGANOGENESIS is happening. Cells are differentiating for form the organs
It is during this period that babies are particularly susceptible to teratogenesis
During this time is also when the placenta is forming and taking a major role
What changes are happening in the fetus after 12 weeks?
After 12 weeks the fetus is mostly just growing and developing - lower risk of teratogenesis
What previous obstetric issues (in previous pregnancy) would make the next pregnancy more high risk?
Previous C/S Pre-term delivery Pre-Eclampsia Prev GDM Recurrent miscarriage Still birth Multiple pregnancy SGA Placenta praevia
***would be wanting to ask a lot of questions about how these complicated the pregnancy and how they were managed at the time
How many consecutive miscarriages do you need to have to be classed as worrying?
3 consecutive
With just 1 or 2 there is a 95% chance the next pregnancy will be fine
If a woman has had a previous caesarean section how should she be encouraged to delivery this time?
VBAC
if just one previous C/S consider VBAC
If a woman has had just one previous C/S what are her chances of delivering successfully vaginally?
What about if she’s had a NVD since that C/S?
What are some RFx for failure?
72-75%
One successful NVD since - 85-90%
RFx for failure: BMI>30, Induction, prev CS for failure to progress
What are some benefits of VBAC?
Reduced recovery period, reduced complications and reduced risk of neonatal respiratory problems.
What are some risks of VBAC?
0.5% risk of uterine rupture (2-3x higher if IOL)
25% chance of EmLSCS
1% risk of haemorrhage
1:100 risk of HIE
What are some contraindications for VBAC?
Previous uterine rupture, previous classical uterine incision
3 or more prev C/S
How should women considering VBAC be managed?
VBAC discussed early on
Seen back in consultant clinic at 36w for final decision regarding MoD
- If elective LSCS then book for 39 weeks
- If VBAC plan to see at 40-41w if not laboured and consider induction
- Delivery will happen with 1:1 midwife care, in delivery suite with continuous CTG
What are some signs of uterine rupture?
Constant pain, scar tenderness, abnormal vaginal bleeding
What is a HIGH RISK factor for development of VTE in pregnancy?
Personal history of previous VTE EXCEPT one caused by major surgery
How should a woman with HIGH RISK for VTE be managed?
Prophylactic LMWH
4500 tinzaparin
What are some intermediate risk factors for VTE in pregnancy? How’s this managed?
Single, previous VTE related to pregnancy High risk thrombophilia Chronic medical condition Hospital admission Any surgical procedure
Prophylactic dose tinzaparin (4500U) should be considered
What are some LOW RISK factors for VTE in pregnancy?
How many of these should they have before you consider VTE prophylaxis?
BMI >30 Age >35 Parity 3 or more Smoker Gross varicose veins Current pre-eclampsia Immobility FH Low risk thrombophilia Multiple pregnancy
MUST HAVE 4 OR MORE FOR LMWH FROM FIRST TRIMESTER
IF WOMAN HAS 3 RISK FACTORS SHE WILL REQUIRE LWMH FROM 28 WEEKS
If a woman has been on LMWH during her pregnancy how will she be followed up?
She will need to continue on LMWH for 6 weeks post-natally
