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Obs & Gynae > Antenatal Care > Flashcards

Antenatal Care Flashcards

1
Q

SFH = symphysis fundal height

  • it should equal what?
  • a difference of +/- __cm is considered significant in suggesting the baby is a bit small/large for gestational age, and would warrant further ix
A
  • should equal gestational age in weeks

- >2cm is significant

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2
Q

Define Pre-eclampsia:

A

high BP >140/90mmHg with significant proteinuria

must have been normotensive <20weeks

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3
Q

Name 3 RFs for Pre-eclampsia (PET):

A
  • PET in previous pregnancies
  • fam hx of PET
  • Pre-existing HT
  • Age
  • Pre-existing renal disease
  • DM esp. if on insulin/systemic disease
  • multiple pregnancy
  • nulliparous
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4
Q

What bloods are done at the booking visit looking at the actual blood?

A
  • FBC (to correct anaemia if present)
  • Haemoglobinopathy screen for thalassaemia, sickle cell etc
  • Blood group (if rhesus negative may need anti-D, can check babys type via NIPT seeing cf DNA, if baby also negative no need for anti D)
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5
Q

What bloods are done at the booking visit looking at infection which could be vertically transmitted to baby? Name 2

A
  • Syphilis (rx w benzylpenicillin)
  • HIV (treat w ARVs to undetectable)
  • Hepatitis B (may need immunoglobulins/vaccine when born)
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6
Q

Dating scan to establish EDD and current gestational age is done at what week?

A

-Dating scan is done at 11-13 weeks (crown rump length CRL is used to date gestational age)

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7
Q

The anomaly scan occurs at what gestational age?

A

20weeks

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8
Q

The flow through the uterine arteries are measured, why? what does it reflect? When would you be worried? If resistance is high, what medication is started to improve outcomes?

A

Reflects perfusion to placenta and uterus
If high resistance of flow, indicates possible risk of perfusion and risk of pre-eclampsia and child being small
-Aspirin if given to stabilise the endothelium of vessels so delays the onset of PET
-

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9
Q

PET = endothelium becomes dysfunctional due to cytokines released by placeta. It lines all organs so pre-eclampsia bloods try to look for any organ dysfunction.
Therefore suggest 4 bloods you would do (&why)

A
  • renal profile (look for creatinine)
  • liver profile (look for transaminitis)
  • haematological: FBC, look for platelet count, anaemia from haemolysis)
  • coagulation profile (DIC risk)
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10
Q

What is the basics of physiological changes of BP in pregnancy?

A
  • vasodilation causes BP to decrease from 6weeks on
  • 20-24 weeks is the lowest BP
  • as progresses towards term, BP will increase (by increased SV and HR) steadily but remains in normal range
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11
Q

BP that is high and presents <20wks gestation is called?

  • if the BP is high and there is significant proteinuria <20weeks gestation this suggests?
  • if normotensive before 20 weeks then develops HT this is called?
A
  • BP high at booking, is pre-existing HT
  • with protenuria is pre-existing HT secondary to renal disease
  • after 20weeks, HT is called PIH (Pregnancy Induced HT)
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12
Q

NB: PET doesn’t only affect the mother systemically, what effects can there be on the foetus?

A

-the uteroplacental unit can -> foetal growth restriction, abnormal umbilical artery Doppler waveform analysis or still birth

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13
Q

Pre-eclampsia is the the leading cause of iatrogenic _____

why? (relates to treatment..)

A

Prematurity - as only rx is to deliver the placenta (offending organ) delivery is only way to avoid eclampsia

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14
Q

Normal = trophoblasts invade maternal vessels in decidua and change narrow spiral arteries into wide bore low-resistance vessels, why is this beneficial?

A
  • good for gas exchange
  • can deliver large amounts of maternal blood
  • better nutrient and o2 delivery to foetus (slower flow so more time for exchange)
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15
Q

What is the pathophys of PET on the uteroplacental circulation?

A

-deficient trophoblast invasion
-spiral arteries not remodelled
-high resistance placental bed
-poorly perfused hypoxic placenta
-deficient nutrient and o2 delivery
-release of inflammatory cytokines (IL, TNF…)
-

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16
Q

What is the pathophys of PET on the maternal endothelium because of the inflammatory cytokines released?

A
  • increased vascular reactivity and vasospasm
  • increased capillary permeability and reduced intravascular volume
  • risk of peripheral and pulmonary oedema (fluid restriction may be necessary to avoid this complication)
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17
Q

State 3 aspects of the management of pre-eclampsia?

(NB: ‘cure’ for PET is delivery

A
  • treat BP aiming for 130/80mmhg
  • monitor sx, signs, bloods
  • growth scan for baby checking blood flow
  • aim to delivery at 37 weeks unless compromise before this
  • if eclampsia: stabilise BP, treat w magnesium sulphate (to prevent seizures) and DELIVER
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18
Q

State a long-term risk for the mothers health from PET after delivery

A
  • 1/3rd develop chronic HT in the year after pregnancy
  • ~50% will have cardiovascular disease later in life
  • so need to see GP annually for a BP check
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19
Q

Why are women in a pro-thrombotic state in pregnancy physiologically?

A
  • extra volume so that if they bleed at delivery they have enough reserve
  • to prevent haemorrhage at delivery
  • clotting factors increase, fibrinolytics decrease
20
Q

Name 5 RFs that increase the pro-thrombotic state, and risk of VTE on top of the physiological changes in pregnancy:

A
  • inherited thrombophilia’s
  • obese
  • smoking
  • older age
  • > parity 3, multiple pregnancy
  • ovarian hyperstimulation syndrome (OHSS) -> intravasc deplete, dehydrated -> clots
  • sepsis
  • haemorrhage
  • C-section surgery (immobility)
21
Q

Where are VTEs most commonly in pregnancy and why?

A
  • left-sided (as uterus usually compresses vessels here more)
  • ilio-femoral
22
Q

What is the rx for VTE in pregnancy?

NB: -warfarin = teratogenic so only used for post-natal complications

A
  • LMWH

- IV heparin, if renal problems or near delivery (easier to reverse if necessary)

23
Q

Name 2 complications of DVT

A
  • PE
  • chronic vascular insufficiency
  • post-thrombotic syndrome
24
Q

Diagnosis of PE in pregnancy?

A
  • look at legs, do a leg doppler: if confirmed can treat

- if negative, need to do CTPA or VQ scan

25
Q

compare and contrast VQ scan and CTPA or no scan for PE dx in pregnancy:

A
  • CTPA: ionising radiation, increases risk of breast cancer 1 in 1000, contrast has 1: 13,000 risk of causing childhood leukaemia to child
  • risk of clot going unnoticed can -> death
  • VQ scan may not pick up clot but is no ionising radiation and no contrast
  • if treated without imaging will affect risk assessments in future and can effect insurance etc
26
Q

What is an amniotic fluid embolism?

NB: if suspected, must initiate a major obstetric haemorrhage protocol to prophylactically get blood products, why?

A
  • amniotic fluid gets into maternal circulation
  • sudden onset chest pain, SOB, collapse, cyanosis
  • then women will come round after resuscitation, they start bleeding profusely (DIC)
  • because the amniotic embolism uses up all the coagulation factors
27
Q

What is the principle of managing an amniotic fluid embolism?

A
  • supportive rx: O2, intubate
  • correct coagulopathy
  • initiate a major obstetric haemorrhage protocol
28
Q

Give 2 causes of antepartum haemorrhage, what are they briefly?

A
  • Placenta praevia: placenta covering the cervix
  • Placental Abruption: placenta coming away from uterine wall prematurely
  • Vasa Praevia: foetal blood vessels run through the membranes that cross over the cervix, when membranes break, so will vessels and baby’s blood supply will bleed out
29
Q

Placenta praevia (1 in 200 pregnancies), placenta covering cervix

  • what is the biggest RF?
  • when/how is it usually diagnosed?
  • how must they deliver?
A
  • previous C-sections, the more history, the worse risk
  • usually dx at 20week scan seen as a low-lying placenta
  • need to deliver by C-section
30
Q

Placenta praevia sx/signs that may make you suspect it?

A
  • high presenting part
  • abnormal lie
  • PAINLESS per vaginal bleeding
  • soft-non-tender uterus
31
Q

PLACENTA
>20mm from interal os = normal
<20mm from internal os = __-____
covering internal os = ____ ____

A
  • <20mm = low-lying

- covering = placenta praevia

32
Q

Name 3 associated risks of placenta praevia:

A
  • maternal blood loss, antepartum haemorrhage
  • malpresentation
  • pre-term birth
  • abnormally invasive placenta (‘placenta accreta) w previous c-section, placenta can invade the scar of the previous c-section
33
Q

Placenta accreta is classified depending on how invasive the placenta is:

  • <50% invaded into myometrium called a____
  • > 50% invaded called i____
  • invaded all the way through to serosa p____
A
  • accreta
  • increta
  • percreta
34
Q

Management principles of placenta praevia:

any foetal/maternal compromise -> immediate delivery by cs

A
  • NO vaginal exams (finger will go into placenta)
  • admit, IV access, wide bore cannula, cross match, check Rh group
  • USS placental localisation
  • consider steroids, to help lung maturation
  • let neonatal unit know (poss expectation of pre-term infant)
  • if well, elective CS at 37weeks
35
Q

Vasa Praevia, when would you deliver, why?

A
  • Deliver by c-section
  • before cervical dilatation
  • aim 35, 36 weeks (not 37 when woman is more likely to go into labour)
36
Q

What is placental abruption?
NB: -associated w: high parity, smoking, poor nutrition, previous abruption(20% risk), PET, trauma, external cephalic version = manually moving baby out of breech position

A

Bleeding from behind a normally situated placenta

-bleeding can be revealed, concealed or mixed

37
Q

How does placental abruption present?

Basics of management?

A
  • +/- bleeding, PAINFUL APH (antepartum haemorrhage)
  • woody hard uterus
  • manage: IV access, cross match blood, ABCDE approach
  • if woman is unstable, you must not deliver baby
  • if woman stable but foetal compromise-> emergency c-s in 20min (category 1)
38
Q

Suggest 3 complications of placental abruption:

A
  • maternal and foetal morbidity and mortality
  • AKI
  • hypovolaemic shock
  • DIC
  • post partum haemorrhage
39
Q

Suggest 2 non-pregnancy related causes of APH, which you could do a speculum exam to examine for?

A
  • cervical cancer
  • cervical polyp
  • cervical erosion
40
Q

Sickle Cell and Thalassaemia Antenatal Screening

  • based on ethnic origin women are screened by blood test
  • between pre-conception, to 10 weeks
  • if +, what are the next ix
A
  • offer partner testing
  • if +, offer prenatal dx with CVS or amniocentesis
  • if foetus affected, offer: termination or early specialist care
41
Q

Chromosomal Abnormalities Screening

  • who gets scan
  • when?
  • what/how?
A
  • all pregnant women offered
  • between 11-14 weeks
  • combined test US: nuchal translucency, bHCG, pappa-A
42
Q

In general trisomy 21 have ____ b–HCG than normal foetus’s,
whereas ___ papp-A is associated with Trisomy 21

A

Trisomy 21:

  • higher bHCG
  • low Pappa-A
43
Q

In trisomy 21, h-HCG is higher, papp-A is low

What about in Trisomy 18 (Edward’s) and trisomy 13 (Patau)?

A

-trisomy 18 & 13: lower B-HCG and lower Pappa-A

44
Q

Fetal Anomaly Scan

  • when?
  • how?
A
  • -18-22weeks

- US : structured review of organ system

45
Q

Risk of amniocentesis is not 1%, it is at most ~___%

A

0.3%

Obs & Gynae (9 decks)

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