Antenatal Care Flashcards
Primigravida vs. multigravida
Primigravida refers to a patient that is pregnant for the first time
Multigravida refers to a patient that is pregnant for at least the second time
para vs gravida
Para (P) refers to the number of times the woman has given birth after 24 weeks gestation, regardless of whether the fetus was alive or stillborn
Gravida (G) is the total number of pregnancies a woman has had
Nulliparous (“nullip”) vs primiparous (primip) vs Multiparous (“multip”)
Nulliparous (“nullip”) refers to a patient that has never given birth after 24 weeks gestation
Primiparous technically refers to a patient that has given birth after 24 weeks gestation once before - but often used to refer to W who has never given birth before
Multiparous (“multip”) refers to a patient that has given birth after 24 weeks gestation two or more times
Gravidity and Parity
A non-pregnant woman with a previous stillbirth (after 24 weeks gestation):
G1 P1
Gravidity and Parity
A pregnant woman with three previous deliveries at term
G4 P3
Gravidity and Parity
A non-pregnant woman with a previous birth of healthy twins:
G1 P1
Gravidity and Parity
A non-pregnant woman with a previous miscarriage:
G1 P0+1
trimester weeks
1-12, 13-26, 27-40
When do fetal movements start?
week 20, continue until birth
who needs anti-D injections
rhesus Negative women
6 things that happen at routine antenatal appointments
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
Urine dipstick for protein for pre-eclampsia
Blood pressure for pre-eclampsia
Urine for microscopy and culture for asymptomatic bacteriuria
what 2 vaccines are offered to all pregnant women?
Whooping cough (pertussis) from 16 weeks gestation Influenza (flu) when available in autumn or winter
Live vaccines, such as the MMR vaccine, are avoided in pregnancy.
Signs of fetal alcohol syndrome
Microcephaly (small head) Thin upper lip Smooth flat philtrum (the groove between the nose and upper lip) Short palpebral fissure (short horizontal distance from one side of the eye to the other) Learning disability Behavioural difficulties Hearing and vision problems Cerebral palsy
what does Smoking in pregnancy increases the risk of?
Fetal growth restriction (FGR)!!
Miscarriage Stillbirth Preterm labour and delivery Placental abruption Pre-eclampsia Cleft lip or palate
Sudden infant death syndrome (SIDS)!!
what GA is ok to fly in pregnancy?
The RCOG advises flying is generally ok in uncomplicated healthy pregnancies up to:
37 weeks in a single pregnancy
32 weeks in a twin pregnancy
What are the booking bloods?
A set of booking bloods are taken for:
- Blood group, antibodies and rhesus D status
- FBC for anaemia
- Screening for thalassaemia (all women) and sickle cell disease(women at higher risk)
Patients are also offered screening for infectious diseases, by testing antibodies for:
HIV
Hepatitis B
Syphilis
What is the combined test?
tests for down syndrome
1st line and most accurate screening test
do it GA 11-14
combine US and maternal blood test results
US - nuchal translucency (>6mm)
blood - B-hCG (higher inc risk), PAPPA (lower inc risk)
what is the difference between triple and quadruple test?
screen for Down's GA 14-20 only maternal blood (no US) - b-hCG (high inc risk) -AFP (low inc risk) -serum oesteriol (low inc risk)
quadruple - same but also test serum inhibit-A (high inc risk)
what is the risk score needed to offer amniocentesis or chorionic villus sampling to investigate Downs?
> 1 in 150 (occurs in 5% of tested W)
take fetal cells and perform karyotyping
CVS <15 weeks GA
amnio > 15 weeks GA
difference btw CVS and amniocentesis
Chorionic villus sampling (CVS) involves an ultrasound-guided biopsy of the placental tissue. This is used when testing is done earlier in pregnancy (before 15 weeks).
Amniocentesis involves ultrasound-guided aspiration of amniotic fluid using a needle and syringe. This is used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample.
what is alternative screening test for Downs not currently available on NHS?
Non-invasive prenatal testing (NIPT)
- blood test from the mother. The blood will contain fragments of DNA, some of which will come from the placental tissue and represent the fetal DNA.
These fragments can be analysed to detect conditions such as Down’s.
NIPT is not a definitive test, but it does give a very good indication of whether the fetus is affected
Possible consequences of untreated hypothyroidism in pregnancy?
miscarriage, anaemia, small for gestational age and pre-eclampsia.
management of hypothyroidism in pregnancy?
Levothyroxine T4
- crosses placenta
- -> inc dose by 25-50 mcg (30-50%)
titrate according to TSH level, aim for low-normal TSH
what meds for HT must be stopped when pregnant?
Medications that should be stopped as they may cause congenital abnormalities:
ACE inhibitors (e.g. ramipril)
Angiotensin receptor blockers (e.g. losartan)
Thiazide and thiazide-like diuretics (e.g. indapamide)
what antihypertensives can be used in pregnancy?
Labetalol (a beta-blocker - although other beta-blockers may have adverse effects)
Calcium channel blockers (e.g. nifedipine)
Alpha-blockers (e.g. doxazosin)
how do you manage epilepsy in pregnancy?
inc folic acid to 5mg
inc risk of seizures
ideally use 1 drug before become pregnant
Levetiracetam, lamotrigine and carbamazepine are the safer anti-epileptic medication in pregnancy
Sodium valproate - teratogenic, do not start childbearing age W on it —> causes neural tube defects and developmental delay
Phenytoin is avoided as it causes cleft lip and palate
management of RA in pregnancy?
well controlled for ≥3 months pre pregnant
symptoms improve in pregnancy, flare up after delivery
Methotrexate is contraindicated, and is teratogenic, causing miscarriage and congenital abnormalities
Hydroxychloroquine is considered safe during pregnancy and is often the first-line choice
Sulfasalazine is considered safe during pregnancy
Corticosteroids may be used during flare-ups
Up to What GA can get congenital rubella syndrome?
aka German measles
rubella virus infection during 1st 20 weeks of pregnancy
high risk <10 weeks GA
how do you prevent congenital rubella syndrome?
planning to have baby
- have MMR vaccine
- if ?, check rubella immunity
- if no antibodies to rubella –> vaccinate w/ 2x doses MMR, 3 months apart
pregnant
- no MMR vaccine bc live
- if non-immune, MMR vaccine after birth
4 features of congenital rubella syndrome
Congenital deafness
Congenital cataracts
Congenital heart disease (PDA and pulmonary stenosis)
Learning disability
3 dangers of chickenpox in pregnancy
Chickenpox is caused by the varicella zoster virus (VZV).
can lead to:
More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis
Fetal varicella syndrome
Severe neonatal varicella infection (if infected around delivery)
Management of chickenpox exposure in pregnancy
if had CP = safe
if unsure - check VZV IgG, if + safe
if no immune –> tx with IV varicella IG as prophylaxis within 10 days of exposure to CP
Management of chickenpox rash in pregnancy
if present within 24 hours exposure and >20 weeks GA –> oral aciclovir
5 features of Congenital varicella syndrome
occurs in 1% CP cases, when inf in 1st 28 weeks GA
Fetal growth restriction
Microcephaly, hydrocephalus and learning disability
Scars and significant skin changes located in specific dermatomes
Limb hypoplasia (underdeveloped limbs)
Cataracts and inflammation in the eye (chorioretinitis)
what gram + infection is more likely when pregnant?
listeria –> causes listeriosis
Infection in the mother may be asymptomatic, cause a flu-like illness, or less commonly cause pneumonia or meningoencephalitis.
risk of Listeriosis in pregnant women
inc rate of:
miscarriage or fetal death.
It can also cause severe neonatal infection.
how do you get listeriosis?
Listeria is typically transmitted by unpasteurised dairy products, processed meats and contaminated foods.
Pregnant women are advised to avoid high-risk foods (e.g. blue cheese) and practice good food hygiene.
how is CMV spread?
from infected saliva or urine of asymptomatic kids
features of congenital CMV
Most cases of CMV in pregnancy do not cause congenital CMV.
Fetal growth restriction Microcephaly Hearing loss Vision loss Learning disability Seizures
what is Congenital Toxoplasmosis?
Toxoplasma gondii parasite infection
It is usually asymptomatic.
It is primarily spread by contamination with faeces from a cat that is a host of the parasite. When infection occurs during pregnancy, it can lead to congenital toxoplasmosis. The risk is higher later in the pregnancy.
Triad of congenital toxoplasmosis
- Intracranial calcification
- Hydrocephalus
- Chorioretinitis (inflammation of the choroid and retina in the eye)
3 other names for parvovirus B19 infection
fifth disease, slapped cheek syndrome and erythema infectiosum
parvovirus infection signs
cause: parvovirus B19 virus
illness is self-limiting, and the rash and symptoms usually fade over 1 - 2 weeks.
starts with non-specific viral symptoms.
After 2 - 5 days, the rash appears quite rapidly as a diffuse bright red rash on both cheeks, as though they have “slapped cheeks”. A few days later a reticular (net like) mildly erythematous rash affecting the trunk and limbs appears, which can be raised and itchy.
incubation period of parvovirus
infection 7-10 days before rash appears
not infectious once have rash
what time means significant exposure to parvovirus?
15 minutes in the same room, or face-to-face contact, with someone that has the virus.
complications of parvovirus
Particularly in the first and second trimesters.
Miscarriage or fetal death
Severe fetal anaemia
Hydrops fetalis (fetal heart failure)
Maternal pre-eclampsia-like syndrome
how does parvovirus cause fetal anaemia?
- inc of euthyroid progenitor cells in fetal bone marrow and liver
- those cells make RBC –> inf causes faulty RBC production with shorter t1/2
- -> heart failure = hydrops fetalis
Cause and triad of maternal pre-eclampsia syndrome?
Parvovirus infection
aka mirror syndrome
rare comp of severe fetal heart failure (hydrops fetalis)
triad 1. hydrops fetalis 2. placental oedema 3. oedema in mom \+ Ht and proteinuria
investigations for parvovirus infection in the pregnant woman
- IgM to parvovirus –> acute infection within the past 4 weeks
- IgG to parvovirus —> long term immunity to the virus after a previous infection
- Rubella antibodies (as a differential diagnosis)
supportive tx, refer to fetal medicine
features of congenital Zika syndrome,
Microcephaly
Fetal growth restriction
Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy
management of congenital Zika syndrome
Pregnant women that may have contracted the Zika virus should be tested with viral PCR and antibodies to the Zika virus.
if + –> fetal medicine for close monitoring of the pregnancy.
There is no treatment for the virus.
who needs anti-D antibodies in pregnancy?
no tx if rhesusD ++++ (+ for antigen)
if rhesus D –
- -> child may be RhD+
- fetal blood into mom (delivery)
- baby’s RBC display RhD ANTIGEN
- mom immune system sees antigen as foreign –> make antibodies to antigen –> becomes sensitised
management - PREVENT SENSITISATION
why is sensitisation to rhesus-D antigens bad?
no probs in 1st pregnancy
later pregs
- mom anti-D antibodies cross placenta in fetus
–> if foetus rh +, antibodies attack foetus RBC to cause haemolysis
= haemolytic disease of newborn
management of Rhesus Incompatibility in Pregnancy
PREVENT SENSITISATION
–> give IM anti-D injections to rhesus D — W (i.e. no antigens)
no way to reverse sensitisation so prophylaxis essential
anti-D
- attaches to rhesusD antigens on fetal RBC in moms circulation –> destroys them
- -> prevents mom IS recognising antigen and creating own antibodies against it
when is anti-D routinely given?
28 weeks gestation
birth (if foetus rhesus ++)
when sensitisation may occur
- Antepartum haemorrhage
- Amniocentesis procedures
- Abdominal trauma
–> give with 72 hours of event
when and why do you perform the Kleihauer test?
after 20 weeks gestation
- see how much fetal blood has passed to mom
- -> determine if need further doses of anti-D
What is the Kleinhauer test?
The Kleihauer test checks how much fetal blood has passed into the mother’s blood during a sensitisation event. This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required.
- add acid to moms blood
- Fetal hb is naturally more resistant to acid –> protected against the acidosis that occurs around childbirth.
–> fetal hb persists in response to the added acid, while the mothers hb is destroyed.
The number of cells still containing haemoglobin (the remaining fetal cells) can then be calculated.
Define small for GA and 2 measurements used on US
fetus that measures below the 10th centile for their GA
on US
- Estimated fetal weight (EFW)
- Fetal abdominal circumference (AC)
how care growth charts customised to assess size of fetus?
based on the mother’s:
Ethnic group
Weight
Height
Parity
what is severe SGA
fetus below 3rd centile for CA
causes of SGA
The causes of SGA can be divided into two categories:
Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart
–> stay on same centile, grows appropriately
Fetal growth restriction (FGR), aka intrauterine growth restriction (IUGR)
= small fetus (or fetus not growing as expected) due to pathology dec amount of nutrients + O2 delivered via placenta –> drop down centiles
difference btw SGA and FGR
Small for gestational age simply means that the baby is small for the dates, without stating why.
The fetus may be constitutionally small, growing appropriately, and not at increased risk of complications.
Alternatively, the fetus may be small for gestational age due to pathology (i.e. FGR), with a higher risk of morbidity and mortality.
–> drops centiles
2 categories of FGR
The causes of fetal growth restriction can be divided into two categories:
Placenta mediated growth restriction
Non-placenta mediated growth restriction,
- baby is small due to a genetic or structural abnormality
Placenta mediated growth restriction causes for FGR
= conditions that affect the transfer of nutrients across the placenta:
Idiopathic Pre-eclampsia Maternal smoking Maternal alcohol Anaemia Malnutrition Infection Maternal health conditions
Non-Placenta mediated growth restriction causes for FGR
= refers to pathology of the fetus, such as:
Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism
signs indicating FGR (aka IUGR)
SGA (main finding)
Reduced amniotic fluid volume
Abnormal Doppler studies
Reduced fetal movements
Abnormal CTGs
Short term complications of fetal growth restriction
Fetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
Long term complications of fetal growth restriction
Cardiovascular disease, particularly hypertension
Type 2 diabetes
Obesity
Mood and behavioural problems
risk factors of SGA
Previous SGA baby Obesity Smoking Diabetes Existing hypertension Pre-eclampsia Older mother (over 35 years) Multiple pregnancy Low pregnancy‑associated plasma protein‑A (PAPPA) Antepartum haemorrhage Antiphospholipid syndrome
how do you monitor low risk W for SGA?
at booking clinic –> low or high risk
if low –> monitor SFH from 24 weeks
- plot on customised growth chart
if SFH <10th centile
–> book for serial growth scans with umbilical artery doppler
