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Antenatal Care Flashcards

1
Q

How would you write the gravidity and parity of a non-pregnant woman with a previous birth of twins?

A

G1 P1

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2
Q

How would you write the gravidity and parity of a non-pregnant woman with a previous miscarriage?

A

G1 P0+1

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3
Q

How would you write the gravidity and parity of a non-pregnant woman with a previous stillbirth?

A

G1 P1

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4
Q

Outline the three trimesters

A

1st: Start of pregnancy to 12 weeks
2nd: 13 to 26 weeks
3rd: 27 weeks to birth

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5
Q

When is the booking clinic appointment?

What is the purpose?

A

Before 10 weeks

Offer baseline assessment and plan pregnancy

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6
Q

When is the dating scan?

What is the purpose?

A

Accurate gestational age is calculated from crown rump length (CRL)

Multiple pregnancies are identified

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7
Q

When is the antenatal appointment?

What is the purpose?

A

Discuss results and plan future appointments

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8
Q

When is the anomaly scan?

What is the purpose?

A

USS to identify any anomalies e.g. heart conditions

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9
Q

What is covered during each routine antenatal appointment?

A

Discuss plans for the remainder of the pregnancy and delivery

Symphysis–fundal height measurement from 24 weeks onwards

Foetal 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

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10
Q

Which vaccines are offered to pregnant women?

A

Whooping cough (pertussis) from 16 weeks gestation

Influenza (flu) when available in autumn or winter

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11
Q

General lifestyle advice for pregnant women

A

Take folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects)

Take vitamin D supplement (10 mcg or 400 IU daily)

Avoid vitamin A supplements and eating liver or pate (vitamin A is teratogenic at high doses)

Don’t smoke or drink alcohol

Avoid unpasteurised dairy or blue cheese (listeriosis)

Avoid undercooked or raw poultry (salmonella)

Continue moderate exercise but avoid contact sports

Sex is safe

Flying increases the risk of VTE

Place car seatbelts above and below the bump (not across it)

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12
Q

Features of foetal alcohol syndrome

A

Microcephaly

Thin upper lip

Smooth flat philtrum

Short palpebral fissure

Learning disability

Behavioural difficulties

Hearing and vision problems

Cerebral palsy

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13
Q

Up to which gestation is flying advised during pregnancy?

A

In uncomplicated healthy pregnancies::

37 weeks in a single pregnancy

32 weeks in a twin pregnancy

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14
Q

What blood tests are done at booking clinic?

A

Blood group, antibodies and rhesus D status

FBC for anaemia

Screening for thalassaemia (all women) and sickle cell disease (women at higher risk) - blood film

Offer screening for infectious diseases (antibodies for HIV, hepatitis B, syphilis)

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15
Q

What conditions are women assessed for at booking clinic?

A

Rhesus negative (book anti-D prophylaxis)

Gestational diabetes (book oral glucose tolerance test)

Foetal growth restriction (book additional growth scans)

Venous thromboembolism (provide prophylactic LMWH if high risk)

Pre-eclampsia (provide aspirin if high risk)

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16
Q

Hypothyroidism in pregnancy

A

Levothyroxine dose needs to be increased usually by 25-50mcg

Treatment is based on TSH level, aiming for a low-normal TSH

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17
Q

What HTN medications should be stopped during pregnancy?

A

ACE inhibitors (e.g. ramipril)

Angiotensin receptor blockers (e.g. losartan)

Thiazide and thiazide-like diuretics (e.g. indapamide)

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18
Q

What HTN medications are safe during pregnancy?

A

Labetalol (a beta-blocker – although other beta-blockers may have adverse effects)

Calcium channel blockers (e.g. nifedipine)

Alpha-blockers (e.g. doxazosin)

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19
Q

What effect can pregnancy have on epilepsy?

A

May lower seizure threshold due to additional stress, lack of sleep, hormonal changes and altered medication regimes

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20
Q

Which anti-epileptic medications are safe during pregnancy?

A

Levetiracetam

Lamotrigine

Carbamazepine

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21
Q

Which anti-epileptic drugs must be stopped during pregnancy and why?

A

Sodium valproate - neural tube defects and developmental delay

Phenytoin - cleft lip and palate

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22
Q

Which rheumatoid arthritis drugs must be stopped during pregnancy?

A

Methotrexate is contraindicated, and is teratogenic, causing miscarriage and congenital abnormalities

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23
Q

Which rheumatoid arthritis drugs are safe during pregnancy?

A

Hydroxychloroquine often the first-line choice

Sulfasalazine

Corticosteroids may be used during flare-ups

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24
Q

NSAIDs in pregnancy

A

Block prostaglandins (which are important in maintaining ductus arteriosus in foetus and neonate)

Prostaglandins also soften cervix and stimulate uterine contractions at time of delivery

Avoid (particularly in 3rd trimester)

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25
Effects of beta-blockers in pregnancy Which is a safe option?
Labetalol safe and first-line for pre-eclampsia Others can cause fatal growth restriction, and bradycardia and hypoglycaemia in neonate
26
Effects of ACE inhibitors and ARBs in pregnancy
Oligohydramnios (reduced amniotic fluid) Miscarriage or foetal death Hypocalvaria (incomplete formation of the skull bones) Renal failure in the neonate Hypotension in the neonate
27
Effects of warfarin in pregnancy
Foetal loss Congenital malformations, particularly craniofacial problems Bleeding during pregnancy, postpartum haemorrhage, fetal haemorrhage and intracranial bleeding
28
Effects of lithium in pregnancy
Particularly avoided in 1st trimester as can cause congenital cardiac abnormalities (especially Ebstein's anomaly) Avoid in breastfeeding
29
Effects of SSRIs in pregnancy
1st trimester use has a link with congenital heart defects 1st trimester use of paroxetine has a stronger link with congenital malformations 3rd trimester use has a link with persistent pulmonary hypertension in the neonate Neonates can experience withdrawal symptoms, usually only mild and not requiring medical management
30
Effects of isotretinion (roaccutane) in pregnancy
Highly teratogenic, causing miscarriage and congenital defects Women need very reliable contraception before, during and for one month after taking isotretinoin
31
What is congenital rubella syndrome?
Caused by maternal infection with rubella virus before 20/40 Women should have MMR vaccine before becoming pregnant Pregnant women should not receive the MMR vaccine as it is live
32
Features of congenital rubella syndrome
Congenital deafness Congenital cataracts Congenital heart disease (PDA and pulmonary stenosis) Learning disability
33
What can chickenpox in pregnancy lead to?
More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis Foetal varicella syndrome Severe neonatal varicella infection (if infected around delivery)
34
How to treat a non-immune woman who is infected with chickenpox during pregnancy?
IV varicella immunoglobulins as prophylaxis against developing chickenpox (within 10 days of exposure) When rash starts in pregnancy oral aciclovir if presented within 24 hours and more than 20/40
35
Features of congenital varicella syndrome
Foetal 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)
36
Listeria in pregnancy
More likely in pregnant women May be asymptomatic, flu-like illness, or less commonly pneumonia or meningoencephalitis High rate of miscarriage or foetal death Unpasteurised dairy products and processed meats
37
Features of congenital CMV
Foetal growth restriction Microcephaly Hearing loss Vision loss Learning disability Seizures
38
Features of congenital toxoplasmosis
Spread by contamination of faeces from cat Intracranial calcification Hydrocephalus Chorioretinitis (inflammation of the choroid and retina in the eye)
39
Parvovirus B19 in pregnancy
Miscarriage or foetal death Severe fetal anaemia Hydrops fetalis (foetal heart failure) Maternal pre-eclampsia-like syndrome
40
Tests in women suspected of parvovirus B19 infection
IgM to parvovirus, which tests for acute infection within the past four weeks IgG to parvovirus, which tests for long term immunity to the virus after a previous infection Rubella antibodies (as a differential diagnosis)
41
Congenital Zika syndrome features
Microcephaly Foetal growth restriction Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy
42
What is rhesus incompatibility in pregnancy?
If a woman is rhesus negative, her child may be rhesus positive Baby's RBCs display rhesus-D antigen Mother's immune system will produce antibodies to rhesus-D antigen, and become sensitised to rhesus-D antigens During subsequent pregnancies, rhesus-D antibodies can cross placenta into foetus If this foetus is rhesus-positive, foetus' immune system attacks itself and causes haemolytic disease of the newborn
43
How do we prevent sensitisation in rhesus-negative women?
Anti-D injections at: 28 weeks Birth (if baby's blood group is found to be rhesus-positive) Antepartum haemorrhage Amniocentesis procedures Abdominal trauma
44
What test is used to check how much foetal blood has passed into the mother's blood during a sensitisation event?
Kleihauer test Used after 20/40
45
What measurements on USS are used to assess foetal size?
Estimated foetal weight (EFW) Foetal abdominal circumference (AC)
46
What is defined as "low birth weight"?
Less than 2500g
47
What is defined as severe SGA
Foetus is below 3rd centile for their gestational age
48
What is defined as SGA
Below 10th centile for gestational age
49
Examples of placental mediated growth restriction
Idiopathic Pre-eclampsia Maternal smoking Maternal alcohol Anaemia Malnutrition Infection Maternal health conditions
50
Examples of non-placenta mediated growth restriction
Genetic abnormalities Structural abnormalities Foetal infection Errors of metabolism
51
Signs of foetal growth restriction (other than SGA)
Reduced amniotic fluid volume Abnormal Doppler studies Reduced foetal movements Abnormal CTGs
52
Short-term complications of foetal growth restriction
Foetal death or stillbirth Birth asphyxia Neonatal hypothermia Neonatal hypoglycaemia
53
Long-term complications of foetal growth restriction
Cardiovascular disease, particularly hypertension Type 2 diabetes Obesity Mood and behavioural problems
54
Risk factors for 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
55
Management of SGA
Identifying those at risk of SGA Aspirin is given to those at risk of pre-eclampsia Treating modifiable risk factors (e.g. stop smoking) Serial growth scans to monitor growth Early delivery where growth is static, or there are other concerns
56
Investigations to determine underlying cause of SGA
Blood pressure and urine dipstick for pre-eclampsia Uterine artery doppler scanning Detailed foetal anatomy scan by foetal medicine Karyotyping for chromosomal abnormalities Testing for infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria)
57
Causes of macrosomia
Constitutional Maternal diabetes Previous macrosomia Maternal obesity or rapid weight gain Overdue Male baby
58
Define macrosomia
More than 4.5kg at birth
59
Risks to mother in macrosomia
Shoulder dystocia Failure to progress Perineal tears Instrumental delivery or caesarean Postpartum haemorrhage Uterine rupture (rare)
60
Risks to baby in macrosomia
Birth injury (Erbs palsy, clavicular fracture, foetal distress and hypoxia) Neonatal hypoglycaemia Obesity in childhood and later life Type 2 diabetes in adulthood
61
Reducing shoulder dystocia risks
Delivery on a consultant lead unit Delivery by an experienced midwife or obstetrician Access to an obstetrician and theatre if required Active management of the third stage (delivery of the placenta) Early decision for caesarean section if required Paediatrician attending the birth
62
Screening for anaemia during pregnancy
Booking clinic 28 weeks
63
What causes anaemia during pregnancy?
Plasma volume increases resulting in reduction in Hb concentration as blood is diluted
64
Presentation of anaemia in pregnancy
Shortness of breath Fatigue Dizziness Pallor
65
Normal Hb ranges at: Booking 28 weeks Postpartum
Booking >110 28 weeks >105 Postpartum >100
66
What might low MCV anaemia indicate?
Iron deficiency
67
What might normal MCV anaemia indicate?
Physiological anaemia due to increased plasma volume in pregnancy
68
What might raised MCV anaemia indicate?
B12 or folate deficiency
69
Management of anaemia in pregnancy
Ferrous sulphate 200mg 3x daily B12 injections or oran cyanobalamin Folate 400mcg daily
70
When is DVT prophylaxis in pregnancy started?
28 weeks if there are three risk factors First trimester if there are four or more risk factors
71
DVT risk factors in pregnancy
Smoking Parity ≥ 3 Age > 35 years BMI > 30 Reduced mobility Multiple pregnancy Pre-eclampsia Gross varicose veins Immobility Family history of VTE Thrombophilia IVF pregnancy
72
VTE prophylaxis in pregnancy
LMWH ASAP in very high risk patients and at 28 weeks in high risk Continue throughout pregnancy and 6 weeks postpartum
73
What is pre-eclampsia?
New hypertension in pregnancy with end-organ dysfunction Proteinuria Occurs after 20 weeks gestation
74
High risk factors for pre-eclampsia
Pre-existing hypertension Previous hypertension in pregnancy Existing autoimmune conditions (e.g. systemic lupus erythematosus) Diabetes Chronic kidney disease
75
Moderate risk factors for pre-eclampsia
Older than 40 BMI >35 More than 10 years since previous pregnancy Multiple pregnancy First pregnancy Family history of pre-eclampsia
76
Which women are offered aspirin from 12 weeks gestation as pre-eclampsia prophylaxis?
One high risk factor More than one moderate risk factor
77
Pre-eclampsia complication symptoms
Headache Visual disturbance or blurriness Nausea and vomiting Upper abdominal or epigastric pain (due to liver swelling) Oedema Reduced urine output Brisk reflexes
78
Diagnosis of pre-eclampsia
Systolic blood pressure above 140 mmHg Diastolic blood pressure above 90 mmHg PLUS any of: Proteinuria (1+ or more on urine dipstick) Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
79
Management of gestational hypertension (without pre-eclampsia)
Treating to aim for a blood pressure below 135/85 mmHg Admission for women with a blood pressure above 160/110 mmHg Urine dipstick testing at least weekly Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile) Monitoring foetal growth by serial growth scans PlGF testing on one occasion
80
Management of pre-eclampsia
Labetolol 1st line, nifedipine 2nd line Methyldopa 3rd line (must be stopped within two days of birth) IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures Fluid restriction during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload
81
What is eclampsia?
Seizures associated with pre-eclampsia Management is IV magnesium sulphate
82
What is HELLP syndrome?
Combination of features that occurs as a complication of pre-eclampsia and eclampsia Haemolysis Elevated Liver enzymes Low Platelets
83
Obstetric cholestasis symptoms
Typically 3rd trimester Pruritis of palms & soles Fatigue Dark urine Pale, greasy tools Jaundice
84
Investigations in obstetric cholestasis
Abnormal liver function tests (LFTs), mainly ALT, AST and GGT Raised bile acids
85
Management of obstetric cholestasis
Ursodeoxycholic acid to improve LFTs, bile acids and symptoms. Symptoms of itching can be managed with emollients and antihistamines
86
Symptoms of polymorphic eruption of pregnancy
Itchy rash tends to start in 3rd trimester Urticarial papules (raised itchy lumps) Wheals (raised itchy areas of skin) Plaques (larger inflamed areas of skin)
87
Management of polymorphic eruption of pregnancy
Topical emollients Topical steroids Oral antihistamines Oral steroids may be used in severe cases
88
Symptoms of atopic eruption of pregnancy
Usually 1st and 2nd trimesters Eczema flare up E-type: eczematous, inflamed, red and itchy skin, typically affecting the insides of the elbows, back of knees, neck, face and chest P-type: intensely itchy papules (spots) typically affecting the abdomen, back and limbs.
89
Management of melasma
No active treatment required if appearance is acceptable to woman Avoid sun exposure and use suncream Makeup (camouflage) Procedures such as chemical peels or laser treatment (not usually on the NHS)
90
Define placenta praevia
Placenta is attached in lower portion of the uterus, lower than the presenting part of the foetus
91
Placenta praevia vs low-lying placenta
Low-lying placenta: placenta is within 20mm of the internal cervical os Placenta praevia: placenta is over the internal cervical os
92
What are the three main causes of antepartum haemorrhage?
Placenta praevia Placental abruption Vasa praevia
93
Causes of spotting or minor bleeding during pregnancy
Cervical ectropion Infection Vaginal abrasions from intercourse or procedures
94
Risks in placenta praevia
Antepartum haemorrhage Emergency caesarean section Emergency hysterectomy Maternal anaemia and transfusions Preterm birth and low birth weight Stillbirth
95
Risk factors for placenta praevia
Previous caesarean sections Previous placenta praevia Older maternal age Maternal smoking Structural uterine abnormalities (e.g. fibroids) Assisted reproduction (e.g. IVF)
96
When is placenta praevia identified?
20 week scan
97
Symptoms of placenta praevia
Painless vaginal bleeding Usually later in pregnancy (36 weeks or later)
98
Management of placenta praevia
Follow up TVUSS at 32 and 36 weeks Corticosteroids between 34 and 35+6 to mature foetal lungs Planned Caesarean section between 36 and 37 weeks
99
What is vasa praevia?
Foetal blood vessels run through the free placental membranes, unprotected by Wharton’s jelly or placental tissue
100
Risk factors for vasa praevia
Low lying placenta IVF pregnancy Multiple pregnancy
101
Presentation of vasa praevia
USS Antepartum haemorrhage (2nd or 3rd trimester) Vaginal examination during labour During labour - foetal distress
102
Management of vasa praevia
Corticosteroids, given from 32 weeks gestation to mature the foetal lungs Elective caesarean section, planned for 34-36 weeks gestation
103
What is placental abruption?
Separation of placenta from wall of uterus during pregnancy
104
Risk factors for placental abruption
Previous placental abruption Pre-eclampsia Bleeding early in pregnancy Trauma (consider domestic violence) Multiple pregnancy Foetal growth restriction Multigravida Increased maternal age Smoking Cocaine or amphetamine use
105
Presentation of placental abruption
Sudden onset severe abdominal pain that is continuous Vaginal bleeding (antepartum haemorrhage) Shock (hypotension and tachycardia) Abnormalities on the CTG indicating foetal distress Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage
106
Severity of antepartum haemorrhage | RCOG guidelines
Spotting: spots of blood noticed on underwear Minor haemorrhage: less than 50ml blood loss Major haemorrhage: 50-1000ml blood loss Massive haemorrhage: more than 1000ml blood loss, or signs of shock
107
What is a concealed abruption?
Cervical os remains closed, and any bleeding that occurs remains within the uterine cavity
108
Initial steps with massive antepartum haemorrhage
Urgent involvement of a senior obstetrician, midwife and anaesthetist 2x grey cannula Bloods include FBC, U&Es, LFTs and coagulation studies Crossmatch 4 units of blood Fluid and blood resuscitation as required CTG monitoring of the foetus Close monitoring of the mother

Obstetrics & Gynaecology (13 decks)

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