Antenatal Care Flashcards
How would you write the gravidity and parity of a non-pregnant woman with a previous birth of twins?
G1 P1
How would you write the gravidity and parity of a non-pregnant woman with a previous miscarriage?
G1 P0+1
How would you write the gravidity and parity of a non-pregnant woman with a previous stillbirth?
G1 P1
Outline the three trimesters
1st: Start of pregnancy to 12 weeks
2nd: 13 to 26 weeks
3rd: 27 weeks to birth
When is the booking clinic appointment?
What is the purpose?
Before 10 weeks
Offer baseline assessment and plan pregnancy
When is the dating scan?
What is the purpose?
Accurate gestational age is calculated from crown rump length (CRL)
Multiple pregnancies are identified
When is the antenatal appointment?
What is the purpose?
Discuss results and plan future appointments
When is the anomaly scan?
What is the purpose?
USS to identify any anomalies e.g. heart conditions
What is covered during each routine antenatal appointment?
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
Which vaccines are offered to pregnant women?
Whooping cough (pertussis) from 16 weeks gestation
Influenza (flu) when available in autumn or winter
General lifestyle advice for pregnant women
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)
Features of foetal alcohol syndrome
Microcephaly
Thin upper lip
Smooth flat philtrum
Short palpebral fissure
Learning disability
Behavioural difficulties
Hearing and vision problems
Cerebral palsy
Up to which gestation is flying advised during pregnancy?
In uncomplicated healthy pregnancies::
37 weeks in a single pregnancy
32 weeks in a twin pregnancy
What blood tests are done at booking clinic?
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)
What conditions are women assessed for at booking clinic?
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)
Hypothyroidism in pregnancy
Levothyroxine dose needs to be increased usually by 25-50mcg
Treatment is based on TSH level, aiming for a low-normal TSH
What HTN medications should be stopped during pregnancy?
ACE inhibitors (e.g. ramipril)
Angiotensin receptor blockers (e.g. losartan)
Thiazide and thiazide-like diuretics (e.g. indapamide)
What HTN medications are safe during pregnancy?
Labetalol (a beta-blocker – although other beta-blockers may have adverse effects)
Calcium channel blockers (e.g. nifedipine)
Alpha-blockers (e.g. doxazosin)
What effect can pregnancy have on epilepsy?
May lower seizure threshold due to additional stress, lack of sleep, hormonal changes and altered medication regimes
Which anti-epileptic medications are safe during pregnancy?
Levetiracetam
Lamotrigine
Carbamazepine
Which anti-epileptic drugs must be stopped during pregnancy and why?
Sodium valproate - neural tube defects and developmental delay
Phenytoin - cleft lip and palate
Which rheumatoid arthritis drugs must be stopped during pregnancy?
Methotrexate is contraindicated, and is teratogenic, causing miscarriage and congenital abnormalities
Which rheumatoid arthritis drugs are safe during pregnancy?
Hydroxychloroquine often the first-line choice
Sulfasalazine
Corticosteroids may be used during flare-ups
NSAIDs in pregnancy
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)
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
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
Effects of warfarin in pregnancy
Foetal loss
Congenital malformations, particularly craniofacial problems
Bleeding during pregnancy, postpartum haemorrhage, fetal haemorrhage and intracranial bleeding
Effects of lithium in pregnancy
Particularly avoided in 1st trimester as can cause congenital cardiac abnormalities (especially Ebstein’s anomaly)
Avoid in breastfeeding
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
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
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
Features of congenital rubella syndrome
Congenital deafness
Congenital cataracts
Congenital heart disease (PDA and pulmonary stenosis)
Learning disability
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)
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
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)
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
Features of congenital CMV
Foetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures
Features of congenital toxoplasmosis
Spread by contamination of faeces from cat
Intracranial calcification
Hydrocephalus
Chorioretinitis (inflammation of the choroid and retina in the eye)
Parvovirus B19 in pregnancy
Miscarriage or foetal death
Severe fetal anaemia
Hydrops fetalis (foetal heart failure)
Maternal pre-eclampsia-like syndrome
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)
Congenital Zika syndrome features
Microcephaly
Foetal growth restriction
Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy
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
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
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
What measurements on USS are used to assess foetal size?
Estimated foetal weight (EFW)
Foetal abdominal circumference (AC)
What is defined as “low birth weight”?
Less than 2500g
What is defined as severe SGA
Foetus is below 3rd centile for their gestational age
What is defined as SGA
Below 10th centile for gestational age
Examples of placental mediated growth restriction
Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions
Examples of non-placenta mediated growth restriction
Genetic abnormalities
Structural abnormalities
Foetal infection
Errors of metabolism
Signs of foetal growth restriction (other than SGA)
Reduced amniotic fluid volume
Abnormal Doppler studies
Reduced foetal movements
Abnormal CTGs
Short-term complications of foetal growth restriction
Foetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
Long-term complications of foetal growth restriction
Cardiovascular disease, particularly hypertension
Type 2 diabetes
Obesity
Mood and behavioural problems
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
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
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)
Causes of macrosomia
Constitutional
Maternal diabetes
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Male baby
Define macrosomia
More than 4.5kg at birth
Risks to mother in macrosomia
Shoulder dystocia
Failure to progress
Perineal tears
Instrumental delivery or caesarean
Postpartum haemorrhage
Uterine rupture (rare)
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
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
Screening for anaemia during pregnancy
Booking clinic
28 weeks
What causes anaemia during pregnancy?
Plasma volume increases resulting in reduction in Hb concentration as blood is diluted
Presentation of anaemia in pregnancy
Shortness of breath
Fatigue
Dizziness
Pallor
Normal Hb ranges at:
Booking
28 weeks
Postpartum
Booking >110
28 weeks >105
Postpartum >100
What might low MCV anaemia indicate?
Iron deficiency
What might normal MCV anaemia indicate?
Physiological anaemia due to increased plasma volume in pregnancy
What might raised MCV anaemia indicate?
B12 or folate deficiency
Management of anaemia in pregnancy
Ferrous sulphate 200mg 3x daily
B12 injections or oran cyanobalamin
Folate 400mcg daily
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
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
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
What is pre-eclampsia?
New hypertension in pregnancy with end-organ dysfunction
Proteinuria
Occurs after 20 weeks gestation
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
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
Which women are offered aspirin from 12 weeks gestation as pre-eclampsia prophylaxis?
One high risk factor
More than one moderate risk factor
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
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)
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
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
What is eclampsia?
Seizures associated with pre-eclampsia
Management is IV magnesium sulphate
What is HELLP syndrome?
Combination of features that occurs as a complication of pre-eclampsia and eclampsia
Haemolysis
Elevated Liver enzymes
Low Platelets
Obstetric cholestasis symptoms
Typically 3rd trimester
Pruritis of palms & soles
Fatigue
Dark urine
Pale, greasy tools
Jaundice
Investigations in obstetric cholestasis
Abnormal liver function tests (LFTs), mainly ALT, AST and GGT
Raised bile acids
Management of obstetric cholestasis
Ursodeoxycholic acid to improve LFTs, bile acids and symptoms.
Symptoms of itching can be managed with emollients and
antihistamines
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)
Management of polymorphic eruption of pregnancy
Topical emollients
Topical steroids
Oral antihistamines
Oral steroids may be used in severe cases
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.
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)
Define placenta praevia
Placenta is attached in lower portion of the uterus, lower than the presenting part of the foetus
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
What are the three main causes of antepartum haemorrhage?
Placenta praevia
Placental abruption
Vasa praevia
Causes of spotting or minor bleeding during pregnancy
Cervical ectropion
Infection
Vaginal abrasions from intercourse or procedures
Risks in placenta praevia
Antepartum haemorrhage
Emergency caesarean section
Emergency hysterectomy
Maternal anaemia and transfusions
Preterm birth and low birth weight
Stillbirth
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)
When is placenta praevia identified?
20 week scan
Symptoms of placenta praevia
Painless vaginal bleeding
Usually later in pregnancy (36 weeks or later)
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
What is vasa praevia?
Foetal blood vessels run through the free placental membranes, unprotected by Wharton’s jelly or placental tissue
Risk factors for vasa praevia
Low lying placenta
IVF pregnancy
Multiple pregnancy
Presentation of vasa praevia
USS
Antepartum haemorrhage (2nd or 3rd trimester)
Vaginal examination during labour
During labour - foetal distress
Management of vasa praevia
Corticosteroids, given from 32 weeks gestation to mature the foetal lungs
Elective caesarean section, planned for 34-36 weeks gestation
What is placental abruption?
Separation of placenta from wall of uterus during pregnancy
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
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
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
What is a concealed abruption?
Cervical os remains closed, and any bleeding that occurs remains within the uterine cavity
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
