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Obstetrics & Gynaecology > Antenatal Care > Flashcards

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
Q

Effects of beta-blockers in pregnancy

Which is a safe option?

A

Labetalol safe and first-line for pre-eclampsia

Others can cause fatal growth restriction, and bradycardia and hypoglycaemia in neonate

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26
Q

Effects of ACE inhibitors and ARBs in pregnancy

A

Oligohydramnios (reduced amniotic fluid)

Miscarriage or foetal death

Hypocalvaria (incomplete formation of the skull bones)

Renal failure in the neonate

Hypotension in the neonate

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27
Q

Effects of warfarin in pregnancy

A

Foetal loss

Congenital malformations, particularly craniofacial problems

Bleeding during pregnancy, postpartum haemorrhage, fetal haemorrhage and intracranial bleeding

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28
Q

Effects of lithium in pregnancy

A

Particularly avoided in 1st trimester as can cause congenital cardiac abnormalities (especially Ebstein’s anomaly)

Avoid in breastfeeding

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29
Q

Effects of SSRIs in pregnancy

A

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

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30
Q

Effects of isotretinion (roaccutane) in pregnancy

A

Highly teratogenic, causing miscarriage and congenital defects

Women need very reliable contraception before, during and for one month after taking isotretinoin

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31
Q

What is congenital rubella syndrome?

A

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

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32
Q

Features of congenital rubella syndrome

A

Congenital deafness

Congenital cataracts

Congenital heart disease (PDA and pulmonary stenosis)

Learning disability

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33
Q

What can chickenpox in pregnancy lead to?

A

More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis

Foetal varicella syndrome

Severe neonatal varicella infection (if infected around delivery)

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34
Q

How to treat a non-immune woman who is infected with chickenpox during pregnancy?

A

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

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35
Q

Features of congenital varicella syndrome

A

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)

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36
Q

Listeria in pregnancy

A

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

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37
Q

Features of congenital CMV

A

Foetal growth restriction

Microcephaly

Hearing loss

Vision loss

Learning disability

Seizures

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38
Q

Features of congenital toxoplasmosis

A

Spread by contamination of faeces from cat

Intracranial calcification

Hydrocephalus

Chorioretinitis (inflammation of the choroid and retina in the eye)

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39
Q

Parvovirus B19 in pregnancy

A

Miscarriage or foetal death

Severe fetal anaemia

Hydrops fetalis (foetal heart failure)

Maternal pre-eclampsia-like syndrome

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40
Q

Tests in women suspected of parvovirus B19 infection

A

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)

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41
Q

Congenital Zika syndrome features

A

Microcephaly

Foetal growth restriction

Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy

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42
Q

What is rhesus incompatibility in pregnancy?

A

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

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43
Q

How do we prevent sensitisation in rhesus-negative women?

A

Anti-D injections at:

28 weeks

Birth (if baby’s blood group is found to be rhesus-positive)

Antepartum haemorrhage

Amniocentesis procedures

Abdominal trauma

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44
Q

What test is used to check how much foetal blood has passed into the mother’s blood during a sensitisation event?

A

Kleihauer test

Used after 20/40

45
Q

What measurements on USS are used to assess foetal size?

A

Estimated foetal weight (EFW)

Foetal abdominal circumference (AC)

46
Q

What is defined as “low birth weight”?

A

Less than 2500g

47
Q

What is defined as severe SGA

A

Foetus is below 3rd centile for their gestational age

48
Q

What is defined as SGA

A

Below 10th centile for gestational age

49
Q

Examples of placental mediated growth restriction

A

Idiopathic

Pre-eclampsia

Maternal smoking

Maternal alcohol

Anaemia

Malnutrition

Infection

Maternal health conditions

50
Q

Examples of non-placenta mediated growth restriction

A

Genetic abnormalities

Structural abnormalities

Foetal infection

Errors of metabolism

51
Q

Signs of foetal growth restriction (other than SGA)

A

Reduced amniotic fluid volume

Abnormal Doppler studies

Reduced foetal movements

Abnormal CTGs

52
Q

Short-term complications of foetal growth restriction

A

Foetal death or stillbirth

Birth asphyxia

Neonatal hypothermia

Neonatal hypoglycaemia

53
Q

Long-term complications of foetal growth restriction

A

Cardiovascular disease, particularly hypertension

Type 2 diabetes

Obesity

Mood and behavioural problems

54
Q

Risk factors for SGA

A

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
Q

Management of SGA

A

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
Q

Investigations to determine underlying cause of SGA

A

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
Q

Causes of macrosomia

A

Constitutional

Maternal diabetes

Previous macrosomia

Maternal obesity or rapid weight gain

Overdue

Male baby

58
Q

Define macrosomia

A

More than 4.5kg at birth

59
Q

Risks to mother in macrosomia

A

Shoulder dystocia

Failure to progress

Perineal tears

Instrumental delivery or caesarean

Postpartum haemorrhage

Uterine rupture (rare)

60
Q

Risks to baby in macrosomia

A

Birth injury (Erbs palsy, clavicular fracture, foetal distress and hypoxia)

Neonatal hypoglycaemia

Obesity in childhood and later life

Type 2 diabetes in adulthood

61
Q

Reducing shoulder dystocia risks

A

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
Q

Screening for anaemia during pregnancy

A

Booking clinic

28 weeks

63
Q

What causes anaemia during pregnancy?

A

Plasma volume increases resulting in reduction in Hb concentration as blood is diluted

64
Q

Presentation of anaemia in pregnancy

A

Shortness of breath

Fatigue

Dizziness

Pallor

65
Q

Normal Hb ranges at:
Booking
28 weeks
Postpartum

A

Booking >110

28 weeks >105

Postpartum >100

66
Q

What might low MCV anaemia indicate?

A

Iron deficiency

67
Q

What might normal MCV anaemia indicate?

A

Physiological anaemia due to increased plasma volume in pregnancy

68
Q

What might raised MCV anaemia indicate?

A

B12 or folate deficiency

69
Q

Management of anaemia in pregnancy

A

Ferrous sulphate 200mg 3x daily

B12 injections or oran cyanobalamin

Folate 400mcg daily

70
Q

When is DVT prophylaxis in pregnancy started?

A

28 weeks if there are three risk factors

First trimester if there are four or more risk factors

71
Q

DVT risk factors in pregnancy

A

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
Q

VTE prophylaxis in pregnancy

A

LMWH ASAP in very high risk patients and at 28 weeks in high risk

Continue throughout pregnancy and 6 weeks postpartum

73
Q

What is pre-eclampsia?

A

New hypertension in pregnancy with end-organ dysfunction

Proteinuria

Occurs after 20 weeks gestation

74
Q

High risk factors for pre-eclampsia

A

Pre-existing hypertension

Previous hypertension in pregnancy

Existing autoimmune conditions (e.g. systemic lupus erythematosus)

Diabetes

Chronic kidney disease

75
Q

Moderate risk factors for pre-eclampsia

A

Older than 40

BMI >35

More than 10 years since previous pregnancy

Multiple pregnancy

First pregnancy

Family history of pre-eclampsia

76
Q

Which women are offered aspirin from 12 weeks gestation as pre-eclampsia prophylaxis?

A

One high risk factor

More than one moderate risk factor

77
Q

Pre-eclampsia complication symptoms

A

Headache

Visual disturbance or blurriness

Nausea and vomiting

Upper abdominal or epigastric pain (due to liver swelling)

Oedema

Reduced urine output

Brisk reflexes

78
Q

Diagnosis of pre-eclampsia

A

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
Q

Management of gestational hypertension (without pre-eclampsia)

A

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
Q

Management of pre-eclampsia

A

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
Q

What is eclampsia?

A

Seizures associated with pre-eclampsia

Management is IV magnesium sulphate

82
Q

What is HELLP syndrome?

A

Combination of features that occurs as a complication of pre-eclampsia and eclampsia

Haemolysis
Elevated Liver enzymes
Low Platelets

83
Q

Obstetric cholestasis symptoms

A

Typically 3rd trimester

Pruritis of palms & soles

Fatigue

Dark urine

Pale, greasy tools

Jaundice

84
Q

Investigations in obstetric cholestasis

A

Abnormal liver function tests (LFTs), mainly ALT, AST and GGT

Raised bile acids

85
Q

Management of obstetric cholestasis

A

Ursodeoxycholic acid to improve LFTs, bile acids and symptoms.

Symptoms of itching can be managed with emollients and
antihistamines

86
Q

Symptoms of polymorphic eruption of pregnancy

A

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
Q

Management of polymorphic eruption of pregnancy

A

Topical emollients

Topical steroids

Oral antihistamines

Oral steroids may be used in severe cases

88
Q

Symptoms of atopic eruption of pregnancy

A

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
Q

Management of melasma

A

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
Q

Define placenta praevia

A

Placenta is attached in lower portion of the uterus, lower than the presenting part of the foetus

91
Q

Placenta praevia vs low-lying placenta

A

Low-lying placenta: placenta is within 20mm of the internal cervical os

Placenta praevia: placenta is over the internal cervical os

92
Q

What are the three main causes of antepartum haemorrhage?

A

Placenta praevia

Placental abruption

Vasa praevia

93
Q

Causes of spotting or minor bleeding during pregnancy

A

Cervical ectropion

Infection

Vaginal abrasions from intercourse or procedures

94
Q

Risks in placenta praevia

A

Antepartum haemorrhage

Emergency caesarean section

Emergency hysterectomy

Maternal anaemia and transfusions

Preterm birth and low birth weight

Stillbirth

95
Q

Risk factors for placenta praevia

A

Previous caesarean sections

Previous placenta praevia

Older maternal age

Maternal smoking

Structural uterine abnormalities (e.g. fibroids)

Assisted reproduction (e.g. IVF)

96
Q

When is placenta praevia identified?

A

20 week scan

97
Q

Symptoms of placenta praevia

A

Painless vaginal bleeding

Usually later in pregnancy (36 weeks or later)

98
Q

Management of placenta praevia

A

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
Q

What is vasa praevia?

A

Foetal blood vessels run through the free placental membranes, unprotected by Wharton’s jelly or placental tissue

100
Q

Risk factors for vasa praevia

A

Low lying placenta

IVF pregnancy

Multiple pregnancy

101
Q

Presentation of vasa praevia

A

USS

Antepartum haemorrhage (2nd or 3rd trimester)

Vaginal examination during labour

During labour - foetal distress

102
Q

Management of vasa praevia

A

Corticosteroids, given from 32 weeks gestation to mature the foetal lungs

Elective caesarean section, planned for 34-36 weeks gestation

103
Q

What is placental abruption?

A

Separation of placenta from wall of uterus during pregnancy

104
Q

Risk factors for placental abruption

A

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
Q

Presentation of placental abruption

A

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
Q

Severity of antepartum haemorrhage

RCOG guidelines

A

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
Q

What is a concealed abruption?

A

Cervical os remains closed, and any bleeding that occurs remains within the uterine cavity

108
Q

Initial steps with massive antepartum haemorrhage

A

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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