Antenatal care Flashcards
What is the combined screening?
First line between 11-14 weeks and consists of measurement of nuchal translucency, b-HCG and PAPPA
Combined screening test results for Down’s
Thick nuchal translucency
High beta-HCG
Low PAPPA
What is the triple test?
For chromosomal abnormalities between 14-20 weeks
Beta-GCG - HIGH
AFP - LOW
Serum estriol - LOW
What is the quadruple test?
between 14-20 weeks
Also includes inhibin A
What does the combined test, triple and quadruple test indicate?
The risk of the fetus having Down’s syndrome
What antenatal testing is available for women high risk of having a child with Down’s syndrome?
Amniocentesis and Chorion villus sampling
Untreated hypothyroidism in pregnancy complications
SPAM
Miscarriage, anaemia, small for gestational age and pre-clampsia
Hypothyroidism in pregnancy management
Increase levothyroxine dose by 30-50% and titrate based on TSH level
Hypertension in pregnancy - medications that must be stopped
ACE inhibitors
ARBs
Thiazides and Thiazide-like-diuretics
Hypertension management in pregnancy
Labetelol
Calcium channel blockers
Alpha blockers
Pre-pregnancy considerations in women with epilepsy
Should take 5mg folic acid daily before conception to reduce risk of neural tube defects
Anti-epileptic drugs in pregnancy
Lamotrigine and carbamazepine are safer in pregnancy
Avoid sodium valproate - neural tube defects and development delay
Phenytoin - cleft lip and palate
Rheumatoid arthritis management in pregnancy
Avoid methotrexate
Hydroxychloroquine (first-line)
Sulfasalazine
NSAIDs MOA and pregnancy
Inhibit prostaglandins and should be avoided as prostaglandins are responsible for maintaining the ductus arteriosus and soften the cervix and stimulate uterine contractions.
Beta blockers in pregnancy - use and side effects
First line for high blood pressure due to pre-clampsia.
Can cause: foetal growth restrictions, hypoglycaemia and Bradycardia in neonate
ACE inhibitors and ARBs in pregnancy
They cross the placenta and cause reduced urine output in the foetus and therefore amniotic fluid (oligohydraminos) and hypocalvaria (incomplete formation of skull bones)
Opiates and pregnancy
Use during pregnancy causes withdrawal symptoms after the neonate is born - neonatal abstinence syndrome
What is neonatal abstinence syndrome?
When the foetus is exposed to opioids during pregnancy. Withdrawal symptoms - irritability, tachypnoea, high temperatures and poor feeding
Why is warfarin contraindicated in pregnancy?
Causes foetal loss
Congenital malformations
Bleeding during pregnancy - PPH, Foetal haemorrhage and intracranial haemorrhage
Why is sodium valproate contraindicated in pregnancy?
Neural tube defects and developmental delay
Why is lithium avoided in pregnancy?
Avoided in first trimester due to congenital cardiac abnormalities - ebstein’s anomaly - tricuspid valve is set lower on the right side of the heart causing a bigger right atrium and smaller right ventricle. Should be avoided in breastfeeding
Risks of SSRIs in pregnancy
First trimester - congenital heart defects
First trimester - paroxetine - congenital malformations
Third trimester - persistent pulmonary hypertension in the neonate
Contraindications of accutane in pregnancy
High teratogenic, causing miscarriage and congenital defects.
Cause of rubella
Togavirus
Rubella incubation period
2-3 weeks and individuals are infectious from 7 days before symptoms and 4 days after onset of rash
Diagnose this
Rubella
When is rubella cause the most risk to the foetus?
In the first 8-10 weeks
Features of congenital rubella syndrome
Sensorineural hearing loss
Congenital heart disease
Congenital cataracts
Cause of chicken pox
Varicella-zoster virus
What does chicken pox during pregnancy increase the mother’s risk of?
Pneumonitis
Features of foetal varicella syndrome
Skin scarring
eye defects (microphthalmia)
Limb hypoplasia
Microcephaly
Learning disabilities
Chicken pox treatment in woman <20 weeks pregnant and not immune
Give varicella-zoster immunoglobulin ASAP
Chicken pox treatment in woman >20 weeks pregnant and not immune
either give Varicella-zoster immunoglobulins or oral aciclovir should be given 7-14 days after exposure
Congenital toxoplasmosis
Infection with toxoplasma gondii. Spread via faeces from a cat. Triad of intracranial calcification, hydrocephalus and chorioretinitis
What is rhesus incompatibility?
When rhesus-D negative woman becomes pregnant, there is the possibility of her having a rhesus positive child. Mother produces rhesus-D antibodies. Subsequent pregnancies rhesus-D antibodies cross into the placenta and if baby is rhesus-positive, they attack the foetus and cause destruction of the red blood cells causing haemolytic -> haemolytic disease of the newborn
How to manage rhesus incompatibility?
Anti-D injections at 28 weeks and birth
When else should anti-D injections be given?
Antepartum haemorrhage
Amniocentesis procedures
Abdominal trauma
What is a Khleihauer test?
Checks how much foetal blood has passed into the mother during a sensitisation event after 20 weeks. Used to assess whether further anti-D injections are required
What measurements are used to assess foetal size?
Estimated foetal weight
Foetal abdominal circumference
Definition of small for gestational age
<10 centile for their gestational age
Definition of severe small for gestational age
<3 centile for their gestational age
What constitutes as low birth weight?
<2.5 kgs
Causes of small for gestational age?
Constitutionally small - matches the mother and others in the family
Foetal growth restriction (intrauterine growth restriction)
Causes of foetal growth restriction categories
Placenta mediated growth restriction
Non-placenta mediated growth restriction i.e. genetic or structural abnormality
Causes of placenta mediated growth restriction
ISPAAM
Idiopathic
Pre-clampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Non-placenta mediated growth restriction
Genetic abnormalities
Structural abnormalities
Foetal infection
Complications of foetal growth restrictions - short term
Foetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
Complications of foetal growth restrictions - long term
Cardiovascular disease - hypertension
Type 2 diabetes
Obesity
Mood and behavioural problems
Risk factors for small for gestational age
Previous SGA baby
Obesity
Smoking
Diabetes
Hypertension
Pre-eclampsia
Older mother >35 years
Multiple pregnancies
Low PAPPA
Antepartum haemorrhage
Antiphospholipid syndrome
Definition of large for gestational age
> 4.5 kgs and estimated foetal weight >90th centile
Causes of macrosomia
Constitutional
Maternal diabetes
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Risks of macrosomia to mother
Shoulder dystocia
Failure to progress
Perineal tears
Instrumental delivery or caesarean
PPH
Uterine rupture (Rare)
Risks of macrosomia to baby
Birth injury (Erb’s palsy, clavicular fracture, foetal distress and hypoxia)
Neonatal hypoglycaemia
Obesity in childhood and later life
T2DM in adulthood
Define monoamniotic
Single amniotic sac
Define diamniotic
Two separate amniotic sacs
Define monochorionic
Share a single placenta
Define dichorionic
Two separate placentas
What is the lambda sign?
triangular appearance where the membrane between the twins meets the chorion
Multiple pregnancies complications to mother
Anaemia
Polyhydraminos
Hypertension
Malpresentation
Spontaneous pre-term birth
Instrumental delivery or caesarean
PPH
Multiple pregnancies complications to foetuses
Miscarriage
Stillbirth
Foetal growth restriction
Prematurity
Twin-twin transfusion syndrome
Twin anaemia polycythaemia sequence
What is twin-twin transfusion syndrome?
When there is a connection between blood supplies of the two foetuses, one foetus may receive the majority of the blood from the placenta and the other foetus is starved of blood. The one with the majority of the blood supply can become fluid overloaded with heart failure and polyhydraminos. Whereas the other foetus has growth restriction, anaemia and oligohydraminos
What is twin anaemia polycythaemia sequence?
Similar to twin-twin transfusion syndrome but less acute. One twin becomes anaemia and the other develops polycythaemia (raised haemoglobin)
Delivery of mono amniotic twins method
Elective Caesarean section between 32-33+6 weeks
Diamniotic twins delivery method
Aim to deliver between 37 and 37+6 weeks
Asymptomatic bacteriuria in pregnancy are at higher risk of developing what?
Lower UTIs and pyelonephritis and subsequently pre-term birth
Presentation of lower UTIs in pregnant women
Dysuria
Suprapubic pain
Increased frequency of urination
Urgency
Incontinence
Haematuria
Presentation of pyelonephritis
Fever
Loin, suprapubic or back pain
Vomiting
Loss of apetite
Haematuria
Organisms causing of UTIs
E. coli
Klebsiella
Pseudomonas
Management of UTIs in pregnancy
Requires 7 days of antibiotics
Avoid nitrofurantoin in third trimester - risk of neonatal haemolysis
Avoid Trimethoprim in first trimester - neural tube defects
Causes of microcytic anaemia
Iron deficiency
Causes of macrocytic anaemia
B12 or folate deficiency
Management of iron deficiency anaemia in pregnancy
Start with iron replacement - ferrous sulphate 200mg TDS
Management of B12 deficiency anaemia in pregnancy
Test for pernicious anaemia (intrinsic factor antibodies)
IM hydroxocobalamin
Oral cyanobalamin tablets
Folate deficiency anaemia in pregnancy
Start folic acid 5mg daily
When should you start VTE prophylaxis in pregnancy?
> 3 risk factors at 28 weeks
4 risk factors in first trimester
Should receive prophylaxis with LMWH - enoxaparin, daltaparin
Management of VTEs in pregnancy
LMWH - enoxaparin, daltaparin
Massive PE and haemodynamic compromise in pregnancy
Unfractionated heparin
Thrombolysis
Surgical embolectomy
Triad of pre-eclampsia
HOP
Hypertension
Proteinuria
Oedema
Risk factors for pre-eclampsia
Pre-existing HTN
Previous hypertension in pregnancy
Existing autoimmune conditions - SLE
Diabetes
CKD
Symptoms of pre-eclampsia
Headache
Visual disturbance or blurriness
Nausea and vomiting
Upper Abdo or epigastric pain
Oedema
Reduced urine output
Diagnosing pre-eclampsia
Systolic BP >140
Diastolic BP >90
+ proteinuria, organ dysfunction, placental dysfunction
Medical management of pre-eclampsia
Labetolol (first line)
Nifedipine (second-line)
Management of eclampsia
Magnesium sulphate
What is HELLP syndrome?
A complication of pre-eclampsia and eclampsia.
H - Hemolysis
EL - Elevated liver enzymes
LP - Low platelet count.
Gestational diabetes- diagnosis
OGTT
Management of gestational diabetes in pregnancy
Fasting glucose <7 mmol/L - trial diet and exercise for 1-2 weeks, then metformin and then insulin
Fasting glucose >7 mmol/L - insulin +/- metformin
Fasting glucose >6mmol/L plus macrosomia - insulin +/- metformin
Pre-existing diabetes management in pregnancy
Women using metformin and insulin and other oral diabetic medications should be stopped.
Referral to ophthalmology to check for diabetic retinopathy - risk of rapid progression
What is obstetric cholestasis?
Reduced outflow of bile acids from the liver. It resolves after delivery of the baby
How would obstetric cholestasis present?
Itching of the palms of the hand and soles of the feet
Fatigue
Dark urine
Pale, greasy stools
Jaundice
Investigations of obstetric cholestasis
LFTs and bile acids
Raised bile acids
Abnormal liver function tests
ALP is usually raised in pregnancy.
What is acute fatty liver of pregnancy?
Rapid accumulation of fat within hepatocytes causing acute hepatitis
How would acute fatty liver of pregnancy present?
General malaise and fatigue
Nausea and vomiting
Jaundice
Abdominal pain
Ascites
What is the management of acute fatty liver of pregnancy?
Requires prompt admission and delivery of the baby.
Management of acute liver failure and consider liver transplant
What are the three causes antepartum haemorrhage?
Planceta praaevia, placental abruption, and vasa praevia
Risks of placenta praevia
Antepartum haemorrhage
Emergency C-section
Emergency hysterectomy
Maternal anaemia and transfusions
Preterm birth and low birth weight
Stillbirth
Grading placenta praevia
Grade I - placenta is in the lower uterus but not reaching the internal cervical os
Grade II - placenta is reaching but not covering the internal cervical os
Grade III - the placental is partially covering the internal cervical os
Grade IV - the placenta is completely covering the internal cervical os
Risk factors for placenta praevia
Previous C-sections
Previous placenta praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities - fibroids
How would placenta praevia diagnosed?
It would present at the 20 week abdominal scan
Management of placenta praevia
Repeat transvaginal ultrasound scans at 32 and 36 weeks.
Give corticosteroids between 34 and 35+6 weeks to mature foetal lungs due to risk of preterm delivery
Plan delivery between 36 and 37 weeks - to reduce the risk of spontaneous labour and bleeding.
Emergency Caesarean section may be required with premature labour or antenatal bleeding
What is the main complication of placenta praevia? How is it managed?
Haemorrhage - emergency c section, blood transfusions, intrauterine balloon tamponade, uterine artery occlusion, emergency hysterectomy
What is placenta accreta?
When the placenta implants deeper, through and past the endometrium. This makes it difficult to separate the placenta after delivery of the baby.
Risk factors for placenta accreta
Previous placenta accreta
Previous endometrial curettage procedures - e.g. for miscarriage or abortion
Previous Caesarean section
Mutligravida
Management of placenta accreta
Delivery planned between 35 to 36+6 weeks gestation to reduce the risk of spontaneous labour and delivery.
Options during caesarean are:
Hysterectomy
Uterus preserving surgery
Expectant management - risks of bleeding and infection
What is breech presentation?
When the presenting part of the foetus is the legs and bottom
Types of breech
Complete breech - legs are fully flexed at the hips and knees
Incomplete breech - one leg flexed at the hip an extended at the knee
Extended breech - also known as frank breech, with both legs flexed at the hip and extended at the knee
Footling breech - with a foot is presenting through the cervix with the leg extended
Management of breech presentation
External cephalic version can be used at term 37 weeks to attempt to turn the foetus.
If that fails, women are given the choice between vaginal delivery and elective caesarean section.
Tocolysis - relax the uterus before procedure. Using subcutaneous terbutaline (beta agonist) - similar contractility of the myometrium, making it easier for the baby to turn.
What is External cephalic version?
A technique used to attempt to turn a foetus from the breech position to a cephalic position using pressure on the pregnant abdomen.
Nulliparous - attempt after 36 weeks
Women with previous births - after 37 weeks
Causes of stillbirths
Unexplained
Pre-eclampsia
Placental abruption
Vasa praevia
Cord colapse
Obstetric cholestasis
Diabetes
Thyroid disease
Causes of obstetric haemorrhage
Ectopic pregnancy
Placental abruption
Placenta praevia
Planceta accreta
Uterine rupture
