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Antenatal Care Flashcards

1
Q

What is perinatal mortality rate?

A

Sum of stillbirths and early neonatal deaths per 1,000 total births

(Early neonatal death = 7 days, neonatal death = 28 days)

2016 in Ireland: 5.8 per 1,000 total births
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2
Q

What is maternal mortality rate?

A

The number of direct and indirect maternal deaths per 100, 000 maternities

6.7 per 100,000 maternities

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3
Q

What is ANC?

A

A system of medical care that aims to assess and reduce risk of harm to the pregnant mother and the foetus.

ANC is all about risk

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4
Q

What are the aims of ANC?

A

Pre-existing maternal disorders
Maternal complications of pregnancy
Foetal complications of pregnancy

Detect congenital foetal problems

Circumstances of delivery

Educate and Advise

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5
Q

What preconception care is given to all? (6)

A
  • Discuss previous pregnancies
  • Folic acid – 0.4mg/day (NTD) optimally threes month before conception and first trimester
  • Rubella status +/- immunisation
  • Advise re smoking, drugs, alcohol
  • Opportunistic promotion: Cervical smear
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6
Q

What preconception care is given to some?

A

Optimise medical conditions – diabetes, epilepsy, hypothyroidism, obesity, medications
? Preconception clinics

Higher folic acid in some 5mg

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7
Q

Who gets the higher folic acid of 5mg in preconception care? (7)

A
  • DM
    • Obesity
    • previous NTD (or family history)
    • Certain medications: anti-epileptics
    • Coeliac Disease
    • Twin pregnancy
    • Sickle cell disease
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8
Q

What are the symptoms of early pregnancy?

A

Amenorrhoea
Urinary symptoms

Breast symptoms

Nausea and vomiting
Tiredness

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9
Q

How is pregnancy approached at the start?

A

Confirmation of pregnancy with GP

Pregnancy test
Look at antenatal risk
Advice (including food):

Refer

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10
Q

What are the different forms of ANC delivery?

A

Combined

Hospital

Mid-wife led

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11
Q

How does the Maternity and Infant Care Scheme differ from the NICE guidelines?

A

GP
Initial examination, if possible before <12 weeks
A further 5-6 examinations during the pregnancy
If significant illness, e.g. Diabetes up to 5 additional visits to the GP may be provided.

Materinty Unit
Booking visit before 20weeks
Further 4-5 visits
Alternated with visits to GP

From 20 weeks:
Every 4 weeks to 28 weeks
Then every 2 weeks to 36 wks
Then weekly til delivery.

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12
Q

What is the maternity and infant care scheme schedule of visits?

A
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13
Q

When is the hospital booking visit?

A

~ 12-16 weeks

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14
Q

What can be determined at booking visit through the woman’s history?

A

Age

Women <17 and > 35 have increased risk of obstetric and medical complications

History of present pregnancy
LMP, cycle length-> EDD
problems

Past Obs history
pre-term labour, IUGR,still birth, APH, PPH, congenital anomalies, pre-eclampsia, Gestational Diabetes

Past Gynae History
Subfertility: ? Assisted conception
previous surgery,
Past Medical history
Hypertension, DM, Hypothyroidism, Autoimmune disease, Hbopathy, cardiac, renal, thromboembolic, psychiatric.

Medications
Adjust to safer options
Folic acid
Vitamin D

Family history:
GD, HTN, thromboembolic, autoimmune disease, pre-eclampsia

Social history: cigs, C2H5, drugs. Nb domestic violence.

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15
Q

What should be checked on general examination?

A

BMI

BP

Urine

(Resp, cardiovascular, breast vv)

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16
Q

What abdominal exam should be done?

A

Inspection
Masses and tenderness
Fundus location (not SFH)
Foetal heart beat on doppler

No VE routinely

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17
Q

When can a woman have a smear postnatally?

A

3 months postnatal

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18
Q

What investigations should be done at booking visit? (4)

A
  • FBC
  • Group and antibody screen
  • Serology for HIV, hepatitis b/c, syphilis, rubella
    (+/- varicella serology –yes in Sligo, not all locations)
  • Urine microscopy and culture
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19
Q

What are the reasons behind some of the booking visit investigations?

A
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20
Q

What u/s is done at 10-13 weeks? And what 4 things can it tell us?

A

Dating scan/Booking scan (10-13wk)
- Viable Pregnancy
- Gestational Age (CRL)
- Major Anomalies
- Multiple Pregnancy

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21
Q

What can be checked for on u/s to determine if the child may have a chromosomal abnormality?

A

Nucheal translucency

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22
Q

What should be asked as part of the routine antenatal visit?

A

Review history, reassess risk, physical/mental state

‘Minor’ conditions
-tiredness
-Heartburn
-Abdominal pain
-Constipation
-Itching
-pelvic girdle pain (SPD)
-backache
-vaginitis
-leg cramps
-ankle oedema
-carpal tunnel syndrome

Foetal Movements: kick charts – at least 10 in 12hours > 30wks

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23
Q

What tests are done routinely in the antenatal visit?

A
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24
Q

What ultrasound is at 20 weeks (18-22)?

A

Anomaly scan

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25
What does the anomaly scan pick up? (4+)
-CNS abnormalities -Cardiac defects -Chest defects -GI defects -Abdominal wall defects -Urogenital defects -Skeletal defects * Dating : BPD/HC * Placental site * Liquor volume
26
What other things may a pregnant mother get during her antenatal care? (Vaccines? Any other products?)
28 weeks – Anti-D to Rh-ve mothers Pertussis vaccination 16-36 weeks (DTAP) Flu vaccine (from Sept) COVID 19 vaccination (mRNA vaccination at any stage of pregnancy for primary vaccination and first booster dose – second booster dose after 16 weeks)
27
How is the foetus assessed antenatal?
Clinical assessment CTG Ultrasound
28
How is fetal wellbeing assessed clinically?
Clinical observations FETAL MOVEMENTS: - Perceived from 18 to 20 weeks - Sleep cycles usually <40 mins rarely up to 90mins - Increase in activity from 32 weeks - Movement don’t stop near term but can change in nature - Lie down , ideally evenings, Count to 10 over 12 hours - If women perceive a change in movement should prompt CTG No evidence to recommend formal fetal movement monitoring in low risk pregnancy. Some evidence in high risk – ‘count to 10’ kick charts BP, Urine
29
When is SFH measured from?
24 weeks - if 2cm < the expected refer for USS
30
What does a CTG(cardiotocograph) do?
Records foetal HR and uterine contractions
31
What are the reasons of use for a fetal scalp electrode? (2)
Multiple pregnancies Obesity
32
What are the CI for fetal scalp electrode use? (1 maternal & 3 fetal)
Maternal: - infections Foetal: - abnormal presentation - bleeding tendency - <34 weeks
33
What do you need for the use of the fetal scalp electrode?
ROM 2-3cm dilated
34
WHat is the pneumonic for assessing CTG?
**Dr. C. Brvado** **D**efine **r**isk **C**ontractions (/10min) – amp, dur, freq **B**aseline **r**ate (110-160bpm) over a ten minute period **V**ariability (baseline): variation in FHR around the baseline (5-25bpm occurs 2-6 times/minute) **A**ccelerations (> 15bpm for 15 secs above baseline. Reassuring). **D**ecelerations: (> 15bpm for 15 secs below the baseline) early, variable, late **O**verall assessment (normal, suspicious or pathological)
35
Define risk: other risk factors – meconium, fever, iugr Contractions: talk about duration and frequency of contractions. Tachysystole: 7 more contractions in 15 minutes BR: tachy: faster in early pregnancy, with fever, foetal infection, also hypoxia (early hypoxia). Sustained slow rate – acute foetal distress Variability: except during foetal sleep (< 50mins). Prolonged decreased variability – hypoxia. Product of competing acceleratory and deceleratory influences. Best measure of CNS oxygenation. Affected by drugs. Accelerations: with movements or contractions Decelerations: early – with a contraction- normal reponse to head compression/benign. Variable: vary in timing – cord compression, can lead to hypoxia. Late: persist after contraction (within 30 secs) – suggestive of hypoxia (depth not important)
36
what is the FIGO classification system for CTGs?
Decelerations are repetitive if present with more than 50% of contractions Sinusoidal pattern: ■A smooth, regular, wave-like pattern ■Frequency of around 3-5 cycles a minute Amplitude 5-15 ■Stable baseline rate around 120-160 bpm ■No beat to beat variability Causes: hypoxia, anaemia, FMH Please note: As the FIGO guideline does not outline a timeframe where variable decelerations become suspicious, we note that variable decelerations need to be present for 90 minutes or more before being considered ‘suspicious’; or alternatively, if they are present for up to 50% of contractions for 30 minutes, or for more than 50% of contractions for less than 30 minutes.
37
What are reversible factors of changes to CTGs? (3)
-Uterine tachysystole: Requiring reduction or discontinuation of uterotonics -Aortocaval compression: Requiring maternal repositioning -Maternal hypotension: Potentially requiring intravenous hydration or ephedrine if triggered by epidural analgesia
38
What are adjunctive factors to changes to CTG?
Digital foetal scalp stimulation Foetal blood sampling
39
How does the foetal heart rate change?
Foetal HR falls by 1bt/min/wk from 28 weeks
40
What are the causes of foetal tachycardia? (5)
-> maternal fever -> B-sympathomimetic drugs -> chorioamnionitis -> acute/subacute hypoxia If > 200 ? Foetal arrythmia
41
What is seen in a normal CTG?
42
What is seen in a CTG with tachycardia?
43
What is seen in a CTG with reduced variability?
44
What can cause reduced variability? (3)
* sleeping * drugs: BZDs, opiates, MgS04, methyldopa * hypoxia
45
What is seen on a CTG with early decelerations?
46
What is seen in a CTG with late decelerations?
47
What is a late deceleration?
When nadir of decel develops within 30 secs of contraction
48
What causes late decelerations?
uteroplacental insufficiency: hypoxia. ? Degree and duration reflect severity
49
What is seen in a CTG with variable decelerations?
50
What usually is seen in variable decelerations?
Typical have shoulders, atypical do not The umbilical vein is often occluded first causing an acceleration in response Then the umbilical artery is occluded causing a subsequent rapid deceleration When pressure on the cord is reduced another acceleration occurs & then the baseline rate returns Accelerations before & after a variable deceleration are known as the “shoulders of deceleration” There presence indicates the foetus is not yet hypoxic & is adapting to the reduced blood flow.
51
What are the advantages of CTG? (3)
* visual record * high sensitivity (distress/hypoxia) * dec short-term neurological morbidity
52
What are the disadvantages of CTG? (4)
* reduces mobility * increased rate of intervention * no dec mortality or long-term morbidity * more puerperal sepsis
53
What are the stages of intra-partum foetal assessment?
54
When are the u/s done in pregnancy?
* dating scan (10-13 weeks) * anomaly scan (18-22 weeks) * third trimester (28 weeks +)
55
What does the third trimester u/s look at? (4)
Foetal growth/biometry –HC/BPD, AC, FL Amniotic fluid Doppler umbilical artery (or other vessels e.g. middle cerebral artery doppler) Placental site
56
How is foetal growth tracked?
Serial u/s measurements
57
Why are serial u/s measurements NB for foetal growth monitoring?
Distinguish small for dates from IUGR -rate of growth (at least 2 wks apart) -pattern of smallness -allow for constitutional factors
58
What is Polyhydramnios?
Liquor volume increased. Deepest pool > 8cm (?10cm) on u/s or amniotic fluid index > 25
59
What is the etiology of polyhydramnios? (Fetal 4 & maternal 1)
Foetal causes: -twin pregnancy, especially uniovular twins -anencephaly (or spina bifida) interferes with foetal swallowing -oesophageal or duodenal atresia prevents foetal swallowing -hydrops foetalis Maternal causes: -poorly controlled maternal diabetes results in foetal polyuria
60
What is the normal liquor volume?
400-1500ml
61
What is oligohydramnios?
Liquor volume decreased. deepest pool < 2cm on u/s or AFI < 5.
62
What is the etiology of oligohydramnios? (4)
Decreased production of fluid -failing placental function -bilateral renal agenesis -post urethral valves Increased loss of fluid - PROM
63
What are the 5 variables for the biophysical profile?
-limb movements -tone -breathing movements -liquor volume -also traditionally reactive CTG
64
What do the biophysical profile scores mean?
Score 2 normal, 0 abnormal. >8: n, 4-6: equivocal, 0-2 abnormal.
65
What markers can be done to check for Down Syndrome, Edwards Syndrome or Neural Tubal Defects?
66
What risks are pregnant women warned about? (5)
* Liver: vitamin A * soft cheese/unpastuerised milk: listeria * raw meat: toxoplasmosis * pate: listeria * caffeine: miscarriage/LBW
67
When should you repeat FBC and group and hold in a normal pregnancy?
@ 28 weeks
68
When should pregnant women have a GTT?
@ 24-28 weeks (depending on risk factors).
69
What serology is routinely checked at the booking visit?
* HIV * Hep B/C * syphilis * rubella
70
What can be done if a mother is Rubella IgG positive @ booking visit?
Give MMR postpartum & warn of risks
71
What can be done if a mother is Hep B surface antigen positive @ booking visit?
* give hep B immunoglobulin and vaccine to infant @ birth * if high viral load give antiviral therapy in 3rd trimester
72
What can be done if a mother is Syphilis positive @ booking visit?
If reactive treat with penicillin and consult GUM specialist
73
What can be done if a mother is HIV positive @ booking visit?
* antiretroviral treatment for mother & infant to reduce vertical transmission rates
74
What can be done if a mother is urine culture positive @ booking visit?
Asymptomatic bacteruria-> treat with antibiotics and repeat culture to ensure fully treated
75
What do UTIs even if asymptomatic pose a risk of in pregnancy?
* premature labour * maternal pyelonephritis
76
What are the 8 indications for continuous CTG monitoring?
* sepsis * maternal tachycardia (>120) * significant meconium * pre-eclampsia (esp >160/110) * fresh APH * delay in labour * use of oxytocin * disproportionate maternal pain
77
What are the different types of decelerations?
* early decelerations = normal, correspond with contractions * late decelerations = after uterine contraction, caused by hypoxia * variable decelerations = unrelated to uterine contractions, fall of >15bpm from baseline, fetal hypoxia & cord compression * prolonged decelerations = 2min-10min with >15bpm drop, indicates umbilical cord compression
78
If a variable acceleration has shoulders (brief accelerations before and after) is that good or bad?
Good shows fetus is coping

OBGYN (25 decks)

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