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OBGYN > Antenatal Care > Flashcards

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
Q

What does the anomaly scan pick up? (4+)

A

-CNS abnormalities
-Cardiac defects
-Chest defects
-GI defects
-Abdominal wall defects
-Urogenital defects
-Skeletal defects

  • Dating : BPD/HC
  • Placental site
  • Liquor volume
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26
Q

What other things may a pregnant mother get during her antenatal care? (Vaccines? Any other products?)

A

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)

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27
Q

How is the foetus assessed antenatal?

A

Clinical assessment

CTG

Ultrasound

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28
Q

How is fetal wellbeing assessed clinically?

A

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

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29
Q

When is SFH measured from?

A

24 weeks

  • if 2cm < the expected refer for USS
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30
Q

What does a CTG(cardiotocograph) do?

A

Records foetal HR and uterine contractions

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31
Q

What are the reasons of use for a fetal scalp electrode? (2)

A

Multiple pregnancies
Obesity

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32
Q

What are the CI for fetal scalp electrode use? (1 maternal & 3 fetal)

A

Maternal:
- infections

Foetal:
- abnormal presentation
- bleeding tendency
- <34 weeks

33
Q

What do you need for the use of the fetal scalp electrode?

A

ROM

2-3cm dilated

34
Q

WHat is the pneumonic for assessing CTG?

A

Dr. C. Brvado

Define risk
Contractions (/10min) – amp, dur, freq
Baseline rate (110-160bpm) over a ten minute period
Variability (baseline): variation in FHR around the baseline (5-25bpm occurs 2-6 times/minute)
Accelerations (> 15bpm for 15 secs above
baseline. Reassuring).
Decelerations: (> 15bpm for 15 secs below the baseline)
early, variable, late
Overall assessment (normal, suspicious or pathological)

35
Q

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)

A
36
Q

what is the FIGO classification system for CTGs?

A

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
Q

What are reversible factors of changes to CTGs? (3)

A

-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
Q

What are adjunctive factors to changes to CTG?

A

Digital foetal scalp stimulation
Foetal blood sampling

39
Q

How does the foetal heart rate change?

A

Foetal HR falls by 1bt/min/wk from 28 weeks

40
Q

What are the causes of foetal tachycardia? (5)

A

-> maternal fever
-> B-sympathomimetic drugs
-> chorioamnionitis
-> acute/subacute hypoxia

If > 200 ? Foetal arrythmia

41
Q

What is seen in a normal CTG?

A
42
Q

What is seen in a CTG with tachycardia?

A
43
Q

What is seen in a CTG with reduced variability?

A
44
Q

What can cause reduced variability? (3)

A
  • sleeping
  • drugs: BZDs, opiates, MgS04, methyldopa
  • hypoxia
45
Q

What is seen on a CTG with early decelerations?

A
46
Q

What is seen in a CTG with late decelerations?

A
47
Q

What is a late deceleration?

A

When nadir of decel develops within 30 secs of contraction

48
Q

What causes late decelerations?

A

uteroplacental insufficiency: hypoxia. ? Degree and duration reflect severity

49
Q

What is seen in a CTG with variable decelerations?

A
50
Q

What usually is seen in variable decelerations?

A

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
Q

What are the advantages of CTG? (3)

A
  • visual record
  • high sensitivity (distress/hypoxia)
  • dec short-term neurological morbidity
52
Q

What are the disadvantages of CTG? (4)

A
  • reduces mobility
  • increased rate of intervention
  • no dec mortality or long-term morbidity
  • more puerperal sepsis
53
Q

What are the stages of intra-partum foetal assessment?

A
54
Q

When are the u/s done in pregnancy?

A
  • dating scan (10-13 weeks)
  • anomaly scan (18-22 weeks)
  • third trimester (28 weeks +)
55
Q

What does the third trimester u/s look at? (4)

A

Foetal growth/biometry –HC/BPD, AC, FL
Amniotic fluid
Doppler umbilical artery (or other vessels e.g. middle cerebral artery doppler)
Placental site

56
Q

How is foetal growth tracked?

A

Serial u/s measurements

57
Q

Why are serial u/s measurements NB for foetal growth monitoring?

A

Distinguish small for dates from IUGR
-rate of growth (at least 2 wks apart)
-pattern of smallness
-allow for constitutional factors

58
Q

What is Polyhydramnios?

A

Liquor volume increased. Deepest pool > 8cm (?10cm) on u/s or amniotic fluid index > 25

59
Q

What is the etiology of polyhydramnios? (Fetal 4 & maternal 1)

A

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
Q

What is the normal liquor volume?

A

400-1500ml

61
Q

What is oligohydramnios?

A

Liquor volume decreased. deepest pool < 2cm on u/s or AFI < 5.

62
Q

What is the etiology of oligohydramnios? (4)

A

Decreased production of fluid
-failing placental function
-bilateral renal agenesis
-post urethral valves

Increased loss of fluid
- PROM
63
Q

What are the 5 variables for the biophysical profile?

A

-limb movements
-tone
-breathing movements
-liquor volume
-also traditionally reactive CTG

64
Q

What do the biophysical profile scores mean?

A

Score 2 normal, 0 abnormal. >8: n, 4-6: equivocal, 0-2 abnormal.

65
Q

What markers can be done to check for Down Syndrome, Edwards Syndrome or Neural Tubal Defects?

A
66
Q

What risks are pregnant women warned about? (5)

A
  • Liver: vitamin A
  • soft cheese/unpastuerised milk: listeria
  • raw meat: toxoplasmosis
  • pate: listeria
  • caffeine: miscarriage/LBW
67
Q

When should you repeat FBC and group and hold in a normal pregnancy?

A

@ 28 weeks

68
Q

When should pregnant women have a GTT?

A

@ 24-28 weeks (depending on risk factors).

69
Q

What serology is routinely checked at the booking visit?

A
  • HIV
  • Hep B/C
  • syphilis
  • rubella
70
Q

What can be done if a mother is Rubella IgG positive @ booking visit?

A

Give MMR postpartum & warn of risks

71
Q

What can be done if a mother is Hep B surface antigen positive @ booking visit?

A
  • give hep B immunoglobulin and vaccine to infant @ birth
  • if high viral load give antiviral therapy in 3rd trimester
72
Q

What can be done if a mother is Syphilis positive @ booking visit?

A

If reactive treat with penicillin and consult GUM specialist

73
Q

What can be done if a mother is HIV positive @ booking visit?

A
  • antiretroviral treatment for mother & infant to reduce vertical transmission rates
74
Q

What can be done if a mother is urine culture positive @ booking visit?

A

Asymptomatic bacteruria-> treat with antibiotics and repeat culture to ensure fully treated

75
Q

What do UTIs even if asymptomatic pose a risk of in pregnancy?

A
  • premature labour
  • maternal pyelonephritis
76
Q

What are the 8 indications for continuous CTG monitoring?

A
  • sepsis
  • maternal tachycardia (>120)
  • significant meconium
  • pre-eclampsia (esp >160/110)
  • fresh APH
  • delay in labour
  • use of oxytocin
  • disproportionate maternal pain
77
Q

What are the different types of decelerations?

A
  • 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
Q

If a variable acceleration has shoulders (brief accelerations before and after) is that good or bad?

A

Good shows fetus is coping

OBGYN (25 decks)

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