Antenatal care Flashcards
Explain the 3 trimesters in pregnancy
1st : start of pregnancy till 12 wks
2nd : 13 weeks until 26 weeks gestation
3rd : 27 weeks until birth
What 2 vaccines are offered to all pregnant women
Whooping cough from 16 wks
Influenza
What is the first line screening test for Down’s
-Combined test between 11 and 14 wks
-USS measuring nuchal translucency (>6mm)
-Maternal bloods :
-Beta-HCG (higher = increased risk)
-PAPPA (Lower = increased risk)
Based on screening, how is down’s then tested for ?
-If risk is greater than 1 in 150 :
- NIPT
- Diagnostic :
-Chorionic villus sampling : US guided biopsy of placental tissue before 15 wks
-Amniocentesis : US guided aspiration of amniotic fluid. Done later in pregnancy
what medications for chronic diseases are altered in pregnancy
-Hypothyroid : levothyroxine is increased.
-HTN : ACEI, ARBs, BB’s and thiazide-like diuretics = stopped. Labetalol is 1st line. CCB and alpha blocker can be used.
-Epilepsy : take folic acid before conception. SV = teratogenic, phenytoin = cleft lip and palate.
-RA : methotrexate = teratogenic BUT hydroxychloroquine, sulfasalazine are safe. Methotraxate has to be stopped in both partners 6 mnths before conceiving
What kind of pain killed is avoided in pregnancy ?
-NSAID’s : they block prostagladins required to maintain ductus arteriosus, soften cervix and stimulate uterine contractions
-Opiates : can cause neonatal abstinence syndrome (withdrawal)
What mood stabilising medication is avoided in pregnancy ?
-Lithium
-Causes Ebstein’s anomaly
What dermatological medication is avoided in pregnancy ?
-Roaccuttane (severe acne)
Name 7 infections dangerous in pregnancy
Rubella -> congenital rubella syndrome (<20wks)
Chickenpox
Listeria -> Listeriosis
Cytomegalovirus -> congenital cytomegalovirus
Toxoplasmosis gondi -> congenital toxoplasmosis
Parovirus B19
Zika virus -> congenital zika syndrome
How is congenital rubella syndrome avoided ?
-Caused by rubella virus in first 20 wks
-Women planning to get pregnant = MMR vaccination
-Syndrome : congenital deafness, cataracts, heart disease (PDA and pulmonary stenosis) and learning disability
What can be given to non immune women exposed to VZV (chickepox)
-IV varicella immunoglobulins (within 7-14 days of exposure). If no rash just exposure and >20 wks. Need to confirm not immune.
-If they start with the rash in pregnancy = oral aciclovir if within 24hrs and >20 wks gestation
Infection with what virus during pregnancy can cause : miscarriage, severe fetal anaemia, hydrops fetalis, maternal pre-eclampsia-like syndrome
Parovirus B19
How is rhesus incompatibility managed ?
-If the mother is rhesus-D-negative Anti-D injections are given at 28 weeks gestation and at birth if baby is +
-Abnti-D IM injections are also given within 72 hrs at any time where sensitisation may occur : entepartum haemorrhage, amniocentesis procedures, abdominal trauma
What test is done >20 wks gestation to see how much fetal blood has pass into mother’s blood to see if further anti-D is required?
Kleihauer test
What is defined as small for gestational age ?
Below 10th centile
How is fetal size measured and what is defined as severe SGA
-Estimated fetal weight (EFW) and fetal abdominal circumference (AC)
-Below 3rd centile for gestational age
What is defined as low birth weight
<2500g
What 2 categories can SGA be divided into ?
-Constitutionally small : growing appropropriately on growth chart and matches family
-Fetal growth restriction : pathology is reducing nutrients and oxygen to fetus causing a small fetus
Give 6 causes of placenta mediated fetal growth restriction
Idiopathic
Pre-eclampsia
Maternal smoking and alcohol
Anaemia
Malnutrition
Infection
Give 4 causes of non placenta mediated fetal growth restriction
Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism
How is the risk of SGA managed ?
-Low risk women = symphysis fundal height monitoring at every antenatal appointment and plotted on growth chart
-Higher risk = Serial USS monitoring estimated fetal weight and abdominal circumference. Umbilical arterial pulsatility index and amniotic fluid volume
what is defined as large for gestational age (macrosomia) ?
- > 4.5kg at birth
- During pregnancy : Estimated fetal weight above 90th centile during pregnancy
Give 6 causes of macrosomia
Constitutional
MATERNAL DM
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Male baby
What risk to the mother does macrosomia cause ?
SHOULDER DYSTOCIA
Failure to prohgress
Perianal tears
Instrumental delivery or caesaran
Postpartum haemorrhage
Uterine rupture
What is the risk to the baby in macrosomia
Birth injury
Neonatal hypoglycaemia
Obesity in childhood
T2DM in adulthood
What Ix are done in macrosomia ?
-USS to exclude polyhydramnios and estimate fetal weight
-Oral glucose tolerance for gestational DM
What 2 signs on USS suggest dichorionic diamniotic twins (2 separate amniotic sacs + 2 separate placentas)
membrane between the twins with lambda sign or twin peak sign
What sign on USS suggests monochorionic diamniotic twins ? (share a placenta)
Membrane between twins, with T sign
What is twin-twin transfusion syndrome and why does it occur
when twins share a placenta, one receives majority of the blood while the other is starved
Recipient = fluid overloaded, HF and polyhydramnios
Donor = growth restriction, anaemia & oligohydramnios
What is twin anaemia polycythaemia sequence
Less acute version of twin-twin transfusion syndrome where one becomes anaemic whilst the other develops polycythaemia
What Abx for UTI is avoided in the 3rd trimester and why
Nitrofurantoin
Risk of neonatal haemolysis
What Abx for UTI is avoided in the 1st trimester
Trimethoprim
Is a folate antagonist
Folate is needed for fetal development and so it can cause congenital malformations (e.g. neural tube defects -> spina bifida)
When are pregant women screening for anaemia ?
booking clinic (this is ideally before 10 wks)
28 wks gestation
Why are VTE more common in pregnant women
They are in a hyper-coagulable state
When is VTE prophylaxis started in pregnancy
28 wks if 3 risk factors
first trimester if 4 or more risk factors
What VTE prophylaxis is given to pregnant women?
-Low molecular weight heparin (e.g. enoxaparin, dalteparin, tinzaparin)
-If CI = intermittent pneumatic compression or compression stockings
How is VTE managed in pregnancy ?
LMWH and continued for rest of pregnancy
What is pre-eclampsia
-HTN in pregnancy >20 weeks gestation with end-organ dysfunction
What is the triad of pre-eclampsia
HTN
Proteinuria
Oedema
Give 5 high-risk factors for pre-eclampsia
Pre existing HTN
Previous HTN in pregnancy
Autoimmune condition (e.g. SLE)
DM
CKD
When are women given prophylaxis against pre-eclampsia and what is it
Single high risk factor
Two or more moderate-risk factors
ASPIRIN from 12 wks gestation till birth
How is pre-eclampsia diagnosed ?
Systolic BP >140/ diastolic >90
PLUS ANY OF :
- Proteinuria (1+)
- Organ dysfunction (raised creatinine, raised LFTs etc)
- Placental dysfunction (feta growth restriction)
What is the medical management of pre-eclampsia
Labetalol - 1st line antihypertensive
What is eclampsia ?
Seizures associated with pre-eclampsia
How are seizures in eclampsia managed
IV magnesium sulphate (SE = respiratory depression, treated with calcium gluconate)
What is HELLP syndrome
Combination of features as a complication of pre-eclampsia and eclampsia
Haemolysis
Elevated Liver enzymes
Low platelets
Give 5 RF for gestational DM
Previous gestational DM
Previous macrosomic baby
BMI >30
Ethnic origin (black caribbean, Middle Eastern, South Asian)
First degree family history of DM
What is the screening test of choice for gestational DM?
OGTT
Patient drinks 75g glucose drink -> fasting blood sugar is measure follow by 2 hrs after drink
Fasting <5.6mmol
At 2 hrs <7.8mmol
What are two major complications of gestational DM
Macrosomia -> risk of shoulder dystocia
Neontal hypoglycaemia
How is gestational DM managed
-Fasting <7mmol = diet and ecercise for 1-2 wks, then metformin, then insulin
-Fasting >7mmol = insulin +/- metformin
- >6mmol + macrosomia = insuline +/- metformin
How should pregnant women with pre existing DM be managed ?
-5mg folic aid from preconecption till 12 wks
-Retinopathy screening shortly after booking & at 28 wks
-Planned delivery between 37 and 38 + 6 wks
-T2DM : metformin + insulin
-T1DM : sliding-scale insulin regime during labour -> dextrose and insulin infusion titrated ti blood sugar levels
What should the blood glucose of a baby from a mother with gestational DM be and how is it managed
> 2mmol/l
If it falls below = neonatal hypoglycaemia = IV dextrose of neogastric feeding
what is obstetric cholestasis ?
Reduced outflow of bile acids from the liver, resolves after delivery
How does obsteric cholestasis present ?
-Third trimester
-Itching : palms of hands and soles of feet
-Fatigue, dark urine, pale greasy stools, jaundice
NO RASH
what bloods are seen in obstertric cholestasis
Raised bilirubin
How is obsteric cholestasis managed?
Ursodeoxycholic acid
Itching : emollients and antihistamines
What is given in obsteric cholestasis if PT time is derranged and why ?
Water-soluble vitamin K
A lack of bile acid can cause vit K deficiency
What is acute fatty liver of pregnancy
Occurs in third trimester
Rapid accumulation of fat within hepatocytes causing acute hepatitis
What is the main cause of acute fatty liver of pregnancy
Long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency
Autosomal recessive
Genetic condition in fetus impairing fatty acid metanolism in placenta
How does acute fatty liver of pregnancy present ?
Vague hepatitis symptoms
Ascites
Malaise and fatigue
N&V
Jaundice
Abdo pain
Anorexia
What bloods are seen in acute fatty liver of pregnancy and how is it managed ?
Elevated ALT mainly and AST
Immediate admission and delivery
Itchy rash in third trimester
Starting on abdomen + striae
Urticarial papules (raised itchy lumps)
Wheals (raised ithcy areas of skin)
Plaques (larger inflammed skin areas)
Tx w/ topical emollients or steroids
Polymorphic eruption of pregnancy
Flare of eczema in the first and second trimester
E-type = eczematous, inflamed, red and itching skin, affecting inside of elbows, knees, neck and face
P-type = intensely itchy spots
Tx with topical emollients/steroids, phototherapy or oral steroids if severe
Atopic eruption of pregnancy
- Increased pigmentation to patches of skin on face
- Symmetrical and flat
Melasma
- Discrete lump with red or dark appearance
- Rapidly growing
- Developes over days
-Common on fingers, upper chest, back, head or neck - Resolve after birth
Pyogenic granuloma : lobular capillary haemangioma
- Second or third trimester
- Initially Itchy red papular or blistering rash around umbilicus
- Speads to other parts of the body
- Large fluid filled blisters form after several weeks
- Pemphigoid gestationis
- Rare autoimmune skin condition
Give 3 causes of antepartum haemorrhage
Placenta praevia
Placental abruption
Vasa praevia
Explain the difference between a low lying placenta and placenta praevia
-Low lying : placenta is within 20mm of internal cervical os
-Placenta praevia : placenta is over the internal cervical os and is lower than the presenting part of the uterus
When is placenta praevia detected
- 20 week anomaly scan
- Is often asymptomatic or may present with painless vaginal bleeding (antepartum haemorrhage)
Explain the management of a low lying placenta and placenta praevia if diagnosed early in pregnancy
- Transvaginal USS at 32 wks
- Repeat at 36 wks if present on previous scan
- Corticosteroids between 34 and 35 +6 wks to mature fetal lungs
- Planned delivery between 36 and 37 wks
Define placental abruption
placenta separates from the wall of the uterus and bleeds excessively = antepartum haemorrhage
Sudden onset continuous abdo pain
Vaginal bleeding
Shock (hypotension, tachycardia)
CTG showing fetal distress
‘Woody’ abdomen on palpation
Placental abruption
How is the severity of an antepartum haemorrhage defined ?
Spotting
Minor : <50ml blood loss
Major : 50-1000ml blood less
Massive >1000ml blood loss, or signs of shock
What is a concealed abruption
The cervical os remains closed and the bleeding remains in the uterine cavity
Define vasa praevia
The fetal vessel are exposed, outside of the usual protection of the umbilical cord or the placenta
-They pass through the chorioamniotic membranes and pass across the internal cervical os
-These vessels are prone to bleed during labour and at birth causing fetal blood loss and death
What are the two types of vasa praevia
I : the fetal vessels are exposed as a velamentous umbilical cord (the umbiical cord inserts into the chorioamniotic membranes) and the fetal vessels travel unprotected
II : the fetal vessels are exposed as they travel to an accessory placental lobe
What is the management of asymptomatic vasa praevia dx early on USS
Corticosteroids from 32 wks
Elective caesarean at 34 to 36 wks
What is the role of giving maternal corticosteroids if there is a risk of premature birth
To allow fetal lungs to mature
Explain the usual pathophysiology of placenta attachment
The placenta attaches to the endometrium, allowing it to separate during the third stage of labour
What occurs in placenta accreta
the placenta embeds past the endometrium
this makes it difficult to separate in delivery
leading to postpartum haemorrhage
What are the 3 types of placenta accreta?
Superficial -> embeds in the myometrium surface
Placenta increta -> attaches deeply into myometrium
Placenta percreta -> invades past myometrium and perimetrium and potentially reaches other organs (e.g. bladder)
What are the 3 types of placenta accreta?
Superficial -> embeds in the myometrium surface
Placenta increta -> attaches deeply into myometrium
Placenta percreta -> invades past myometrium and perimetrium and potentially reaches other organs (e.g. bladder)
How is placenta accreta managed if diagnosed antenatally
- Planned delivery between 35 and 36 + 6 wks
- Antenatal steroids
- Caesarean :
- Hysterectomy with placenta remaining in uterus (preferred) - 2. Uterus preserving surgery with resection of part of myometrium + placenta or 3. Expectant management (leaving placenta to be reabsorbed)
What is cephalic presentation
Head of the fetus is the presenting part
What are the 4 types of breech
complete : legs fully flexed at hips and knees
incomplete : one leg flexed at hip and extended at knee
extended (frank) : both legs flexed at hip, extended at knee
footling : foot presenting through cervix with leg extended
What is used to attempt to turn a fetus at 37 wks ?
External cephalic version (ECV)
What is ECV
- Women are given tocolysis with subcut terbutaline to relax the uterus
- Terbutaline is a beta-agonist so reduces contractility of myometrium making it easier for baby to turn
- Pressure is then put on abdomen to turn the fetus
what is defined as stillbirth
- Death of fetus after 24 wks gestation
result of intrauterine fetal death
What is 1st line for IUFD
Vaginal birth with either induction of labour or expectant management
How is labour induced for IUFD
Oral mifepristone (anti-progesterone) and vaginal or oral misoprostol (prostaglandin analogue)
How is lactation suppressed after stillbirth
Cabergoline (dopamine agonist)
what are the 3 major causes of cardiac arrest in pregnancy
obstetric haemorrhage
PE
sepsis leading to metabolic acidosis and septic shock
What are 5 causes of obstetric haemorrhage leading to hypovolaemia and cardiac arrest
ectopic pregnancy
placental abruption
placental praevia
placental accreta
uterine rupture
what is aortocaval compression and why can it cause cardiac arrest
when laying supine, uterus can compress IVC and aorta
VC compression reduces vernous return
this reduces cardiac output and causes hypotension
this can lead to cardiac arrest
managed by laying women in the left lateral position
what are 5 differing principles of resuscitation in pregnancy
-15 degrees tilt to left side for CPR
-Early intubation to protect airway
-Early supplementary oxygen
-Aggressive fluid resuscitation
-Delivery of baby after 4 mins and within 5 mins of starting CPR
what is a risk to the baby when using SSRIs in the third trimester of pregnancy
persistent pulmonary hypertension of newborn
Define nulliparous
pt never given birth after 24 wks gestation
Define primiparous
pt that has given birth after 24 weeks once before
P = no. of times a woman has given birth after 24 wks gestation regardless of whether the fetus was alive or stillborn
Give the key dates and events during pregnancy
Before 10 wks -> booking clinic
Between 10 and 13 + 6 -> dating scan (CRL)
16 wks -> antenatal appointment
Between 18 and 20+6 -> Anomaly scan
Give 8 features of fetal alcohol syndrome
Microcephaly
Thin upper lip
Smooth flat philtrum
Short palpebral fissure
Learning disability
Behavoural difficulties
Hearing and vision problems
cerebral palsy
Give 8 things smoking in pregnancy increases the risk of
FGR
SIDS
Miscarriage
Stillbirth
Preterm labour and birth
Placental abruption
Pre-eclampsia
Cleft lip or palate
when is flying generally ok up until and what does it increase the risk of
single pregnancy : 37 wks
twin pregnancy : 32 wks
DVT
what 3 infectious diseases are screened for at the booking clinic
HIV
Hep B
syphillis
what 3 things are measured at booking clinic
BMI
BP
Urine (protein and bacteria)
what 5 things are checked for on bloods at the booking clinic
FBC - anaemia
Thalassaemia
Rhesus D
Blood group
Sickle cell (high risk women)
Give 2 other screening tests done between 14 and 20 wks for Down’s
Triple test : b-HCG, AFP (lower = greater risk), serum oestriol (lower = greater risk)
-Quadruple test : same as above + inhibin A (higher = greater risk)
HIGH : hCG and inhibin A, high = increased risk
The other 2, lower = increased risk.
Congenital rubella syndrome
deafness, catarats, PDA and pulmonary stenosis + learning disability
Congenital VZV
Limb hypoplasia
Microcephaly and hydrocephalus
Congenital CMV
Seizures
Hearing loss
Vision loss
Congenital intracranial calcification, hydrocephalus and choorioentinitis
congenital toxoplasmosis
microcephaly
fetal growth restriction
ventriculomegaly and cerebellar atrophy
congenital zika syndrome
give 4 short term and 4 long term complications of FGR
-Short : fetal death/stillbirth, birth asphyxia, neonatal hypothermia/hypoglycaemia
-Long : CVD, T2DM, Obesity, mood and behavioural problems
How are twins delivered
-Monoamniotic : elective caesarean section (32-33 + 6 wks)
-Diamniotic : vaginal if first baby is cephalic, C section for second
Dysuria
Suprapubic pain
Increased frequency
Urgency
Incontinence
Haematuria
Lower urinary tract infection
Fever
Loin, suprapubic or back pain
Looking/feeling unwell
Loss of appetite
Haematuria
Renal angle tenderness
Pyelonephritis
Most common cause of UTI
Gram negative anaerobic rod
E.coli
How is DVT diagnosed in pregnant women
- Doppler USS
IF not present and PE considered :
-CTPA
VQ scan
-Spontaneous rupture of membranes
-Dark red vaginal bleeding
-Fetal distress
Vasa praevia
what is there an increased risk of with obstertric cholestasis
Stillbirth
when is labetalol CI in gestational HTN
-Asthma
-Nifedipine and methyldopa are alternatives
-Methydopa is CI in depression
what is define as Oligohydramnios
- <500 ml at 32-36 wks
- AFI <5th percentile / 5cm
Give 5 causes of Oligohydramnios
- PROM
- Renal agenesis
- IUGR
- Post term gestation
- Pre-eclampsia
How can Oligohydramnios present
Smaller symphysiofundal height
when is anti-d given during pregnancy
28 wks and 34 wks
what does the quadruple test screen for
Down’s
Edward’s
Patau’s
Neural tube defects
What are the results of the quadruple test in downs
HIGH
-> hGC = high
-> Inhib A = high
-Other 2 (oestriol and AFP low)
How would neural tube defects present on quadruple test
Isolated raised AFP
How would edwards present on quadruple test
Low everything
Normal inhibin A
when is an OGT done in pregnancy
-> Any present RF for gestational DM
-> Any signs of gestational DM : macrosomia, glucose on dipstick, polyhydramnios.
-> Done at 24-28 wks
What DM medication is safe during breastfeeding
Metformin
What 4 ways can vasa praevia present
- Diagnosed on USS
- APH in 2nd or 3rd trimester
- Detected on vaginal exam in labour
- Dark red bleeding & fetal distress following ROM
When is the combined screening test for Down’s done
between 11 and 14 wks
what can the mother experience in TTTS
- > sudden increase in size of the abdomen
- > SOB
How is a suspected PE in a pregnanct women with a confirmed DVT managed ?
LMWH first, then investigate to rule in / out
what can cause placental abruption
Cocaine use
Pre-eclampsia
HELLP
How would placental abruption caused by cocaine use present
- > Constant lower abdo pin
- > Vaginal bleeding
-> Hypotension
-> Dialted pupils
-> Hyperreflexia
How can the reflexes be described in placental abruption
Brisk
