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3a > Antenatal care > Flashcards

Antenatal care Flashcards

1
Q

Explain the 3 trimesters in pregnancy

A

1st : start of pregnancy till 12 wks
2nd : 13 weeks until 26 weeks gestation
3rd : 27 weeks until birth

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2
Q

What 2 vaccines are offered to all pregnant women

A

Whooping cough from 16 wks
Influenza

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3
Q

What is the first line screening test for Down’s

A

-Combined test between 11 and 14 wks
-USS measuring nuchal translucency (>6mm)
-Maternal bloods :
-Beta-HCG (higher = increased risk)
-PAPPA (Lower = increased risk)

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4
Q

Based on screening, how is down’s then tested for ?

A

-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
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5
Q

what medications for chronic diseases are altered in pregnancy

A

-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

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6
Q

What kind of pain killed is avoided in pregnancy ?

A

-NSAID’s : they block prostagladins required to maintain ductus arteriosus, soften cervix and stimulate uterine contractions
-Opiates : can cause neonatal abstinence syndrome (withdrawal)

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7
Q

What mood stabilising medication is avoided in pregnancy ?

A

-Lithium
-Causes Ebstein’s anomaly

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8
Q

What dermatological medication is avoided in pregnancy ?

A

-Roaccuttane (severe acne)

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9
Q

Name 7 infections dangerous in pregnancy

A

Rubella -> congenital rubella syndrome (<20wks)
Chickenpox
Listeria -> Listeriosis
Cytomegalovirus -> congenital cytomegalovirus
Toxoplasmosis gondi -> congenital toxoplasmosis
Parovirus B19
Zika virus -> congenital zika syndrome

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10
Q

How is congenital rubella syndrome avoided ?

A

-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

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11
Q

What can be given to non immune women exposed to VZV (chickepox)

A

-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

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12
Q

Infection with what virus during pregnancy can cause : miscarriage, severe fetal anaemia, hydrops fetalis, maternal pre-eclampsia-like syndrome

A

Parovirus B19

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13
Q

How is rhesus incompatibility managed ?

A

-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

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14
Q

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?

A

Kleihauer test

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15
Q

What is defined as small for gestational age ?

A

Below 10th centile

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16
Q

How is fetal size measured and what is defined as severe SGA

A

-Estimated fetal weight (EFW) and fetal abdominal circumference (AC)
-Below 3rd centile for gestational age

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17
Q

What is defined as low birth weight

A

<2500g

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18
Q

What 2 categories can SGA be divided into ?

A

-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

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19
Q

Give 6 causes of placenta mediated fetal growth restriction

A

Idiopathic
Pre-eclampsia
Maternal smoking and alcohol
Anaemia
Malnutrition
Infection

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20
Q

Give 4 causes of non placenta mediated fetal growth restriction

A

Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism

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21
Q

How is the risk of SGA managed ?

A

-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

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22
Q

what is defined as large for gestational age (macrosomia) ?

A
  • > 4.5kg at birth
  • During pregnancy : Estimated fetal weight above 90th centile during pregnancy
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23
Q

Give 6 causes of macrosomia

A

Constitutional
MATERNAL DM
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Male baby

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24
Q

What risk to the mother does macrosomia cause ?

A

SHOULDER DYSTOCIA
Failure to prohgress
Perianal tears
Instrumental delivery or caesaran
Postpartum haemorrhage
Uterine rupture

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25
Q

What is the risk to the baby in macrosomia

A

Birth injury
Neonatal hypoglycaemia
Obesity in childhood
T2DM in adulthood

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26
Q

What Ix are done in macrosomia ?

A

-USS to exclude polyhydramnios and estimate fetal weight
-Oral glucose tolerance for gestational DM

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27
Q

What 2 signs on USS suggest dichorionic diamniotic twins (2 separate amniotic sacs + 2 separate placentas)

A

membrane between the twins with lambda sign or twin peak sign

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28
Q

What sign on USS suggests monochorionic diamniotic twins ? (share a placenta)

A

Membrane between twins, with T sign

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29
Q

What is twin-twin transfusion syndrome and why does it occur

A

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

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30
Q

What is twin anaemia polycythaemia sequence

A

Less acute version of twin-twin transfusion syndrome where one becomes anaemic whilst the other develops polycythaemia

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31
Q

What Abx for UTI is avoided in the 3rd trimester and why

A

Nitrofurantoin
Risk of neonatal haemolysis

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32
Q

What Abx for UTI is avoided in the 1st trimester

A

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)

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33
Q

When are pregant women screening for anaemia ?

A

booking clinic (this is ideally before 10 wks)
28 wks gestation

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34
Q

Why are VTE more common in pregnant women

A

They are in a hyper-coagulable state

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35
Q

When is VTE prophylaxis started in pregnancy

A

28 wks if 3 risk factors
first trimester if 4 or more risk factors

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36
Q

What VTE prophylaxis is given to pregnant women?

A

-Low molecular weight heparin (e.g. enoxaparin, dalteparin, tinzaparin)
-If CI = intermittent pneumatic compression or compression stockings

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37
Q

How is VTE managed in pregnancy ?

A

LMWH and continued for rest of pregnancy

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38
Q

What is pre-eclampsia

A

-HTN in pregnancy >20 weeks gestation with end-organ dysfunction

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39
Q

What is the triad of pre-eclampsia

A

HTN
Proteinuria
Oedema

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40
Q

Give 5 high-risk factors for pre-eclampsia

A

Pre existing HTN
Previous HTN in pregnancy
Autoimmune condition (e.g. SLE)
DM
CKD

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41
Q

When are women given prophylaxis against pre-eclampsia and what is it

A

Single high risk factor
Two or more moderate-risk factors
ASPIRIN from 12 wks gestation till birth

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42
Q

How is pre-eclampsia diagnosed ?

A

Systolic BP >140/ diastolic >90

PLUS ANY OF :

  • Proteinuria (1+)
  • Organ dysfunction (raised creatinine, raised LFTs etc)
  • Placental dysfunction (feta growth restriction)
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43
Q

What is the medical management of pre-eclampsia

A

Labetalol - 1st line antihypertensive

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44
Q

What is eclampsia ?

A

Seizures associated with pre-eclampsia

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45
Q

How are seizures in eclampsia managed

A

IV magnesium sulphate (SE = respiratory depression, treated with calcium gluconate)

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46
Q

What is HELLP syndrome

A

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

Haemolysis
Elevated Liver enzymes
Low platelets

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47
Q

Give 5 RF for gestational DM

A

Previous gestational DM
Previous macrosomic baby
BMI >30
Ethnic origin (black caribbean, Middle Eastern, South Asian)
First degree family history of DM

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48
Q

What is the screening test of choice for gestational DM?

A

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

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49
Q

What are two major complications of gestational DM

A

Macrosomia -> risk of shoulder dystocia
Neontal hypoglycaemia

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50
Q

How is gestational DM managed

A

-Fasting <7mmol = diet and ecercise for 1-2 wks, then metformin, then insulin
-Fasting >7mmol = insulin +/- metformin
- >6mmol + macrosomia = insuline +/- metformin

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51
Q

How should pregnant women with pre existing DM be managed ?

A

-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

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52
Q

What should the blood glucose of a baby from a mother with gestational DM be and how is it managed

A

> 2mmol/l
If it falls below = neonatal hypoglycaemia = IV dextrose of neogastric feeding

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53
Q

what is obstetric cholestasis ?

A

Reduced outflow of bile acids from the liver, resolves after delivery

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54
Q

How does obsteric cholestasis present ?

A

-Third trimester
-Itching : palms of hands and soles of feet
-Fatigue, dark urine, pale greasy stools, jaundice
NO RASH

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55
Q

what bloods are seen in obstertric cholestasis

A

Raised bilirubin

56
Q

How is obsteric cholestasis managed?

A

Ursodeoxycholic acid
Itching : emollients and antihistamines

57
Q

What is given in obsteric cholestasis if PT time is derranged and why ?

A

Water-soluble vitamin K
A lack of bile acid can cause vit K deficiency

58
Q

What is acute fatty liver of pregnancy

A

Occurs in third trimester
Rapid accumulation of fat within hepatocytes causing acute hepatitis

59
Q

What is the main cause of acute fatty liver of pregnancy

A

Long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency
Autosomal recessive
Genetic condition in fetus impairing fatty acid metanolism in placenta

60
Q

How does acute fatty liver of pregnancy present ?

A

Vague hepatitis symptoms
Ascites
Malaise and fatigue
N&V
Jaundice
Abdo pain
Anorexia

61
Q

What bloods are seen in acute fatty liver of pregnancy and how is it managed ?

A

Elevated ALT mainly and AST
Immediate admission and delivery

62
Q

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

A

Polymorphic eruption of pregnancy

63
Q

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

A

Atopic eruption of pregnancy

64
Q
  • Increased pigmentation to patches of skin on face
  • Symmetrical and flat
A

Melasma

65
Q
  • Discrete lump with red or dark appearance
  • Rapidly growing
  • Developes over days
    -Common on fingers, upper chest, back, head or neck
  • Resolve after birth
A

Pyogenic granuloma : lobular capillary haemangioma

66
Q
  • 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
A
  • Pemphigoid gestationis
  • Rare autoimmune skin condition
67
Q

Give 3 causes of antepartum haemorrhage

A

Placenta praevia
Placental abruption
Vasa praevia

68
Q

Explain the difference between a low lying placenta and placenta praevia

A

-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

69
Q

When is placenta praevia detected

A
  • 20 week anomaly scan
  • Is often asymptomatic or may present with painless vaginal bleeding (antepartum haemorrhage)
70
Q

Explain the management of a low lying placenta and placenta praevia if diagnosed early in pregnancy

A
  • 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
71
Q

Define placental abruption

A

placenta separates from the wall of the uterus and bleeds excessively = antepartum haemorrhage

72
Q

Sudden onset continuous abdo pain
Vaginal bleeding
Shock (hypotension, tachycardia)
CTG showing fetal distress
‘Woody’ abdomen on palpation

A

Placental abruption

73
Q

How is the severity of an antepartum haemorrhage defined ?

A

Spotting
Minor : <50ml blood loss
Major : 50-1000ml blood less
Massive >1000ml blood loss, or signs of shock

74
Q

What is a concealed abruption

A

The cervical os remains closed and the bleeding remains in the uterine cavity

75
Q

Define vasa praevia

A

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

76
Q

What are the two types of vasa praevia

A

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

77
Q

What is the management of asymptomatic vasa praevia dx early on USS

A

Corticosteroids from 32 wks
Elective caesarean at 34 to 36 wks

78
Q

What is the role of giving maternal corticosteroids if there is a risk of premature birth

A

To allow fetal lungs to mature

79
Q

Explain the usual pathophysiology of placenta attachment

A

The placenta attaches to the endometrium, allowing it to separate during the third stage of labour

80
Q

What occurs in placenta accreta

A

the placenta embeds past the endometrium
this makes it difficult to separate in delivery
leading to postpartum haemorrhage

81
Q

What are the 3 types of placenta accreta?

A

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)

81
Q

What are the 3 types of placenta accreta?

A

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)

82
Q

How is placenta accreta managed if diagnosed antenatally

A
  • Planned delivery between 35 and 36 + 6 wks
  • Antenatal steroids
  • Caesarean :
  1. 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)
83
Q

What is cephalic presentation

A

Head of the fetus is the presenting part

84
Q

What are the 4 types of breech

A

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

85
Q

What is used to attempt to turn a fetus at 37 wks ?

A

External cephalic version (ECV)

86
Q

What is ECV

A
  • 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
87
Q

what is defined as stillbirth

A
  • Death of fetus after 24 wks gestation
    result of intrauterine fetal death
88
Q

What is 1st line for IUFD

A

Vaginal birth with either induction of labour or expectant management

89
Q

How is labour induced for IUFD

A

Oral mifepristone (anti-progesterone) and vaginal or oral misoprostol (prostaglandin analogue)

90
Q

How is lactation suppressed after stillbirth

A

Cabergoline (dopamine agonist)

91
Q

what are the 3 major causes of cardiac arrest in pregnancy

A

obstetric haemorrhage
PE
sepsis leading to metabolic acidosis and septic shock

92
Q

What are 5 causes of obstetric haemorrhage leading to hypovolaemia and cardiac arrest

A

ectopic pregnancy
placental abruption
placental praevia
placental accreta
uterine rupture

93
Q

what is aortocaval compression and why can it cause cardiac arrest

A

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

94
Q

what are 5 differing principles of resuscitation in pregnancy

A

-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

95
Q

what is a risk to the baby when using SSRIs in the third trimester of pregnancy

A

persistent pulmonary hypertension of newborn

96
Q

Define nulliparous

A

pt never given birth after 24 wks gestation

97
Q

Define primiparous

A

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

98
Q

Give the key dates and events during pregnancy

A

Before 10 wks -> booking clinic
Between 10 and 13 + 6 -> dating scan (CRL)
16 wks -> antenatal appointment
Between 18 and 20+6 -> Anomaly scan

99
Q

Give 8 features of fetal alcohol syndrome

A

Microcephaly
Thin upper lip
Smooth flat philtrum
Short palpebral fissure
Learning disability
Behavoural difficulties
Hearing and vision problems
cerebral palsy

100
Q

Give 8 things smoking in pregnancy increases the risk of

A

FGR
SIDS
Miscarriage
Stillbirth
Preterm labour and birth
Placental abruption
Pre-eclampsia
Cleft lip or palate

101
Q

when is flying generally ok up until and what does it increase the risk of

A

single pregnancy : 37 wks
twin pregnancy : 32 wks
DVT

102
Q

what 3 infectious diseases are screened for at the booking clinic

A

HIV
Hep B
syphillis

103
Q

what 3 things are measured at booking clinic

A

BMI
BP
Urine (protein and bacteria)

104
Q

what 5 things are checked for on bloods at the booking clinic

A

FBC - anaemia
Thalassaemia
Rhesus D
Blood group
Sickle cell (high risk women)

105
Q

Give 2 other screening tests done between 14 and 20 wks for Down’s

A

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.

106
Q

Congenital rubella syndrome

A

deafness, catarats, PDA and pulmonary stenosis + learning disability

107
Q

Congenital VZV

A

Limb hypoplasia
Microcephaly and hydrocephalus

108
Q

Congenital CMV

A

Seizures
Hearing loss
Vision loss

109
Q

Congenital intracranial calcification, hydrocephalus and choorioentinitis

A

congenital toxoplasmosis

110
Q

microcephaly
fetal growth restriction
ventriculomegaly and cerebellar atrophy

A

congenital zika syndrome

111
Q

give 4 short term and 4 long term complications of FGR

A

-Short : fetal death/stillbirth, birth asphyxia, neonatal hypothermia/hypoglycaemia
-Long : CVD, T2DM, Obesity, mood and behavioural problems

112
Q

How are twins delivered

A

-Monoamniotic : elective caesarean section (32-33 + 6 wks)
-Diamniotic : vaginal if first baby is cephalic, C section for second

113
Q

Dysuria
Suprapubic pain
Increased frequency
Urgency
Incontinence
Haematuria

A

Lower urinary tract infection

114
Q

Fever
Loin, suprapubic or back pain
Looking/feeling unwell
Loss of appetite
Haematuria
Renal angle tenderness

A

Pyelonephritis

115
Q

Most common cause of UTI
Gram negative anaerobic rod

A

E.coli

116
Q

How is DVT diagnosed in pregnant women

A
  • Doppler USS

IF not present and PE considered :

-CTPA
VQ scan

117
Q

-Spontaneous rupture of membranes
-Dark red vaginal bleeding
-Fetal distress

A

Vasa praevia

118
Q

what is there an increased risk of with obstertric cholestasis

A

Stillbirth

119
Q

when is labetalol CI in gestational HTN

A

-Asthma
-Nifedipine and methyldopa are alternatives
-Methydopa is CI in depression

120
Q

what is define as Oligohydramnios

A
  • <500 ml at 32-36 wks
  • AFI <5th percentile / 5cm
121
Q

Give 5 causes of Oligohydramnios

A
  • PROM
  • Renal agenesis
  • IUGR
  • Post term gestation
  • Pre-eclampsia
122
Q

How can Oligohydramnios present

A

Smaller symphysiofundal height

123
Q

when is anti-d given during pregnancy

A

28 wks and 34 wks

124
Q

what does the quadruple test screen for

A

Down’s
Edward’s
Patau’s
Neural tube defects

125
Q

What are the results of the quadruple test in downs

A

HIGH

-> hGC = high
-> Inhib A = high

-Other 2 (oestriol and AFP low)

126
Q

How would neural tube defects present on quadruple test

A

Isolated raised AFP

127
Q

How would edwards present on quadruple test

A

Low everything
Normal inhibin A

128
Q

when is an OGT done in pregnancy

A

-> Any present RF for gestational DM
-> Any signs of gestational DM : macrosomia, glucose on dipstick, polyhydramnios.
-> Done at 24-28 wks

129
Q

What DM medication is safe during breastfeeding

A

Metformin

130
Q

What 4 ways can vasa praevia present

A
  1. Diagnosed on USS
  2. APH in 2nd or 3rd trimester
  3. Detected on vaginal exam in labour
  4. Dark red bleeding & fetal distress following ROM
131
Q

When is the combined screening test for Down’s done

A

between 11 and 14 wks

132
Q

what can the mother experience in TTTS

A
  • > sudden increase in size of the abdomen
  • > SOB
133
Q

How is a suspected PE in a pregnanct women with a confirmed DVT managed ?

A

LMWH first, then investigate to rule in / out

134
Q

what can cause placental abruption

A

Cocaine use
Pre-eclampsia
HELLP

135
Q

How would placental abruption caused by cocaine use present

A
  • > Constant lower abdo pin
  • > Vaginal bleeding
    -> Hypotension
    -> Dialted pupils
    -> Hyperreflexia
136
Q

How can the reflexes be described in placental abruption

A

Brisk

3a (45 decks)

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