Antenatal care

Question 1

how many routine antenatal appointments do women have

Answer 1

Nulliparous: 10
Parous: 7

Question 2

What are the indications for consultant-led care

Answer 2

Existing medical problems
High (>30) or low BMI (<18.5)
>40yo at booking
Multiple pregnancy
Complex social factors
Complications in previous pregnancies
Complications develop during current pregnancy

Question 3

When is the booking visit

Answer 3

8-12 weeks

Question 4

When is the dating scan

Answer 4

10-13+6 weeks

Question 5

When is Down’s syndrome testing done

Answer 5

11-13+6 weeks

Question 6

When is the anomaly scan

Answer 6

18-20+6

Question 7

When is anti-D prophylaxis given

Answer 7

28 weeks
Second dose at 34 weeks

Question 8

When are the routine antenatal appointments

Answer 8

28, 34, 36, 38, 41, 42 weeks gestation

Nulliparous: + 25, 31, 40

Question 9

What is done at the booking appointment

Answer 9

1. Clinical history + establish gestation
2. Risk assessment
3. Examination and investigations
4. Medication review
5. Screening for conditions
6. Lifestyle advice
7. Information about pregnancy
8. Scans
9. Safeguarding screen

Question 10

What is done at routine antenatal visits

Answer 10

BP measurement
Urine dipstick
Discuss concerns and birth plan
Serial growth scans
>25 weeks: SFH
<28 weeks: handheld doppler heart monitoring
>28 weeks: CTG

Question 11

What does the risk assessment at the booking visit look for

Answer 11

Gestational diabetes risk
Pre-eclampsia
Foetal growth restriction
Venous thromboembolism

Question 12

What examinations and investigations should be done at booking visit

Answer 12

BMI (weight and height)
BP
Urine dipstick and culture
Bloods:
- FBC
- Haemoglobinopathies e.g. SCD, thal
- Blood group and rhesus status
- Red cell alloantibodies
- Serology: HIV, hep B, syphillis, rubella
- Chromosome abnormality screening

Question 13

Give examples of medications contraindicated in pregnancy

Answer 13

ACEi
Statins
Diuretics
Warfarin
Sodium valproate
Vitamin A supplementation
Lithium

Question 14

When is folic acid given and why

Answer 14

Pre-conception if possible → 12 weeks of pregnancy
normal: 400micrograms

Given to prevent neural tube defects

Question 15

What is the higher dose of folic acid and when is it indicated

Answer 15

5mg

Diabetes
Epilepsy
BMI >30
Sickle cell disease
Coeliac disease
Previous pregnancy with NTD

Question 16

When is aspirin given in pregnancy

Answer 16

For those at high risk of pre-eclampsia (aged >40, BMI >35, HTN, previous pre-eclampsia)
Daily aspirin from 12 weeks to birth

Question 17

When is vitamin D supplementation recommended in pregnancy

Answer 17

Generally recommended to all, particularly darker-skin patients
10 micrograms per day

Question 18

What dietary advice should be given to pregnant women at booking visit

Answer 18

Eat a variety of foods, including fruit and veg, carbohydrates, proteins, fibre-rich foods, dairy foods
Eat folic acid-rich foods: green leady vegetables, fortified breakfast cereals
Vit D: oily fish, eggs, fortified cereals

Avoid:
* Unpasteurised diary products or mould-ripened cheeses (camembert, brie)
* Raw/uncooked meats
* Liver and liver products (vitamin A)
* All types of pate
* Swordfish/raw shellfish
* Duck/quail eggs

Question 19

What is the effects of smoking during pregnancy

Answer 19

Miscarriage
Ectopic pregnancy
Stillbirth
Congenital abnormalities
Growth restriction
Abruption
Preterm birth <37 weeks
SIDS

Question 20

At what point do you advise pregnant women to not sleep on their back

Answer 20

28 weeks: sleep in left lateral position
Consider using a pillow to maintain position

Question 21

How is gestational age determined

Answer 21

<14 weeks: crown-rump length (CRL)
>14 weeks: abdominal circumference

Question 22

How is screening for Down’s, Edward’s and Patau’s syndrome carried out

Answer 22

At 11-14 weeks: nuchal translucency + combined test

Down’s syndrome: ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
Edward’s: ↑ HCG (lower than Down’s), ↓ PAPP-A, thickened nuchal translucency
Patau’s: ↑ HCG (lower than Down’s), ↓ PAPP-A, thickened nuchal translucency

Question 23

When is the quadruple test offered

Answer 23

Instead of the combined test OR the woman books later in pregnancy
offered between 15-20 weeks

Question 24

What is the quadruple test

Answer 24

Alpha-fetoprotein
Unconjugated oestriol
Human chorionic gonadotrophin
Inhibin A

Question 25

What are the possible outcomes from a combined/quadruple test

Answer 25

‘lower chance’: 1 in 150 chance or more e.g. 1 in 300
‘higher chance’: 1 in 150 chance or less e.g. 1 in 100

Question 26

What are the next steps after there is a ‘higher chance’ result from either combined or quadruple test

Answer 26

Either non-invasive prenatal screening (NIPT) or diagnostic (amniocentesis, chorionic villus sampling/CVS)

Question 27

What is noninvasive prenatal screening

Answer 27

analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA)
cffDNA derives from placental cells and is usually identical to fetal DNA
sensitivity and specificity are very high for trisomy 21 (>99%) and similarly high for other chromosomal abnormalities
private companies (e.g. Harmony) offer NIPT screening from 10 weeks gestation

Question 28

How is gestational diabetes screened for

Answer 28

Oral glucose tolerance test at 24-28 weeks if there are any risk factors:
- BMI >30
- Prvious macrosomic baby
- GDM in previous pregnancy (should have OGTT earlier)
- FHx diabetes
- South Asian, Black, African-Caribbean, Middle Eastern origin
Urine results of:
- Glycosuria of 2+ or above on 1 occasion.
- Glycosuria of 1+ or above on 2 or more occasions.

Question 29

What vaccinations are offered during antenatal care

Answer 29

Whooping cough: 16-32 weeks
Influenza vaccine: at any gestation
Covid-19 vaccine

Question 30

What occurs at the 28 week appointment

Answer 30

Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women