Antenatal Care Flashcards
Nutritional supplements
folic acid
vitamin D
iron supplementation should be offered routinely
false
Describe reccomendations for folic acid
folic acid 400mcg should be given from before conception until 12 weeks to reduce the risk of neural tube defects. Certain women may require higher doses (women who take antiepileptics)
indications for more folic acid
MORE folic acid (5mg)
M etabolic diseases (diabetes, coeliac)
O besity (BMI >30)
R elative (family Hx of NTD)
E pilepsy (taking anticonvulsants)
Describe reccomendations regarding vitamin A
vitamin A supplementation (intake above 700 micrograms) might be teratogenic. Liver is high in vitamin A so consumption should be avoided
Describe reccomendations for vitamin D
‘women should be advised to take a vitamin D supplement (10 micrograms of vitamin D per day), as found in the Healthy Start multivitamin supplement. Women who are not eligible for the Healthy Start benefit should be advised where they can buy the supplement’. Particular care should be taken with higher risk women (i.e. those with darker skin or who cover their skin for cultural reasons)
Describe reccomendations for alcohol
the government now recommend pregnant women should not drink. The wording of the official advice is ‘If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk.’
Describe reccomendations for smoking
risks of smoking including low birthweight and preterm birth should be discussed
NRT may be used but women must have stopped smoking and risks/benefits need to be discussed
neither varenicline nor bupropion should be offered to pregnant or breastfeeding women
Describe reccomendations for food acquired infections
listeriosis: avoid unpasteurised milk, ripened soft cheeses (Camembert, Brie, blue-veined cheeses), pate or undercooked meat
salmonella: avoid raw or partially cooked eggs and meat, especially poultry
Describe reccomendations for work
inform women of their maternity rights and benefits
for the majority of women it is safe to continue working. Women should be asked whether they work. The Health and Safety Executive should be consulted if there are any concerns about possible occupational hazards during pregnancy
Describe reccomendations for air travel
women > 37 weeks with singleton pregnancy and no additional risk factors should avoid air travel
women with uncomplicated, multiple pregnancies should avoid travel by air once >32 weeks
associated with increased risk of venous thromboembolism
wearing correctly fitted compression stockings is effective at reducing the risk
Prescribed medicines
avoid unless the benefits outweigh the risks
true
Over-the-counter medicines
should be used as little as possible during pregnancy
true
Pregnant women should be informed that few complementary therapies have been established as being safe and effective during pregnancy. Women should not assume that such therapies are safe and they should be used as little as possible during pregnancy
true
Exercise in pregnancy
women should be informed that beginning or continuing moderate exercise is not associated with adverse outcomes
certain activities should be avoided e,g, high-impact sports where there is a risk of abdominal trauma and scuba diving
Sexual intercourse
not known to be associated with any adverse outcomes
true
Nausea and vomiting
natural remedies
ginger and acupuncture on the ‘p6’ point (by the wrist) are recommended by NICE
Nausea and vomiting drugs
antihistamines should be used first-line (BNF suggests promethazine as first-line)
All women should be informed at the booking appointment about the importance for their own and their baby’s health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding
true
NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. They recommend:
10 antenatal visits in the first pregnancy if uncomplicated
7 antenatal visits in subsequent pregnancies if uncomplicated
women do not need to be seen by a consultant if the pregnancy is uncomplicated
What is booking visit for?
general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
BP, urine dipstick, check BMI
When is booking visit?
8 - 12 weeks (ideally < 10 weeks)
Booking bloods/urine?
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
hepatitis B, syphilis
HIV test is offered to all women
urine culture to detect asymptomatic bacteriuria
What appointments for first 16 weeks?
8 - 12 weeks (ideally < 10 weeks) Booking visit
10 - 13+6 weeks Early scan to confirm dates, exclude multiple pregnancy
11 - 13+6 weeks Down’s syndrome screening including nuchal scan
16 weeks Information on the anomaly and the blood results.
Routine care: BP and urine dipstick
at 16 weeks if If Hb < 11 g/dl consider
iron
appointments between 18 - 28 weeks
18 - 20+6 weeks: Anomaly scan
25 weeks (only if primip) Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
28 weeks: Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies.
If Hb < 10.5 g/dl consider iron
anti-D prophylaxis to rhesus negative women is given when?
First dose 28 weeks
Second dose 34 weeks
Second screen for anaemia and atypical red cell alloantibodies is when
28 weeks
Describe antenatal care after 28 weeks
31 weeks: (only if primip) Routine care as above
34 weeks: Routine care as above
Second dose of anti-D prophylaxis to rhesus negative women*
Information on labour and birth plan
36 weeks: Routine care as above
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, ‘baby-blues’
38 weeks: Routine care as above
40 weeks: (only if primip) Routine care as above
Discussion about options for prolonged pregnancy
41 weeks: Routine care as above
Discuss labour plans and possibility of induction
Conditions for which screening should NOT be offered
Chlamydia Group B Streptococcus Bacterial vaginosis Fragile X Cytomegalovirus Hepatitis C Toxoplasmosis
Conditions which all pregnant women should be offered screening
Anaemia Bacteriuria Blood group, Rhesus status and anti-red cell antibodies Down's syndrome Fetal anomalies Hepatitis B HIV Neural tube defects Risk factors for pre-eclampsia Syphilis
Conditions which all pregnant women with relevant hx should be offered screening
Placenta praevia Psychiatric illness Sickle cell disease Tay-Sachs disease Thalassaemia
good source of folic acid?
Green, leafy vegetables
Folic acid is converted to
tetrahydrofolate (THF).
THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA
Causes of folic acid deficiency:
phenytoin
methotrexate
pregnancy
alcohol excess
Consequences of folic acid deficiency:
macrocytic, megaloblastic anaemia
neural tube defects
Prevention of neural tube defects (NTD) during pregnancy
all women should take 400mcg of folic acid until the 12th week of pregnancy
women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
women are considered higher risk of NTD if any of the following apply:
either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
The symphysis-fundal height (SFH) is
measured from the top of the pubic bone to the top of the uterus in centimetres
It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm
A nuchal scan is performed at
11-13 weeks.
Causes of an increased nuchal translucency include:
Down’s syndrome
congenital heart defects
abdominal wall defects
Causes of hyperechogenic bowel:
cystic fibrosis
Down’s syndrome
cytomegalovirus infection
NICE issued guidelines on antenatal care in March 2008 including advice on screening for Down’s syndrome
the combined test is now standard
if women book later in pregnancy either the triple or quadruple test should be offered between 15 - 20 weeks
What does the combined test for downs consist of?
nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)
Down’s syndrome is suggested by what results on combined testing
↑ HCG, ↓ PAPP-A, thickened nuchal translucency
how do other syndromes compare to combined test results for downs
trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower
if women book later in pregnancy either the triple or quadruple test should be offered between 15 - 20 weeks
triple test consists of?
alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin
if women book later in pregnancy either the triple or quadruple test should be offered between 15 - 20 weeks
quadruple test consists of?
alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin-A
pathophysiology rhesus negative pregnancies?
along with the ABO system the Rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus system
if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur
this causes anti-D IgG antibodies to form in mother
in later pregnancies these can cross placenta and cause haemolysis in fetus
around ?% of mothers are rhesus negative (Rh -ve)
15%
Rhesus reaction never occurs in first pregnancy
false
can also occur in the first pregnancy due to leaks
test for D antibodies in all Rh -ve mothers happens when
at booking
NICE (2008) advise giving what to non-sensitised Rh -ve mothers at 28 and 34 weeks
anti d
in terms of anti D the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used ‘depending on local factors’
true
anti-D is prophylaxis - once sensitization has occurred it is irreversible
true
(rhesus -ve pregnancy) if event is in 2nd/3rd trimester what should you do?
give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present
Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:
delivery of a Rh +ve infant, whether live or stillborn
any termination of pregnancy
miscarriage if gestation is > 12 weeks
ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
abdominal trauma
all babies born to Rh -ve mother should have what tests at delivery?
cord blood taken at delivery for FBC, blood group & direct Coombs test
What is coombs test
Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
What is Kleihauer test
Kleihauer test: add acid to maternal blood, fetal cells are resistant
Fetus affected by rhesus disease will present with
oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
jaundice, anaemia, hepatosplenomegaly
heart failure
kernicterus
Fetus affected by rhesus disease mx
treatment: transfusions, UV phototherapy
