Antenatal care Flashcards
Reena, a 25-year-old woman who moved to the UK from India 10 years ago, presented to her GP accompanied by her mother. She was 28 weeks into her first pregnancy. She had suffered mild hyperemesis up until week 14 but otherwise had had an uneventful pregnancy.
She complained of a mild fever and generally feeling unwell. She also had a rash that had appeared the evening before.
The patient looked well, her temperature was 37.6ºC, oxygen saturation 98% in air, heart rate 89 beats per minute, respiratory rate of 19 breaths per minute and blood pressure 110/72 mmHg. On examination, she had a macular rash with some early papular and vesicular lesions.
On further questioning, she recalled visiting a children’s birthday party with her niece about two weeks ago and spent the afternoon there. One of the parents had phoned her five days later to state that her child had developed chickenpox.
Reena’s mother confirmed that Reena had not had chickenpox as a child.
What is the next step in the management of chickenpox in this case?
A. Arrange for practice nurse to administer chickenpox vaccination
B. Organise admission for varicella zoster immunoglobulin (VZIG)
C. Organise an assay for varicella zoster (VZ) antibodies
D. Prescribe oral aciclovir
E. Reassure and send the patient home
D. Prescribe oral aciclovir
Pregnant women ≥ 20 weeks who develop chickenpox are generally treated with oral aciclovir if they present within 24 hours of the rash
The RCOG state ‘oral aciclovir should be prescribed for pregnant women with chickenpox if they present within 24 hours of the onset of the rash and if they are 20+0 weeks of gestation or beyond. Use of aciclovir before 20+0 weeks should also be considered.’ (Green-top guideline No. 13). As she has been infected before 28 weeks gestation, she should also be referred to a fetal medicine specialist 5 weeks after infection.
The chickenpox vaccination can not be given in pregnancy.
VZIG has no therapeutic benefit once chickenpox has developed and should therefore not be used in pregnant women who have developed a chickenpox rash.
A 32-year-old woman has a telephone consultation with her GP. She is 23 weeks pregnant, with no complications so far. She is now concerned, as last week she met with her sister and nephew. Several days after, her sister informed her that the child has since developed a rash, which she suspects to be chickenpox. The patient herself was unsure of whether or not she had chickenpox as a child, but she said her lack of symptoms reassured her. However, in the past 12 hours, she has developed a rash and is now worried for the health of her baby. Aside from the rash, she feels well in herself.
What would be the most appropriate management at this stage?
A. Intravenous aciclovir
B. Oral aciclovir
C. Urgent blood test to determine varicella antibody status
D. Varicella-zoster immunoglobulin
E. Varicella-zoster immunoglobulin and oral aciclovir
B. Oral aciclovir
Pregnant women ≥ 20 weeks who develop chickenpox are generally treated with oral aciclovir if they present within 24 hours of the rash
A Cardiotocogram (CTG) is performed on a 34-year-old female at 40 weeks gestation who has attended labour ward in spontaneous labour. The CTG shows a fetal heart rate of 150bpm. There is good variability in fetal heart rate, and it is a low risk pregnancy. The midwife rings you concerned that there are late decelerations present on the CTG trace. Which is the most appropriate next step in management?
A. Fetal blood sampling
B. Continue close monitoring with CTG
C. Prepare patient for urgent caesarean delivery
D. It is likely that the fetus is asleep, so re-check CTG in 30 minutes
E. Induction of labour
A. Fetal blood sampling
Late decelerations on CTG are a pathological finding and urgent fetal blood sampling is needed to assess for fetal hypoxia and acidosis. A pH of >7.2 in labour is considered normal. Urgent delivery should be considered if there is fetal acidosis. Although the normal fetal heart rate and variability is reassuring, the late decelerations are a concerning feature which needs to be quickly investigated and managed.
Which one of the following statements regarding hepatitis B and pregnancy is correct?
A. Without intervention the vertical transmission rate is around 3%
B. Only at risk groups should be screened for hepatitis B during pregnancy
C. Around 30% of mothers with hepatitis B develop pre-eclampsia
D. It is safe for a mother with hepatitis B to breastfeed her newborn
E. All pregnant women with hepatitis B should take oral ribavirin in the last trimester of pregnancy
D. It is safe for a mother with hepatitis B to breastfeed her newborn
Without intervention the vertical transmission rate is around 20%, which increases to 90% if the woman is positive for HBeAg.
Basics
all pregnant women are offered screening for hepatitis B
babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin
studies are currently evaluating the role of oral antiviral treatment (e.g. Lamivudine) in the latter part of pregnancy
there is little evidence to suggest caesarean section reduces vertical transmission rates
hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)
A 27-year-old patient presents to the Emergency Department with fresh red vaginal bleeding and lower abdominal pain.
The patient is at 34 weeks gestation and gravida 2, para 1. She is rhesus positive and a current smoker. Access to her current maternity notes is unavailable. She tells you she has pre-eclampsia for which she takes labetalol.
Maternal observations are normal and there are no concerns with foetal movements. A cardiotocograph (CTG) demonstrates that the foetal heart rate is 140 beats/min, variability is 15 beats/min, accelerations are present and there are no decelerations noted.
On examination, the uterus is hard and tender to palpation. The doctor suspects that the foetus may be in a transverse lie. The patient’s pad is partially soaked but there is no active bleeding noted on a quick inspection.
What would the most appropriate first course of action be in this scenario?
A. Administer anti-D antibodies and perform a Kleihauer test
B. Administer corticosteroids and arrange admission to the ward
C. Arrange induction of labour
D. Emergency caesarean section
E. Perform a sterile speculum examination
B. Administer corticosteroids and arrange admission to the ward
Management of placental abruption when the fetus is alive, <36 weeks and not showing signs of distress is to admit and administer steroids
This patient has presented with painful bleeding and a hard, tender uterus - this is suggestive of placental abruption. Risk factors for placental abruption identified in this case are being a current smoker, pre-eclampsia and transverse lie. Management of placental abruption depends on gestation, foetal condition and maternal condition. In this scenario, the patient is haemodynamically stable, is at 34 weeks gestation and there are no signs of foetal distress. The most appropriate plan, therefore, is to administer steroids and admit to the ward for observation.
Not D. Emergency caesarean section would be appropriate if foetal distress was noted. However, as there are no signs of foetal distress and the mother is haemodynamically stable, emergency operative delivery is not indicated.
A 34-year-old male with rheumatoid arthritis attends his GP practice as he wants counselling regarding starting a family. His wife does not have any medical conditions and has been taking folic acid for the past four weeks. They are keen to start trying for a baby as soon as possible. He has no other medical history and his regular medications are methotrexate, paracetamol, ibuprofen, and lansoprazole. He is aware that his sister had to stop some of her medications for rheumatoid arthritis prior to conceiving and wants to know if he needs to do the same.
What is the appropriate management advice for this patient?
A. No need to stop methotrexate as he is male
B. No need to stop methotrexate in males or females attempting conception
C. Stop methotrexate at least one month before conception
D. Stop methotrexate at least six months before conception
E. Stop methotrexate at least three months before conception
D. Stop methotrexate at least six months before conception
Methotrexate: must be stopped at least 6 months before conception in both men and women
This question assesses the knowledge regarding discontinuation of the dihydrofolate reductase inhibitor methotrexate prior to conception. There is a risk that methotrexate can damage the sperm in males and can cause spontaneous early abortion in females. In order to allow full ‘wash-out’ of the drug and to improve sperm quality, it is advised that methotrexate is stopped at least six months prior to conception.
Methotrexate should be stopped in both male and female patients prior to attempting conception to ensure that both gametes have minimised risk of DNA changes.
Polymorphic Eruption of Pregnancy vs Pemphigoid Gestationis
Polymorphic Eruption of Pregnancy (aka pruritic and urticarial papules and plaques of pregnancy PUPP , spares umbilicus, usually 3rd trimester): It is characterised by:
- Urticarial papules (raised itchy lumps)
- Wheals (raised itchy areas of skin)
- Plaques (larger inflamed areas of skin)
vs Pemphigoid gestationis is a rare autoimmune skin condition that occurs in pregnancy (around umbilicus, blisters)
A pregnant woman at 32 weeks is seen in the obstetric clinic due to reduced symphysial fundal height.
The patient was recently infected with rubella. She has a history of type 2 diabetes and pre-eclampsia diagnosed earlier in the pregnancy. She missed her anomaly scan at 12 weeks, but the anatomy scan at 20 weeks showed normal foetal growth.
An ultrasound scan of the pregnant abdomen shows the following:
Head circumference - 4th percentile
Abdominal circumference - 1st percentile
Estimated foetal weight - 2nd percentile
Which of the following factors is most likely contributing to the intrauterine growth restriction (IUGR)?
A. Family history of small-for-gestational-age babies
B. Poorly controlled maternal type 2 diabetes
C. Maternal rubella infection
D. Foetal chromosomal abnormality
E. Maternal pre-eclampsia
E. Maternal pre-eclampsia
Due to the later onset of growth restriction, and the head circumference being reduced less than the abdominal circumference, this can be classed as asymmetrical IUGR. This is most commonly caused by maternal conditions such as hypertension, pre-eclampsia or pre-existing renal or cardiac disease. This can also be caused by maternal substance abuse.
Not: C: maternal rubella infection:
Due to the later onset of growth restriction, and the head circumference being reduced less than the abdominal circumference, this can be classed as asymmetrical IUGR. Maternal rubella infection would be more likely to cause symmetrical IUGR in which the head circumference and abdominal circumference are equally reduced. This usually presents in the first trimester.
Not C: Poorly controlled T2DM
Poorly controlled maternal diabetes is more likely to cause a baby that is large for gestational age, rather than small. Due to the later onset of growth restriction, and the head circumference being reduced less than the abdominal circumference, this can be classed as asymmetrical IUGR. This is most commonly caused by maternal conditions such as hypertension, pre-eclampsia or pre-existing renal or cardiac disease. This can also be caused by maternal substance abuse.
Not A: FH of small for gestational age babies;
Due to the later onset of growth restriction, and the head circumference being reduced less than the abdominal circumference, this can be classed as asymmetrical IUGR. ‘Normally small’ babies would be more likely to have symmetrical IUGR in which the head circumference and abdominal circumference are equally reduced. This usually presents in the first trimester.
IUGR classifications
A 23 year old woman is called by her midwife following her booking appointment. The midwife tells her she has bacteria in her urine following routine sampling at booking.
The woman is well and does not have any urinary symptoms.
Which of the following is true regarding the management of asymptomatic bacteriuria in pregnancy?
A. Blood cultures should be performed to exclude systemic infection
B. Renal ultrasound scan should be performed to exclude hydronephrosis, congenital abnormality and calculi
C. Antibiotic therapy is not recommended for asymptomatic bacteriuria
D. Oral antibiotics are recommended in asymptomatic bacteriuria in pregnancy
E. Repeat urine culture should be performed to confirm bacteriuria
D. Oral antibiotics are recommended in asymptomatic bacteriuria in pregnancy
Oral antibiotics (e.g. nitrofurantoin or cefalexin)are recommended in cases of asymptomatic bacteriuria to prevent progression to pyelonephritis and increased risk of preterm labour.
Women should have a routine urinalysis at booking to screen for asymptomatic bacteriuria. If this is positive for nitrites or leukocytes, it should be sent for culture
what should be done if mother has ROM >24 hours
IOL
- If the woman does not choose to go through an induction, she should be monitored for her temperature, foetal movements, foetal heart rate and vaginal discharge and return if there are any abnormalities.
complications of Pre-labour ROM:
- The rupture of the amniotic membranes can allow bacteria into the uterus. This can lead to chorioamnionitis due to ascending infection.
- Increased risk of preterm birth and the associated complications (e.g. respiratory distress syndrome, necrotising enterocolitis, foetal death).
- Low levels of amniotic fluid due to PPROM can lead to developmental problems such as pulmonary hypoplasia, facial and limb deformities (due to compression in the uterus) and cord prolapse.
bcause of trace glycosuria in pregnancy:
common finding during pregnancy as there is an increased glomerular filtration rate and a reduction in tubular reabsorption of filtered glucose
what are some absolute contraindications to ECV:
-Caesarean section is already indicated for other reason
-Antepartum haemorrhage has occurred in the last 7 days
-Non-reassuring cardiotocograph
-Major uterine abnormality
-Placental abruption or placenta praevia
-Membranes have ruptured
-Multiple pregnancy (but may be considered for delivery of the second twin)
what are some relative contraindications to ECV:
-Intrauterine growth restriction with abnormal umbilical artery Doppler index
-Pre-eclampsia
-Maternal obesity
-Oligohydramnios
-Major foetal abnormalities
-Uterine scarring from previous caesarean section or myomectomy
-Unstable foetal lie
when is ECV offered (primiparous vs multiparous):
Is offered at 36 weeks for breech presentation (provided there is no absolute contraindication) for primiparous women.
For multiparous women it is offered at 37 weeks.
How is ECV performed?
ECV is a manual procedure where an experienced physician attempts to turn the baby using their hands on the abdomen. It generally has around a 50% success rate. ECV is usually carried out under ultrasound guidance. The mother is given analgesia, tocolytics and anti-D immunoglobulin (if required) during the procedure. If ECV is unsuccessful and the baby is still breech presentation at term, the mother may choose to deliver vaginally or via caesarean section.
-Overall, vaginal birth is safer for the mother, and caesarean section is safer for the baby.
-There is about a 40% chance of requiring an emergency caesarean section when vaginal birth is attempted.
-When the first baby in a twin pregnancy is breech, caesarean section is required.
There is a higher risk of complications with breech vaginal deliveries compared to cephalic births. There is also a greater risk of needing instrumentation or an emergency caesarean section.
what is acute fatty liver of pregnancy/pathophysiology:
Acute fatty liver of pregnancy is a rare condition that occurs in the third trimester of pregnancy. There is a rapid accumulation of fat within the liver cells (hepatocytes), causing acute hepatitis. There is a high risk of liver failure and mortality, for both the mother and fetus.
Acute fatty liver of pregnancy results from impaired processing of fatty acids in the placenta. This is the result of a genetic condition in the fetus that impairs fatty acid metabolism. The most common cause is long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus, which is an autosomal recessive condition. This mode of inheritance means the mother will also have one defective copy of the gene.
Th LCHAD enzyme is important in fatty acid oxidation, breaking down fatty acids to be used as fuel. The fetus and placenta are unable to break down fatty acids. These fatty acids enter the maternal circulation, and accumulate in the liver. The mother’s defective copy of the gene may also contribute to the accumulation of fatty acids. The accumulation of fatty acids in the mother’s liver leads to inflammation and liver failure.
presentation of Acute fatty liver of pregnancy:
The presentation is with vague symptoms associated with hepatitis :
General malaise and fatigue
Nausea and vomiting
Jaundice
Abdominal pain
Anorexia (lack of appetite)
Ascites
Bloods in acute fatty liver of pregnancy:
Liver function tests will show elevated liver enzymes (ALT and AST).
Other bloods may be deranged, with:
Raised bilirubin
Raised WBC count
Deranged clotting (raised prothrombin time and INR)
Low platelets
TOM TIP: In your exams, elevated liver enzymes and low platelets should make you think of HELLP syndrome rather than acute fatty liver of pregnancy. HELLP syndrome is much more common, but keep acute fatty liver of pregnancy in mind as a differential.
Management of Acute fatty liver of pregnancy:
Before delivery, maternal stabilisation should be achieved with correction of hypoglycaemia, coagulopathy and hypertension.
Maternal intensive supportive care in a multidisciplinary team is required following the delivery.
Six-hourly LFTs, renal function and haematological parameters should be performed within the first 24–48 hours after delivery.
In non-randomised trials, plasma exchange has been associated with hastening hepatic improvement and decreasing intensive care stay, but not with improved maternal mortality.
Acute fatty liver of pregnancy is an obstetric emergency and requires prompt admission and delivery of the baby. Most patients will recover after delivery.
Management also involves treatment of acute liver failure if it occurs, including consideration of liver transplant.
AFLP vs HELLP syndrome:
Women with AFLP are more likely to have synthetic liver dysfunction with coagulopathy, hypofibrinogenaemia, lower cholesterol levels, higher bilirubin levels, hypoglycaemia, hepatic encephalopathy, hyperammonaemia, DIC and more severe AKI.
When is CVS performed?
between 11-13 weeks gestation
How is CVS analysed?
Both transcervical and transabdominal routes. It takes a sample from the early placenta (chorion).
Cells are cultured for karyotype analysis.
CVS is the procedure of choice for molecular genetic tests since DNA can be extracted directly from trophoblastic cells (biochemical assays can also be performed on these trophoblastic cells).
Risk of miscarriage: 1.5-2% (double risk of amniocentesis)
How is amniocentesis analysed?
passing needle under LA & USS guidance to take amniotic fluid around foetus (foetal urine: The fetus’s pee makes up most of the amniotic fluid after about 15-20 weeks of pregnancy).
This is the standard test to culture foetal amniocytes & perform karyotype analysis eg for Down’s syndrome.
DNA can be extracted from cultured amniocytes for molecular genetic testing. Biochemical tests eg enzyme deficiency can also be performed on foetal amniocytes
Risk of miscarriage: 1%
when is amniocentesis performed?
> 15 weeks gestation
motivational interview stages (eg for smoking cessation during pregnancy:
The four steps of the MI process are 1. engage (establish rapport & see if she wants to discuss behavioural change)
2. focus
3. evoke (eg use numerical scale to ask how important it is for her to stop smoking)
4. plan.
3As method
fundus of uterus & weeks
At about 12 weeks in pregnancy, your fundus is in almost the same spot as your pubic bone. By the time you reach 20 weeks, your fundus is at your belly button.
tests for aneuploidies (mnemonic)
down’s tests summary
what are the different types of breech presentation:
- Complete breech, where the legs are fully flexed at the hips and knees
- Incomplete breech, with one leg flexed at the hip and extended at the knee
- Extended breech, also known as frank breech, with both legs flexed at the hip and extended at the knee
- Footling breech, with a foot is presenting through the cervix with the leg extended
