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Finals > Antenatal care > Flashcards

Antenatal care Flashcards

1
Q

What is pre-eclampsia

A

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

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2
Q

What is the triad of pre-eclampsia

A

HTN
Proteinuria
Oedema

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3
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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4
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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5
Q

what are the moderate risk factors for pre-eclampsia ?

A
  • Older than 40
  • BMI > 35
  • More than 10 years since previous pregnancy
  • Multiple pregnancy
  • First pregnancy
  • Family history of pre-eclampsia
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6
Q

How is pre-eclampsia diagnosed ?

A
  • Systolic >149 or diastolic >90. PLUS any of :
  • Proteinuria
  • Organ dysfunction
  • Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
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7
Q

How is proteinuria quantified in pre-eclampsia ?

A
  • Urine protein:creatinine ratio (above 30mg/mmol is significant)
  • Urine albumin:creatinine ratio (above 8mg/mmol is significant)
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8
Q

What is the first line management of pre eclampsia ?

A

Labetolol

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9
Q

Following delivery, how is pre eclampsia managed

A
  1. Enalapril (first-line)
  2. Nifedipine or amlodipine (first-line in black African or Caribbean patients)
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10
Q

What is eclampsia and how is it managed ?

A
  • Seizures associated with pre-eclampsia
  • Iv magnesium sulphate
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11
Q

what is HELLP syndrome ?

A
  • Haemolysis
  • Elevated Liver enzymes
  • Low Platetes

= N&V, RUQ pain and lethargy
»» Deliver baby

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12
Q

Define pregnancy-induced hypertension

A

hypertension occurring after 20 wks gestation, without proteinuria

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13
Q

When is an OGTT done in pregnancy ?

A
  • If pt has RF
  • Features suggesting gestational DM present : large for dates fetus, polyhydramnios, glucose on urine dip
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14
Q

what are the cute of values for diagnosing gestational DM ?

A

5-6-7-8

-> Fasting : <5.6mmol/l
-> 2 hrs : <7/8mmol/l

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15
Q

how often do women diagosed with gestational DM have an USS?

A
  • 4 wkly from 28-36 wks gestation to monitor fetal growth and amniotic fluid volume
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16
Q

How is gestational DM managed if fasting glucose <7mmol/l ?

A
  • Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
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17
Q

How is gestational DM managed if fasting glucose >7mmol/l?

A
  • Fasting glucose above 7 mmol/l: start insulin ± metformin
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18
Q

How is gestational DM managed if fasting glucose >6mmol/l plus macrosomia or other complications

A

Insulin +/- metformin

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19
Q

What are the target blood sugar levels in gestational DM ?

A
  • Fasting: 5.3 mmol/l
  • 1 hour post-meal: 7.8 mmol/l
  • 2 hours post-meal: 6.4 mmol/l
  • Avoiding levels of 4 mmol/l or below
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20
Q

How much folic acid should women with pre existing DM take ?

A

5mg from preconception till 12 wks gestation

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21
Q

How are women with pre existing Type 2 diabetes managed ?

A
  • Metformin and insulin
  • Other oral meds are stopped
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22
Q

what should be performed shortly after booking and at 28 wks gestation in women with pre existing DM?

A
  • Retinopathy screening
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23
Q

What planned delivery is advised in women with pre existing DM?

A
  • Between 37 and 38+6 wks
  • Gestational DM can give birth up to 40+6 wks
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24
Q

Give 5 complications to the baby of mothers with DM

A
  • Neonatal hypoglycaemia
  • Polycythaemia (raised haemoglobin)
  • Jaundice (raised bilirubin)
  • Congenital heart disease
  • Cardiomyopathy
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25
Q

What is the target blood sugar level in neonates ?

A
  • Maintain blood sugar above 2 mmol/l,
  • If it falls below this -> IV dextrose of nasogastric feeding.
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26
Q

What is the most significant complication of gestational DM?

A
  • Large for dates feus and macrosomia
  • Risk of shoulder dystocia
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27
Q
  • Third trimester -> itching of the palms of the hands and soles of the feet
A

Obstetric cholestasis

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28
Q

What are the other symptoms of obstetric cholestasis ?

A

Fatigue
Dark urine
Pale, greasy stools
Jaundice

NO RASH

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29
Q

what is obstetric cholestasis ?

A
  • Reduction in the outflow of bile acids from the liver -> build up in the blood causing pruritis
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29
Q

What is seen on LFT’s in obstetric cholestasis ?

A
  • Raised ALT, AST and GGT
  • Raised bile acids
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30
Q

What is the primary treatment of obstetric cholestasis ?

A
  • Ursodeoxycholic acid
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31
Q

How can the itching and sleeping symptoms be managed in obstetric cholestasis ?

A
  • Itching : emollients
  • Sleeping : antihistamines (chlorphenamine)
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32
Q

Patient presents with painless vaginal bleeding following ROM -> fetal bradycardia

A

Vasa Praevia

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33
Q

If detected on antenatal USS, how is vasa praevia managed ?

A
  • Corticosteroids from 32 wks
  • Elective planned c section for 34-36 wks
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34
Q

Define low lying placenta and placenta praevia

A
  • Low-lying placenta : placenta is within 20mm of the internal cervical os
  • Placenta praevia : when the placenta is over the internal cervical os
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35
Q

Define the 4 grades of placenta praevia

A
  • Minor praevia / grade I : placenta is in the lower uterus but not reaching the internal cervical os
  • Marginal praevia / grade II : the placenta is reaching, but not covering, the internal cervical os
  • Partial praevia / grade III : placenta is partially covering the internal cervical os
  • Complete praevia / grade IV : placenta is completely covering the internal cervical os
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36
Q

If not diagnosed on antenatal USS, how will placenta praevia present ?

A
  • Shock in proportion to visible loss
  • NO pain
  • Uterus not tender*
  • Lie and presentation may be abnormal
  • Fetal heart usually normal
  • Coagulation problems rare
  • Small bleeds before large
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37
Q

If detected on antenatal USS, how is placenta praevia managed ?

A
  • Corticosteroids between 34 and 35+6 wks
  • Planned delivery between 36 and 37 wks
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38
Q

How does placental abruption present ?

A
  • Sudden onset severe abdominal pain that is CONTINUOUS
  • Vaginal bleeding
  • Shock out of keeping with visible loss
  • Fetal distress
  • Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage
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39
Q

How is the severity of an antepartum haemorrhage defined ?

A
  • Minor haemorrhage: <50ml blood loss
  • Major haemorrhage: 50 – 1000ml blood loss
  • Massive haemorrhage: >1000 ml blood loss, or signs of shock
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40
Q

What test is used to determine how much anti-D prophylaxis is required following antipartum haemorrhage ?

A

Kleihauer test

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41
Q

what are the management options of placenta accreta ?

A

During c section :

  • Hysterectomy with the placenta remaining in the uterus (recommended)
  • Uterus preserving surgery, with resection of part of the myometrium along with the placenta
  • Expectant management, leaving the placenta in place to be reabsorbed over time
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42
Q

Explain the trimesters of pregnancy

A
  • First trimester : start of pregnancy - 12 wks gestation.
  • Second trimester : 13 weeks - 26 weeks gestation.
  • Third trimester : 27 weeks gestation until birth.
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43
Q

when is the booking clinic done in pregnancy ?

A

BEfore 10 wks

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44
Q

When is the dating scan in pregnancy and what is used to calculate gestational age ?

A
  • Between 10 and 13+6
  • Crown rump length
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45
Q

when is the anomaly scan done in pregnancy ?

A
  • Between 18 and 20 + 6 weeks
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46
Q

what 2 vaccines are offered during pregnancy ?

A
  • Whooping cough (pertussis) from 16 weeks gestation
  • Influenza (flu) when available in autumn or winter
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47
Q

when should women take folic acid and vitamin D in pregnancy ?

A
  • Folic acid (400mcg) from before pregnancy to 12 wks
  • Vitamin D (10 mcg or 400 IU daily)
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48
Q

What are the features of fetal alcohol syndrome ?

A
  • Microcephaly
  • Thin upper lip
  • Smooth flat philtrum
  • Short palpebral fissure
  • Learning disability
  • Behavioural difficulties
  • Hearing and vision problems
  • Cerebral palsy
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49
Q

what does smoking in pregnancy increase the risk of ?

A
  • FGR
  • Miscarriage
  • Stillbirth
  • Preterm labour and delivery
  • Placental abruption
  • Pre-eclampsia
  • Cleft lip or palate
  • Sudden infant death syndrome (SIDS)
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50
Q

when is flying ok until in pregnancy ?

A
  • 37 weeks in a single pregnancy
  • 32 weeks in a twin pregnancy
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51
Q

what bloods are done at the booking clinic ?

A
  • Blood group, antibodies and rhesus D status
  • Full blood count for anaemia
  • Screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
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52
Q

what screening are women offered at the booking clinic ?

A
  • HIV
  • Hepatitis B
  • Syphilis
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53
Q

when is the combined screening test done and what does it involve ?

A
  • Between 11 and 14 wks
  • Combined results from USS and maternal bloods
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54
Q

What results of the combined test suggest what risk of downs syndrome ?

A
  • USS -> Nuchal translucency of >6mm.
  • Bloods : higher beta-HCG, lower pregnancy associated plasma protein-A (PAPPA)
55
Q

when is the triple test done and what does it involve ?

A
  • Between 14 and 20 wks
  • Beta-HCG -> higher = greater risk
  • AFP ->lower = greater risk
  • Serum oestriol -> lower = greater risk
56
Q

when is the quadruple screening test done and what does it involve ?

A
  • Between 14 and 20 wks
  • Higher b-HCG
  • Lower AFP
  • Lower serum oestriol
  • Higher Inhibin A
57
Q

Based on the screening tests for Downs syndrome, when is antenatal testing done and what is offered ?

A
  • If the risk is greater than 1 in 150
  • Amniocentesis or chorionic villus sampling
58
Q

What is chorionic villous sampling ?

A
  • USS guided biopsy of placental tissue
  • Done before 15 wks
59
Q

When is amniocentesis done ?

A
  • USS guided aspiration of amniotic fluid
  • Later in pregnancy
60
Q

what medication needs to be increased in pregnancy ?

A

Levothyroxine - by at least 25-50

61
Q

what HTN medications can cause congenital abnormalities

A
  • ACEI
  • ARBs
  • Thiazide and thiazide-like diuretics
62
Q

what should women with epilepsy take from before conception

A

Folic acid 5mg daily

63
Q

What anti-epileptic medications are deemed safe in pregnancy

A
  • Levetiracetam, lamotrigine and carbamazepine
64
Q

What anti-epileptic drugs should not be taken in pregnancy ?

A
  • SV
  • Phenytoin
65
Q

what is the first line choice of medication for RA in pregnancy ?

A

Hydroxychloroquine

66
Q

what painkiller is avoided in pregnancy and why

A
  • NSAIDs
  • Block prostoglandins
  • Especially in the 3rd trimester as can cause premature closure of ductus arteriosus
67
Q

why are BB avoided in pregnancy

A
  • Fetal growth restriction
  • Hypoglycaemia in the neonate
  • Bradycardia in the neonate
68
Q

what can the use of ACEI or ARBs cause in pregnancy ?

A
  • Oligohydramnios
  • Miscarriage or fetal death
  • Hypocalvaria (incomplete formation of the skull bones)
  • Renal failure in the neonate
  • Hypotension in the neonate
69
Q

what can the use of opiates in pregnancy cause nd how does in present ?

A
  • Neonatal abstinence syndrome
  • Irritability, tachycardia, high fever and poor feeding 3-72 hrs after birth
70
Q

what VTE prophylaxis is avoided in pregnancy

A

warfarin

71
Q

what is the use of lithium in the first trimester associated with

A

Ebstein’s anomaly

72
Q

what are the features of congenital rubella syndrome and when is the biggest risk ?

A
  • Before 10 wks gestation
  • Congenital deafness
  • Congenital cataracts
  • Congenital heart disease (PDA and pulmonary stenosis)
  • Learning disability
73
Q

Give 5 features of congenital varicella syndrome

A
  • Fetal growth restriction
  • Microcephaly, hydrocephalus and learning disability
  • Scars and significant skin changes located in specific dermatomes
  • Limb hypoplasia
  • Cataracts and inflammation in the eye (chorioretinitis)
74
Q

management of chickenpox exposure <=20 wks gestation if not immune

A
  • Varicella-Zoster immunoglobulin (VZIG) up to 10 days after exposure
75
Q

management of chickenpox exposure if >20 wks gestation and not immune

A
  • VZIG or aciclovir 7 to 14 days after exposure
76
Q

How is chickenpox in pregnancy managed ?

A
  • Oral aciclovir IF ≥ 20 weeks and she presents within 24 hours of onset of the rash
77
Q

what can listeria in pregnancy cause and how is it avoided ?

A
  • Miscarriage
  • Fetal death
  • Severe neonatal infection
  • Avoid high risk foods (unpasteurised dairy products, processed meats, blue cheese)
77
Q

Give 6 features of congenital CMV

A

Fetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures

78
Q

How is toxoplasma gondii contracted and what is the triad of congenital toxoplasmosis ?

A
  • Faeces from a cat
  • Intracranial calcification
  • Hydrocephalus
  • Chorioretinitis
79
Q

what causes fifth disease / slapped cheek syndrome

A

Parvovirus B19

80
Q

what can parvovirus B19 in the first or second trimester of pregnancy cause ?

A
  • Miscarriage or fetal death
  • Severe fetal anaemia -> leads to HF (hydrops fetalis)
  • Maternal pre-eclampsia-like syndrome
81
Q

what is mirror syndrome

A
  • Rare complication hydrops fetalis
  • Triad of : hydrops fetalis, placental oedema and oedema in the mother.
82
Q

what do women suspected of parvovirus infection need tests for ?

A
  • IgM to parvovirus, which tests for acute infection within the past four weeks
  • IgG to parvovirus, which tests for long term immunity to the virus after a previous infection
  • Rubella antibodies (as a differential diagnosis)
83
Q

what are the features of congenital Zika syndrome

A
  • Microcephaly
  • Fetal growth restriction
  • Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy
84
Q

when are Anti-D injections routinely given to women who are rhesus negative

A
  • 28 weeks gestation
  • Birth (if the baby’s blood group is found to be rhesus-positive)
85
Q

On what other occasions are Anti-D injections given

A
  • Antepartum haemorrhage
  • Amniocentesis procedures
  • Abdominal trauma

Any time where sensitisation can occur - within 72 hrs of the event

86
Q

What is defined as small for gestational age and what 2 measurements on USS are used to assess fetal size

A
  • Below 10th centile for their gestational age
  1. Estimated fetal weight (EFW)
  2. Fetal abdominal circumference (AC)
87
Q

What is deemed as severe SGA and low birth weight ?

A
  • Severe SGA : below 3rd centile
  • Low birth weight : 2500g
88
Q

what are the 2 categories of SGA ?

A
  1. Constitutionally small -> matches family and growing ok on growth charts.
  2. Fetal growth restriction -> intrauterine growth restriction (IUGR)
89
Q

what are the 2 categories of fetal growth restriction

A
  • Placenta mediated growth restriction
  • Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality
90
Q

Give 8 placenta mediated causes of FGR

A

Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions

91
Q

Give 4 non placenta mediated causes of FGR

A

Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism

92
Q

give 4 signs indicating FGR over the fetus being SGA

A

Reduced amniotic fluid volume
Abnormal Doppler studies
Reduced fetal movements
Abnormal CTGs

93
Q

Give 4 short term complications of FGR

A

Fetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia

94
Q

What are the long term risks of FGR

A
  • Cardiovascular disease, particularly hypertension
  • Type 2 diabetes
  • Obesity
  • Mood and behavioural problems
95
Q

How are low risk women monitored for SGA ?

A
  • Monitoring of symphysis fundal height (SFH) at every antenatal appointment from 24 wks onward
  • SFH is plotted on a growth chart to assess the appropriate size for the individual woman
96
Q

When are women booked for serial growth scans with umbilical artery doppler ?

A
  • Three or more minor risk factors
  • One or more major risk factors
  • Issues with measuring the symphysis fundal height (e.g. large fibroids or BMI > 35)
  • If the symphysis fundal height is less than the 10th centile (in low risk women)
97
Q

what is assessed on serial growth scans ?

A
  • Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity
  • Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery
  • Amniotic fluid volume
98
Q

when is early delivery considered in SGA ?

A
  • Growth is static on growth charts
99
Q

When is a baby deemed large for gestational age ?

A
  • Weight >4.5kg
  • EFW >90th centile
100
Q

GIve 6 causes of macrosomia

A

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

101
Q

what is the main risk of macrosomia ?

A

Shoulder dystocia

102
Q

what 2 Ix are done in macrosomia

A

-> USS : exclude polyhydramnios and eastimate fetal weight
-> Oral glucose tolerance test for gestational DM

103
Q

what would be seen on USS in dichorionic diamniotic twins ?

A
  • Lambda or twin peak sign on membrane
104
Q

What would be seen on USS in monochorionic diamniotic twins ?

A

T sign

105
Q

what can occur in twins that share a placenta ?

A

-> Twin-Twin Transfusion syndrome
-> Recipient can become fluid overloaded with HF & polyhydramnios
-> Donor : FGR, anaemia and oligohydramnios

106
Q

what additional monitoring do women with multiple pregnancies require

A

-> FBC for anaemia at : booking, 20 wks and 28 wks
- > Additional USS : 2 wkly scans from 16 wks in monochorionic twins and 4 wkly scans from 20 wks in dichorionic twins

107
Q

when do monoamniotic twins require elective c section ?

A

32 and 33+6 wks

108
Q

when do diamniotic twins require elective c section

A

Between 37 and 37 + 6 wks

109
Q

Treatment of anaemia in pregnant women

A

Ferrous sulphate 200mg 3x daily

110
Q

If B12 deficiency is the cause of anaemia, how can it be managed

A

Intramuscular hydroxocobalamin injections
Oral cyanocobalamin tablets

111
Q

Folate deficiency management

A
  • Should already be taking folic acid 400mcg per day
  • Folate deficiency : 5mg daily
112
Q
  • Itchy rash starting in the third trimester.
  • Starts on the abdomen and associated with stretch marks
  • Characterised by urticarial papules, wheals and plaques
A

Polymorphic Eruption of Pregnancy

113
Q

what is atopic eruptiomn of pregnancy and when does it present ?

A
  • Eczema flare up in pregnancy
  • First and second trimester
114
Q
  • Increased pigmentation to patches of skin on the face (symmetrical and flat, affecting sun exposed areas)
A

Melasma

115
Q
  • Rapidly growing lump developing over days up to 1-2cm in size
  • Red / dark appearance
  • Often occuring on the FINGERS, upper chest, back, neck or head
A

Pyogenic granuloma -> benign rapidly growing tumour of capillaries

116
Q
  • Presents in second or third trimester
  • Initially : itchy red papular or blistering rash around umbilicus
  • Over several wks : large, fluid-filled blisters
A
  • Pemphigoid gestationis
  • Rare autoimmune condition where Abx are produced which causes epidermis and dermis to separate
117
Q

Risk to baby with pemphigoid gestationis

A
  • Fetal growth restriction
  • Preterm delivery
  • Blistering rash after delivery (as the maternal antibodies pass to the baby)
118
Q

Explain the 4 types of breech

A

-> 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

119
Q

what can be used at 37 wks to attempt to turn the fetus ?

A
  • External cephalic version (ECV)
120
Q

What is given prior to ECV

A
  • Tocolysis with subcut terbutaline to relax uterus
  • Anti-D prophylaxis in Rhesus-D negative women
121
Q

How does terbutaline work ?

A
  • Beta agonist
  • Reduces contractility of myometrium making it easier for the baby to turn
122
Q

What is defined as stillbirth ?

A
  • Birth of dead fetus after 24 wks gestation
  • Result of intrauterine fetal death (IUFD)
123
Q

What is the Ix of choice for diagnosing IUFD?

A

USS

124
Q

what is the first line management of IUFD ?

A

Vaginal birth

125
Q

what is given to suppress lactation after stillbirth

A

Cabergoline -> dopamine agonist

126
Q

3 major causes of cardiac arrest in pregnancy

A
  • Obstetric haemorrhage
  • Pulmonary embolism
  • Sepsis leading to metabolic acidosis and septic shock
127
Q

What are the additional factors to resuscitation in pregnancy

A
  • A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta
  • Early intubation to protect the airway
  • Early supplementary oxygen
  • Aggressive fluid resuscitation (caution in pre-eclampsia)
  • Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR
128
Q

When is immediate c section performed in cardiac arrest ?

A
  • There is no response after 4 minutes to CPR performed correctly
  • CPR continues for more than 4 minutes in a woman more than 20 weeks gestation
129
Q

when is VTE prophylaxis suggested in pregnancy ?

A

-> 28 weeks if there are three risk factors
-> First trimester if there are four or more of these risk factors

130
Q

What VTE prophylaxis is used in pregnancy ?

A
  • LMWH (e.g. enoxaparin, dlateparin)
131
Q

How is a VTE managed in pregnancy ?

A

-> LMWH
- > Continued for the rest of pregnancy + 3 wks postnatally or 3mnths in total (whichever is longer)

132
Q

At what week should a woman be referred to an obstetrician for lack of fetal movements ?

A

24 wks

133
Q

what is the first line treatment for respiratory depression caused by mag sulphate

A

Calcium gluconate

Finals (92 decks)

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