Antenatal care Flashcards
What is pre-eclampsia
-HTN in pregnancy >20 weeks gestation with end-organ dysfunction
What is the triad of pre-eclampsia
HTN
Proteinuria
Oedema
Give 5 high-risk factors for pre-eclampsia
- Pre existing HTN
- Previous HTN in pregnancy
- Autoimmune condition (e.g. SLE)
- DM
- CKD
When are women given prophylaxis against pre-eclampsia and what is it
- Single high risk factor
- Two or more moderate-risk factors
- ASPIRIN from 12 wks gestation till birth
what are the moderate risk factors for pre-eclampsia ?
- Older than 40
- BMI > 35
- More than 10 years since previous pregnancy
- Multiple pregnancy
- First pregnancy
- Family history of pre-eclampsia
How is pre-eclampsia diagnosed ?
- Systolic >149 or diastolic >90. PLUS any of :
- Proteinuria
- Organ dysfunction
- Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
How is proteinuria quantified in pre-eclampsia ?
- Urine protein:creatinine ratio (above 30mg/mmol is significant)
- Urine albumin:creatinine ratio (above 8mg/mmol is significant)
What is the first line management of pre eclampsia ?
Labetolol
Following delivery, how is pre eclampsia managed
- Enalapril (first-line)
- Nifedipine or amlodipine (first-line in black African or Caribbean patients)
What is eclampsia and how is it managed ?
- Seizures associated with pre-eclampsia
- Iv magnesium sulphate
what is HELLP syndrome ?
- Haemolysis
- Elevated Liver enzymes
- Low Platetes
= N&V, RUQ pain and lethargy
»» Deliver baby
Define pregnancy-induced hypertension
hypertension occurring after 20 wks gestation, without proteinuria
When is an OGTT done in pregnancy ?
- If pt has RF
- Features suggesting gestational DM present : large for dates fetus, polyhydramnios, glucose on urine dip
what are the cute of values for diagnosing gestational DM ?
5-6-7-8
-> Fasting : <5.6mmol/l
-> 2 hrs : <7/8mmol/l
how often do women diagosed with gestational DM have an USS?
- 4 wkly from 28-36 wks gestation to monitor fetal growth and amniotic fluid volume
How is gestational DM managed if fasting glucose <7mmol/l ?
- Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
How is gestational DM managed if fasting glucose >7mmol/l?
- Fasting glucose above 7 mmol/l: start insulin ± metformin
How is gestational DM managed if fasting glucose >6mmol/l plus macrosomia or other complications
Insulin +/- metformin
What are the target blood sugar levels in gestational DM ?
- 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
How much folic acid should women with pre existing DM take ?
5mg from preconception till 12 wks gestation
How are women with pre existing Type 2 diabetes managed ?
- Metformin and insulin
- Other oral meds are stopped
what should be performed shortly after booking and at 28 wks gestation in women with pre existing DM?
- Retinopathy screening
What planned delivery is advised in women with pre existing DM?
- Between 37 and 38+6 wks
- Gestational DM can give birth up to 40+6 wks
Give 5 complications to the baby of mothers with DM
- Neonatal hypoglycaemia
- Polycythaemia (raised haemoglobin)
- Jaundice (raised bilirubin)
- Congenital heart disease
- Cardiomyopathy
What is the target blood sugar level in neonates ?
- Maintain blood sugar above 2 mmol/l,
- If it falls below this -> IV dextrose of nasogastric feeding.
What is the most significant complication of gestational DM?
- Large for dates feus and macrosomia
- Risk of shoulder dystocia
- Third trimester -> itching of the palms of the hands and soles of the feet
Obstetric cholestasis
What are the other symptoms of obstetric cholestasis ?
Fatigue
Dark urine
Pale, greasy stools
Jaundice
NO RASH
what is obstetric cholestasis ?
- Reduction in the outflow of bile acids from the liver -> build up in the blood causing pruritis
What is seen on LFT’s in obstetric cholestasis ?
- Raised ALT, AST and GGT
- Raised bile acids
What is the primary treatment of obstetric cholestasis ?
- Ursodeoxycholic acid
How can the itching and sleeping symptoms be managed in obstetric cholestasis ?
- Itching : emollients
- Sleeping : antihistamines (chlorphenamine)
Patient presents with painless vaginal bleeding following ROM -> fetal bradycardia
Vasa Praevia
If detected on antenatal USS, how is vasa praevia managed ?
- Corticosteroids from 32 wks
- Elective planned c section for 34-36 wks
Define low lying placenta and placenta praevia
- Low-lying placenta : placenta is within 20mm of the internal cervical os
- Placenta praevia : when the placenta is over the internal cervical os
Define the 4 grades of placenta praevia
- 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
If not diagnosed on antenatal USS, how will placenta praevia present ?
- 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
If detected on antenatal USS, how is placenta praevia managed ?
- Corticosteroids between 34 and 35+6 wks
- Planned delivery between 36 and 37 wks
How does placental abruption present ?
- 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
How is the severity of an antepartum haemorrhage defined ?
- Minor haemorrhage: <50ml blood loss
- Major haemorrhage: 50 – 1000ml blood loss
- Massive haemorrhage: >1000 ml blood loss, or signs of shock
What test is used to determine how much anti-D prophylaxis is required following antipartum haemorrhage ?
Kleihauer test
what are the management options of placenta accreta ?
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
Explain the trimesters of pregnancy
- First trimester : start of pregnancy - 12 wks gestation.
- Second trimester : 13 weeks - 26 weeks gestation.
- Third trimester : 27 weeks gestation until birth.
when is the booking clinic done in pregnancy ?
BEfore 10 wks
When is the dating scan in pregnancy and what is used to calculate gestational age ?
- Between 10 and 13+6
- Crown rump length
when is the anomaly scan done in pregnancy ?
- Between 18 and 20 + 6 weeks
what 2 vaccines are offered during pregnancy ?
- Whooping cough (pertussis) from 16 weeks gestation
- Influenza (flu) when available in autumn or winter
when should women take folic acid and vitamin D in pregnancy ?
- Folic acid (400mcg) from before pregnancy to 12 wks
- Vitamin D (10 mcg or 400 IU daily)
What are the features of fetal alcohol syndrome ?
- Microcephaly
- Thin upper lip
- Smooth flat philtrum
- Short palpebral fissure
- Learning disability
- Behavioural difficulties
- Hearing and vision problems
- Cerebral palsy
what does smoking in pregnancy increase the risk of ?
- FGR
- Miscarriage
- Stillbirth
- Preterm labour and delivery
- Placental abruption
- Pre-eclampsia
- Cleft lip or palate
- Sudden infant death syndrome (SIDS)
when is flying ok until in pregnancy ?
- 37 weeks in a single pregnancy
- 32 weeks in a twin pregnancy
what bloods are done at the booking clinic ?
- 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)
what screening are women offered at the booking clinic ?
- HIV
- Hepatitis B
- Syphilis
when is the combined screening test done and what does it involve ?
- Between 11 and 14 wks
- Combined results from USS and maternal bloods
What results of the combined test suggest what risk of downs syndrome ?
- USS -> Nuchal translucency of >6mm.
- Bloods : higher beta-HCG, lower pregnancy associated plasma protein-A (PAPPA)
when is the triple test done and what does it involve ?
- Between 14 and 20 wks
- Beta-HCG -> higher = greater risk
- AFP ->lower = greater risk
- Serum oestriol -> lower = greater risk
when is the quadruple screening test done and what does it involve ?
- Between 14 and 20 wks
- Higher b-HCG
- Lower AFP
- Lower serum oestriol
- Higher Inhibin A
Based on the screening tests for Downs syndrome, when is antenatal testing done and what is offered ?
- If the risk is greater than 1 in 150
- Amniocentesis or chorionic villus sampling
What is chorionic villous sampling ?
- USS guided biopsy of placental tissue
- Done before 15 wks
When is amniocentesis done ?
- USS guided aspiration of amniotic fluid
- Later in pregnancy
what medication needs to be increased in pregnancy ?
Levothyroxine - by at least 25-50
what HTN medications can cause congenital abnormalities
- ACEI
- ARBs
- Thiazide and thiazide-like diuretics
what should women with epilepsy take from before conception
Folic acid 5mg daily
What anti-epileptic medications are deemed safe in pregnancy
- Levetiracetam, lamotrigine and carbamazepine
What anti-epileptic drugs should not be taken in pregnancy ?
- SV
- Phenytoin
what is the first line choice of medication for RA in pregnancy ?
Hydroxychloroquine
what painkiller is avoided in pregnancy and why
- NSAIDs
- Block prostoglandins
- Especially in the 3rd trimester as can cause premature closure of ductus arteriosus
why are BB avoided in pregnancy
- Fetal growth restriction
- Hypoglycaemia in the neonate
- Bradycardia in the neonate
what can the use of ACEI or ARBs cause in pregnancy ?
- Oligohydramnios
- Miscarriage or fetal death
- Hypocalvaria (incomplete formation of the skull bones)
- Renal failure in the neonate
- Hypotension in the neonate
what can the use of opiates in pregnancy cause nd how does in present ?
- Neonatal abstinence syndrome
- Irritability, tachycardia, high fever and poor feeding 3-72 hrs after birth
what VTE prophylaxis is avoided in pregnancy
warfarin
what is the use of lithium in the first trimester associated with
Ebstein’s anomaly
what are the features of congenital rubella syndrome and when is the biggest risk ?
- Before 10 wks gestation
- Congenital deafness
- Congenital cataracts
- Congenital heart disease (PDA and pulmonary stenosis)
- Learning disability
Give 5 features of congenital varicella syndrome
- 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)
management of chickenpox exposure <=20 wks gestation if not immune
- Varicella-Zoster immunoglobulin (VZIG) up to 10 days after exposure
management of chickenpox exposure if >20 wks gestation and not immune
- VZIG or aciclovir 7 to 14 days after exposure
How is chickenpox in pregnancy managed ?
- Oral aciclovir IF ≥ 20 weeks and she presents within 24 hours of onset of the rash
what can listeria in pregnancy cause and how is it avoided ?
- Miscarriage
- Fetal death
- Severe neonatal infection
- Avoid high risk foods (unpasteurised dairy products, processed meats, blue cheese)
Give 6 features of congenital CMV
Fetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures
How is toxoplasma gondii contracted and what is the triad of congenital toxoplasmosis ?
- Faeces from a cat
- Intracranial calcification
- Hydrocephalus
- Chorioretinitis
what causes fifth disease / slapped cheek syndrome
Parvovirus B19
what can parvovirus B19 in the first or second trimester of pregnancy cause ?
- Miscarriage or fetal death
- Severe fetal anaemia -> leads to HF (hydrops fetalis)
- Maternal pre-eclampsia-like syndrome
what is mirror syndrome
- Rare complication hydrops fetalis
- Triad of : hydrops fetalis, placental oedema and oedema in the mother.
what do women suspected of parvovirus infection need tests for ?
- 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)
what are the features of congenital Zika syndrome
- Microcephaly
- Fetal growth restriction
- Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy
when are Anti-D injections routinely given to women who are rhesus negative
- 28 weeks gestation
- Birth (if the baby’s blood group is found to be rhesus-positive)
On what other occasions are Anti-D injections given
- Antepartum haemorrhage
- Amniocentesis procedures
- Abdominal trauma
Any time where sensitisation can occur - within 72 hrs of the event
What is defined as small for gestational age and what 2 measurements on USS are used to assess fetal size
- Below 10th centile for their gestational age
- Estimated fetal weight (EFW)
- Fetal abdominal circumference (AC)
What is deemed as severe SGA and low birth weight ?
- Severe SGA : below 3rd centile
- Low birth weight : 2500g
what are the 2 categories of SGA ?
- Constitutionally small -> matches family and growing ok on growth charts.
- Fetal growth restriction -> intrauterine growth restriction (IUGR)
what are the 2 categories of fetal growth restriction
- Placenta mediated growth restriction
- Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality
Give 8 placenta mediated causes of FGR
Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions
Give 4 non placenta mediated causes of FGR
Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism
give 4 signs indicating FGR over the fetus being SGA
Reduced amniotic fluid volume
Abnormal Doppler studies
Reduced fetal movements
Abnormal CTGs
Give 4 short term complications of FGR
Fetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
What are the long term risks of FGR
- Cardiovascular disease, particularly hypertension
- Type 2 diabetes
- Obesity
- Mood and behavioural problems
How are low risk women monitored for SGA ?
- 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
When are women booked for serial growth scans with umbilical artery doppler ?
- 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)
what is assessed on serial growth scans ?
- 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
when is early delivery considered in SGA ?
- Growth is static on growth charts
When is a baby deemed large for gestational age ?
- Weight >4.5kg
- EFW >90th centile
GIve 6 causes of macrosomia
Constitutional
GESTATIONAL DM
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Male baby
what is the main risk of macrosomia ?
Shoulder dystocia
what 2 Ix are done in macrosomia
-> USS : exclude polyhydramnios and eastimate fetal weight
-> Oral glucose tolerance test for gestational DM
what would be seen on USS in dichorionic diamniotic twins ?
- Lambda or twin peak sign on membrane
What would be seen on USS in monochorionic diamniotic twins ?
T sign
what can occur in twins that share a placenta ?
-> Twin-Twin Transfusion syndrome
-> Recipient can become fluid overloaded with HF & polyhydramnios
-> Donor : FGR, anaemia and oligohydramnios
what additional monitoring do women with multiple pregnancies require
-> 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
when do monoamniotic twins require elective c section ?
32 and 33+6 wks
when do diamniotic twins require elective c section
Between 37 and 37 + 6 wks
Treatment of anaemia in pregnant women
Ferrous sulphate 200mg 3x daily
If B12 deficiency is the cause of anaemia, how can it be managed
Intramuscular hydroxocobalamin injections
Oral cyanocobalamin tablets
Folate deficiency management
- Should already be taking folic acid 400mcg per day
- Folate deficiency : 5mg daily
- Itchy rash starting in the third trimester.
- Starts on the abdomen and associated with stretch marks
- Characterised by urticarial papules, wheals and plaques
Polymorphic Eruption of Pregnancy
what is atopic eruptiomn of pregnancy and when does it present ?
- Eczema flare up in pregnancy
- First and second trimester
- Increased pigmentation to patches of skin on the face (symmetrical and flat, affecting sun exposed areas)
Melasma
- 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
Pyogenic granuloma -> benign rapidly growing tumour of capillaries
- Presents in second or third trimester
- Initially : itchy red papular or blistering rash around umbilicus
- Over several wks : large, fluid-filled blisters
- Pemphigoid gestationis
- Rare autoimmune condition where Abx are produced which causes epidermis and dermis to separate
Risk to baby with pemphigoid gestationis
- Fetal growth restriction
- Preterm delivery
- Blistering rash after delivery (as the maternal antibodies pass to the baby)
Explain the 4 types of breech
-> 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
what can be used at 37 wks to attempt to turn the fetus ?
- External cephalic version (ECV)
What is given prior to ECV
- Tocolysis with subcut terbutaline to relax uterus
- Anti-D prophylaxis in Rhesus-D negative women
How does terbutaline work ?
- Beta agonist
- Reduces contractility of myometrium making it easier for the baby to turn
What is defined as stillbirth ?
- Birth of dead fetus after 24 wks gestation
- Result of intrauterine fetal death (IUFD)
What is the Ix of choice for diagnosing IUFD?
USS
what is the first line management of IUFD ?
Vaginal birth
what is given to suppress lactation after stillbirth
Cabergoline -> dopamine agonist
3 major causes of cardiac arrest in pregnancy
- Obstetric haemorrhage
- Pulmonary embolism
- Sepsis leading to metabolic acidosis and septic shock
What are the additional factors to resuscitation in pregnancy
- 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
When is immediate c section performed in cardiac arrest ?
- 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
when is VTE prophylaxis suggested in pregnancy ?
-> 28 weeks if there are three risk factors
-> First trimester if there are four or more of these risk factors
What VTE prophylaxis is used in pregnancy ?
- LMWH (e.g. enoxaparin, dlateparin)
How is a VTE managed in pregnancy ?
-> LMWH
- > Continued for the rest of pregnancy + 3 wks postnatally or 3mnths in total (whichever is longer)
At what week should a woman be referred to an obstetrician for lack of fetal movements ?
24 wks
what is the first line treatment for respiratory depression caused by mag sulphate
Calcium gluconate
