Antenatal care Flashcards
AN mx plan (hx of abruption)
Scenario 1 - Hx of abruption req PRBC & emCS
Scenario 2 - Hx of abruption @34/40 bkg of PET/IUGR
Hx
- current preg - hx/ix…
- OGHx - G&P, previous AN course
- RFs - PPROM/HTN crisis/previa/trauma/ECV/polyhydro/fibroid) MOD/gestation.cx/outcome
- Phx - hypothyroid/HTN
- Meds - ?anti-HTN, thyroxine
- SHx - ?smoke ?illicit substance
- Psych - previous Obs trauma, PNMH
Exam
- height/weight/vitals
- thyroid/breast/cardioresp
- abdopelvic…
Ix
- baseline bloods (to assess any underlying medical condition that may predispose pt…e.g. TFT)
- tertiary morphology
Mx
- Education re: risks of abruption
- Optimize and min RFs
- Consider LDA +/-Ca depends on RFs
- Timing of delivery by 38/40
(term abruption -> preterm recurrence)
- MOD - obstetric indications
AN mx (minimal AN care)
- Spont/OI/IVF
- Establish EDD/BMI
- AN serology + Booking bloods
- Blood group +/- anti-D
- Aneuploidy screening/testing
- OGTT -> Hb1ac/random BSL
- Placenta localization
- Growth & Wellbeing scan
- Optimization of co-morbidities
- Vaccination recommendations
- Education - AN/Labour/PN
- Psychosocial support
- Follow-up OPC
AN mx plan (AMA)
Scenario 1 - 43yo G2P1 (CS) 15/40 visit
Scenario 2 - 40yo pre-preg counselling
Scenario 3 - 43yo unplanned wanted preg, previous IUGR due to aneuploidy - NND, ?recurrence risk
Pre-preg
- Advice to conceive ASAP
- Hx/Exam/Ix
- +/- Infertility workup (only 6mo of trying should prompt this)
- +/- optimization of comorbidities
- +/- referral for tertiary MDT
- +/- referral to RBU
- Full precon bloods/vaccination
- Full precon advice lifestyle/diet/risks
AMA specific
- M risk - GDM/PIH/PET/IOL/CS
- F risk - MC/Aneuploidy/IUGR/PTB
- early GDM screen
- +/- LDA + Ca
- Aneuploidy testing
- Tertiary morph
- G/S 28, 32, 36
- Timing of del - IOL from 39/40
- MOD - obstetric indication
AMA aneuploidy risks
- 40yo – T21 1:85, any chromosomal abnormality 1:40
- 45yo – T21 1:20, any chromosomal abnormality 1:10
- role of screening vs diagnostic testing
AN mx plan (asplenia)
Scenario 1 - asplenia (post trauma)
- immunocompromised
- higher risk of infection
- vaccinations - flu/pertussis
- prophylactic antibiotics
AN mx plan (vaginal lump)
Scenario 1 - para-vaginal cyst (Gartner) in early pregnancy
DDx
- prolapsing fibroid
- uterine prolapse
- cystocoele/rectocoele
- vaginal cyst
- vaginal polyp
- vaginal cancer
Hx
- onset/duration/previous
- difficult tampon insertion/dyspareunia
- pain/bleeding/dc/urinary/bowel/LOW
- FM…
- AN course
- OGHx/PHx…
Exam
- speculum
- +/- CST +/- HVS
- +/-urine MCS
Ix (for paravaginal cyst)
- +/- pelvic MRI
- renal tract USS (e.g. may communicate with ectopic ureter)
Mx
- reassure
- education
- gynae OPC postpartum
- plan for excision postpartum
- present case at MDT
- exclude any renal abn
- experienced gynae surgeon to excise
AN mx plan (high BMI)
Scenario 1 - 27yo BMI35
Scenario 2 - 32yo P0, BMI55
Scenario 3 - 34yo G2P0, BMI30
Pre-preg
- Ed - risks - mum/baby - AN/IP/PP
- Ref to bariatric mx - Preg interval 2yr
- High dose folate 5mg pre-conception
- Pre-preg vaccinations
- Lifestyle mod - exercise/diet/substance
Antenatal
- MDI - Obs/Diet/Ano/LC +/- Obs med
- Ed - risks - mum/baby - AN/IP/PP
- ensure no weight loss drugs
- ?hx of bariatric surgery/rapid LOW
- LDA+/-Ca+Fe - baseline PET sx
- adhere to recommended GWG
(eg 5-9 BMI>30)
- weigh every trimester
- urine dipstick +/- uPCR each visit
- aneuploidy screen - NIPT FR
- early OGTT then routine
- tertiary morphology
- growth scans 28/32/26
- lifestyle - smoke/etoh/exercise…
- delivery at facility w equipment/expert
- IOL from 39/40 following local guide
- MOD - obstetric indications
Intrapartum
- RTS @SOl or IOL
- x2 wide bore IVC -> FBE + G&S
- CEFM +/- FSE +/- uterine transducer
- recommend early epidural
- assisted delivery in OT
- higher dose of IVAbx at CS
Postpartum
- Wound care - NPWT
- Extended VTE prophylaxis
- Breastfeeding support
- Contraception
- +/- MH support
- postpartum weight ix/mx/ref plan
AN mx of adnexal mass
Scenario 1 - 27yo 11cm dermoid on 8/40 scan
Scenario 2 - 36yo multip, dermoind on 32/40 scan
- Hx/Exam/Ix
- previous hx
- prior USS - progression
- rpt USS +/- MRI ~14-16/40
- +/- tumor markers
- MDT rv of bloods/image
- Observation vs Removal from 14/40
(size, nature, gestation) - Open vs Lap (preferred if benign)
- Adequate counselling
- Experienced surgeon
- +/- removal at elective CS…
Note - risk of torsion decrease with increase gestation, removal becomes more difficult with increase in gestation
Lap - less bleeding/uterine irritability not assoc with increase FGR/SB
Open - minimise intra-op spill, longer recovery
AN Mx (previous FDIU/NND)
Pre-preg
- optimization of comorbidities (HTN, DM)
- rv previous FDIU investigations
- rv circumstances around FDIU/NND
- supplementation - eg high dose folate
AN ix
- dating/nuchal/tertiary morph
- early & routine OGTT
- G/S 28, 32, 36
- IOL by 38/40 vs CS
- CEFM during labor
LMWH if APLS
MDI if DM/HTN or other medical conditions
Asthma mx in preg
Mx of asthma in preg
- MDI - Obs med +/- Resp
- Preventer/Reliever safe in preg
- Pred exac, minimal transplacental pass
- Vax/Trigger /Smoking cessation
- rv of inhaler tech/asthma mx plan
Mx of exac of asthma in preg
- Admit for I/P mx
- MDI - Obs Med +/- Resp
- Bloods/Imaging - CXR
- High Flow O2
- B-agonist with nebuliser or spacer
- Ipratropium bromide
- Oral corticosteroid
- IV hydration
- +/- CTG +/- growth scan
AN mx of hyperemesis
DDx
- Gestational
- Multiple preg
- Thyroid dysfunction
- Molar preg
Hx
- Freq vomit & retch/duration
- establish - PUQ score
- pain/bleeding
- palpitation/diarrhea/LOW/heat intol
- fever/chills/rigors/urinary/bowel
- FM, PVB/SROM/TPL…
- AN course - Ix/supplements
- OGHx…
- PHx…
Exam
- vitals/BMI/BSL
- skin/mucous/CR/tremor
- cardioresp/thyroid
- abdopelvic +/- MCS
- FWD
Ix
- FBE/UEC/LFT/CRP/TFT +/- thyroid receptor autoantibodies
- urine MCS + ketones
- Obs USS - confirm gestational age, exclude molar & multiple
Mx
- MDI - Obs/MW/Dietician+/-psych
- Education - resolution by end of T2
- Admission based on severity
- Exclude reversible causes & rx
- Sx mx - antiemetic local guideline
- 1st - antihistamines - doxylamine/chlopromazine
- 2nd - dopamine/serotonin antagonist - metoclopramide/ondansetron
- 3rd line - steroids for refractory cases
- Others - PPI, acupoint, ginger, pyridoxine, thiamine replacement
- Small frequent meals
- Regular OP F/U - IVT/IV vitamins
- consider G/S if concern re: malnutrition
AN mx plan (breast lump)
Scenario 1 - 32/40 with breast ca, subsequently found to be BRCA+’ve
- initially breast ca must be excluded
- breast USS +/- FNA
- detection of breast ca
- refer to tertiary center
- MDI - MFM/Paed/MONC/RadONC/Breast Onc
- Obs Mx options
1. Continue preg w surgery +/- chemo - prognosis not impacted by preg
2. Termination of preg
Ongoing preg mx
- surgery such as mastectomy safe under GA
- radiation reserved for postpartum unless life saving
- chemo not teratogenic outside 1st trimester
- chemo impact on maternal - N&V/malnutrition/anemia/PPCM
- chemo impact on fetus - FGR/PTB/LBW
- chemo impact on fertility - POF
- Rx for mum - antiemetic, pred/ PPI, TTE, dietician
- Monitoring for baby - serial T3 G/S
- timing of delivery 2 weeks after last dose of chemo
- plan IOL from 37/40 +/- stress steroid coverage
- MOD would be obstetric indication
Termination of preg
- Feticide + Mife/Miso
Postpartum
- ongoing F/U & completion of rx
- advice preg interval >=2 years
- encourage breast feeding however expect difficulty/low supply, can’t have chemo/biological/hormonal rx whilst breastfeeding, need 14 day interval btw chemo
- extended LMWH
- contraception - non-hormonal
- psychosocial support
- fertility preservation support
Fertility preservation options
? chemo
- chemo/rad dmg to growing follicles & cause ovarian insufficiency
- ART based - oocyte/embryo/ovarian tissue cryopreservation -> transplant
- Non-art based
1. chemoprotection (GnRH agonist)
2. ovarian transposition/shielding
VBAC counselling
Risk evaluation
- VBAC risks with IOL 1:100 rupture risk
- Mum - D=0.02:1000, major cx 3:1000
- Baby - D=0.7:1000, major cx 1:1000
- Baby >39/40 - D=1.8 in 1000
Success rate
- pro - BMI/LR AN/SOL/VBAC/NVD
- against - BMI/LGA/IOL/cx AN/labor dys
Benefits of VBAC
- early initiation of breast feeding
- maternal satisfaction
- quicker recovery
- subsequent VBAC
- less TTN before 40/40
Risks to mother of VBAC
- rupture - emCS - cx
- pelvic floor/OASIS/PPH
Mx of F>D
Scenario 1 - referred to from rural for increased fundal height 28/40, previous failed assisted del of 3.5kg
DDx
- macrosomia
- polyhydramnios
- fibroid uterus
- M risk - OASIS/PPH/operative del
- F risk - SD/#/HIE/CP
- OGTT if not already done
- formal USS - biometry/AFI
+/- other if Poly - RFs - male/GDM/GWG/BMI
- timing/MOD - IOL by 39/40
Mx of uterine prolapse
- 35yo P3 10/40 p/w PVB
DDx
- miscarriage
- subchorionic hemorrhage
- cervical ulceration 2nd to POP
- cervical polyp/dysplasia
- vaginal infection
- sexually transmitted infection
Hx
- PVB quality/quantity
- pain/fullness/dragging
- urinary - diffcult empty/bowel sx/fever
- psychosocial impact
- AN course & Ix
- OGHx…STI/CST
- PHx/Med/SHx…
Exam
- weight/height/vitals
- abdopelvic - POP-Q
- spec - HVS +/- STI screen +/- CST
Ix
- FBE/UEC/CRP
- Obstetric USS - fetal wellbeing
- Routine antenatal testing
- MCS where appropriate
Mx
- MDI - Obs/Physio
- Pelvic floor exercise
- Pessary for sx relief/PTL prevention
- Consider steroid loading (risk of PTL)
- Regular Follow-up
Mx of uterine incarceration
- 35yo P3 13/40 p/w acute urinary retention
DDx
- uterine incarceration
- pelvic organ prolapse
- acute cystitis
Hx
- pain - abdo/suprapubic/lower back, PVB
- dysuria/hematuria/incomplete emptying/dribbling
- dragging/fullness/bulge/rectal pressure/constipation
- OGHx…hx of uterine incaration/PID/endo/cysts/fibroid/POP
- AN course - rv of results - scans, uterine axis (e.g. retroflexion)
- PHx - recurrent UTIs…Med/SHx…
Exam
- weigh/height/vitals
- abdo-pelvic exam - fundus not palpable, distended abdomen (bladder overdistension)
- spec - anterior displacement of cervix (can’t see cervix on spec), vagina angulated anteriorly rather than posterior, large/soft/smooth/non-tender mass fills cul-de-sac
- POP-Q - cystocele/enterocele
- urinalysis
Ix
- FBE/UEC/CRP (?AKI)
- urine MCS
- TA USS +/- MRI
Mx
- Admission - analgesia/IDC +/- TOV
- Mx depends on when the incarceration took place
<14/40: expectant & F/U - bimanual at 16/40 check fundus
14-20/40: passive reduction vs manual reduction vs lap reduction
- passive - empty bladder + knee-chest 10min TDS for 1/52 +/- IDC if can’t wee
- manual - regional + empty bladder - displace ute cephalad from posterior fornix or in rectum
- lap - manual reduction +/- pulling on round ligaments
- post reduction care = USS for fetal wellbeing & uterine position
> 20/40:
- supportive care (e.g. ISC)
- monitor preg cx - PTL/PPROM/Oligo/FGR
MOD - CS - as progression of labor -> risk of uterine rupture
Timing - high rate of PTL, if not aim 36/40 to avoid labor
MRI for pre-op planning due to anatomical distortion
AN Mx (GDM)
Scenario 1 - 32yo, raised NT, BMI55, early severe GDM
- MDI Obs/Obs Med/Diet/DNE
- LDA+Ca
- Strict BSL targets - DNE supp
- Dietary mod + Exercise + GWG goals
- Tertiary morph
- Multi-D OPC - urine dipstick +/- uPCR
- Serial G/S 28/32/36
- Close monitor insulin req/FGR/PET
- IOL from 38/40 - poor ctrl/LGA
Thickened NT
- T21, Turner, genetic syndrome & CHD
- +/- diagnostic testing + fetal echo
- IUGR risk
AN Mx of substance use (etoh/smoke)
Etoh
AN mx
- MDI - Obs/D&A/Dietician/Paeds
- no amount is safe, teratogenic
- FASD - physical & neurodevelopmental
- Screen for other substance
- Screen for DV/MH
- Thiamin 100mg daily
Intrapartum mx
- high dose analgesia may be req
Postpartum mx
- withdrawal scale PRN benzo
- discourage if heavy drinker
- psychosocial support
Smoke
AN mx
- education - risks to mum & baby
(MC/PTL/PTB/FGR/abruption/SIDS)
- telephone support service - Quitline
- CBT +/- NRT
Postpartum
- SIDS education
- encourage breast feeding
- beware of smoking & COCP
Opioids (e.g. heroin)
- methadone as replacement
- risk of neonatal withdrawal -> nursery
- do not use narcan after delivery if need resus
AN mx of genital ulcer/HSV
DDx
- herpetic ulcer (HSV) - HSV PCR/Serol
- Chancre (treponema pallidum) TPHA/RPR/VDRL
- Chancroid (haemophilus ducreyi)
- Lymphogranuloma venereum (chlamydia trachomatis) - chlam PCR
- aphthous ulcer, bechet’s
- vulval SCC
Initial Mx (suspecting HSV)
- Determine primary vs recurrent - Hx
- Confirm w type specific serology + PCR
- Screen for other STIs
- Ed: dx/natural course-
relapse/remission/implication for preg/contact tracing
- Most fetal transmission contracted perinatally, <5% intra-uterine
- Primary lesion late gestation -> 25-50% vertical transmission
- Recurrent lesion at birth -> 1-3% vertical transmission
- Recurrent or seroconversion before 34/40 -> <1% vertical transmission
Sx mx
- antiviral - acyclovir
- topical LA, SITZ bath
- monitor systemic sx
Preventative strategies
Recurrent
- suppressive therapy from 36/40
- exam/spec in labor exclude lesion
- consider CS if lesion in labour
- avoid FSE/Instrumental
Primary
- rx as for recurrent in T1&2
- dx in T3, suppressive rx + CS (unless ROM >6/24)
- avoid FSE/instrumental if vag birth unavoidable
Postpartum mx
- MDI - D&A/Psych/SW…
- hand hygiene ed for parents
- paeds opinion
- monitor sx +/- investigations
AN mx of N&V - in setting of Addison’s
- Triggers - dehydration/infection/trauma/GA
- HOPC - dehydration/diarrhoea/abdo pain/confusion
- Targeted H/E/I
- Admit
- Endo advice/rv
- IVC -> IVT/IV Hydrocortisone
- Fetal wellbeing - CTG
- Ix & Rx for triggers
AN mx of polyhydramnios
DDx
- Idiopathic
- Diabetes
- Aneuploidy - T18/21/Turner
- Infection - TORCH
- Thal - A-thal - hydrop fetalis
- Structural - GIT obstruction
- Isoimmunization - RBC abs
- even though Dx may be obvious, must do additional tests to exclude DDx
Hx
- FM, APH/SROM/TPL
- PET sx (mirror syndrome)
- AN Ix - aneuploidy/Morph/G&S
Exam
- vitals ?PET
- abdopalp
- FH/presentation
Ix - if not already done
- OGTT
- TORCH
- +/- amnio
- +/- PET screen
Mx
M risk - discomfort/SOB/abruption/PPH
F risk - PPROM/cord pro/PTL/PTB/SB/Malpresentation
- MFM +/- counselling for amnio
- rpt tertiary scan ?anomalies
- monitor - serial G/S, weekly CTG+AFI
- +/- rx cause - anemia/optimize DM ctrl
- +/- amnioreduction for mat sx/reduce risk of PPROM/prior to IOL reduce cord prolapse risk
- IOL 38-39/40 - risk of cord
- IP - ctrl ARM/CEFM/active 3rd stage
- PP - inform neonates ?NGT/CXR
AN mx of anhydraminos
Scenario 1 - incidental finding on morph, 5/52 post amnio for HR aneuploidy
DDx
- PPROM
- Renal tract anomalies
- Placental insufficiency
- Drugs
- Confirm dx w ix
+ spec/amnisure
+ HVS/MSU
+/- pad check
+/- Tertiary USS - M risk - Chorio/PTL (if PPROM)
- F risk - PTB/Lung develop/contracture/SB/NND
- MDI - FMU/Paeds - discuss risks above
- Expectant vs TOP
- Expectant - ongoing monitoring (depends on cause)
1. PPROM - bloods/MCS
2. Plac insufficiency - growth, PET
3. Monitor own sx - Timing/Mod - obstetric indication
- IP - nil specific
- PN - routine +/- LS +/- PM ix + debrief 6/52
AN mx of chronic hypertension
Scenario 1 - 34yo, G2P0 20/40, on anti-HTN from GP, no ix for cause
DDx
- PIH
- PET
- chronic HTN
- white coat
Confirm dx w ix (? 2ndary ?end-organ dmg)
1. renal artery doppler (2nd HTN) +/- TTE
2. plasma metaneph/urine catecho (2nd HTN)
3. FBE/UEC/LFT/uPCR (PET/endo-organ dmg)
- M risk - PET/IOL/CS
- F risk - IUGR/PTB
- MDI - Obs/Obs Med
- +/- LDA+/-Ca if prior to 16/40
+/- cFTS w UtA/PAPP-A/PIGF - tertiary morph
- serial G/S from 28/40
- home BP, valid machine
- ambulatory clinic monitoring
- urine dipstick to screen each visit
- education about PET sx
- lifestyle modification
- timing/MOD individualized
- PN
1. routine
2. ongoing F/U with GP re: BP
AN mx (hx of DV)
- Assess risk-> non-immediate
- Offer referral to SW
- Offer referral to police
- Written info/contact numbers for emergencies (refuge, police)
- Screen again in subsequent rv
AN mx (personal & FHx of ID)
DDx
- Fragile X syndrome
Ix
- mat karyotype + FMR1 testing
- +/- CVS/amnio to check fetus
Mx
- N risks - diffcult anticipat pheno (M>F)
- Tertiary referral
- MDI - Obs/genetics/SW
- If infant affected - TOP vs Continue
- Tertiary morph (may be normal)
- ?competence +/- neuropsych ax
- identify support/MPOA…
AN mx (SCI)
- M risk - resp comp in T3/UTI/POP/pressure sore/AC compres/VTE
- F risk - malpresentation/PTB
- MDI - MFM/MW/PT/OT/ano/SW
- AN - tertiary morph & growth + routine
- IP - CEFM/air mattress, avoid supine (AC comp risk), epi
- PP - extended LMWH
AN mx (Hx of PPROM)
- risk of recurrence is 30%
- RFs - twin/infection
- cervical surveillance +/- P4 +/- CC
- MSU/HVS
- Monitor sx
