Antenatal care Flashcards

1
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

AN mx (minimal AN care)

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

AN mx plan (asplenia)

Scenario 1 - asplenia (post trauma)

A
  • immunocompromised
  • higher risk of infection
  • vaccinations - flu/pertussis
  • prophylactic antibiotics
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

AN mx plan (vaginal lump)

Scenario 1 - para-vaginal cyst (Gartner) in early pregnancy

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

AN mx plan (high BMI)

Scenario 1 - 27yo BMI35

Scenario 2 - 32yo P0, BMI55

Scenario 3 - 34yo G2P0, BMI30

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

AN mx of adnexal mass

Scenario 1 - 27yo 11cm dermoid on 8/40 scan

Scenario 2 - 36yo multip, dermoind on 32/40 scan

A
  • 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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

AN Mx (previous FDIU/NND)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Asthma mx in preg

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

AN mx of hyperemesis

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

AN mx plan (breast lump)

Scenario 1 - 32/40 with breast ca, subsequently found to be BRCA+’ve

A
  • 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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Fertility preservation options

? chemo

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

VBAC counselling

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Mx of F>D

Scenario 1 - referred to from rural for increased fundal height 28/40, previous failed assisted del of 3.5kg

A

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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Mx of uterine prolapse
- 35yo P3 10/40 p/w PVB

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Mx of uterine incarceration
- 35yo P3 13/40 p/w acute urinary retention

A

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

17
Q

AN Mx (GDM)

Scenario 1 - 32yo, raised NT, BMI55, early severe GDM

A
  • 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

18
Q

AN Mx of substance use (etoh/smoke)

A

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

19
Q

AN mx of genital ulcer/HSV

A

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

20
Q

AN mx of N&V - in setting of Addison’s

A
  • 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
21
Q

AN mx of polyhydramnios

A

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
22
Q

AN mx of anhydraminos

Scenario 1 - incidental finding on morph, 5/52 post amnio for HR aneuploidy

A

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
23
Q

AN mx of chronic hypertension

Scenario 1 - 34yo, G2P0 20/40, on anti-HTN from GP, no ix for cause

A

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
24
Q

AN mx (hx of DV)

A
  • 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
25
Q

AN mx (personal & FHx of ID)

A

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…

26
Q

AN mx (SCI)

A
  • 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
27
Q

AN mx (Hx of PPROM)

A
  • risk of recurrence is 30%
  • RFs - twin/infection
  • cervical surveillance +/- P4 +/- CC
  • MSU/HVS
  • Monitor sx