ANTENATAL CARE Flashcards
1
Q
What is an uncomplicated pregnancy?
A
a singleton pregnancy where the mother is healthy and requires only routine antenatal care.
Women are usually managed in the community by a midwife.
2
Q
Which women are at higher risk of developing complications in pregnancy?
A
Women with existing medical problems
High BMI 30 or more, or low bMI <18.5
Who are aged over 40 at booking
With multiple pregnancy
With complex social factors e.g. substance abuse, recent migrants, asylum seekers or refugees, women who have difficulty reading/speaking English, young women aged under 20, women who experience domestic abuse
Who have experienced complications in a previous pregnancy
Who develop complications during the current pregnancy
3
Q
Outline when the antenatal appointments are for nulliparous women?
A
Booking appointment
14-16 week
25 week*
28 week
31 week*
34 week
36 week
38 week
40 week*
41 week for those not given birth
4
Q
Outline when the antenatal appointments are for parous women?
A
Booking appointment
14-16 week
28 week
34 week
36 week
38 week
41 week for those who have not yet given birth
5
Q
When should pregnant women be offered an USS?
A
11+2 - 14+1
18+0 - 20+6
6
Q
When should the booking appointment should take place?
A
By 10+0 weeks - if women is referred to maternity services later than 9+0 weeks then she should be offered a booking appointment within 2 weeks
7
Q
How should you manage a woman at the booking appointment?
A
Take a history
Assess the woman for risk of gestational diabetes
Assess the women for risk of pre-eclampsia
Assess for risk of foetal growth restriction
Assess for risk of VTE
Assess the woman’s risk of and, if appropriate, discuss female genital mutilation
Measure height&weight for BMI, blood pressure, urine dipstick and blood tests (FBC, blood group, rhesus D status)
If there are any medical concerns or review of long term meds is needed then refer to obstetrician
Offer screening for infectious diseases, haemoglobinopathies and foetal anomalies
Discuss changes during pregnancy
Discuss staying healthy during pregnancy
Discuss how to contact the midwifery team or the maternity services
Provide information on resources and support
Update woman’s antenatal records
8
Q
Who should you offer screening for gestational diabetes?
A
Women with any of the following:
BMI >30
Previous macrosomic baby
Previous gestational diabetes
FHx of diabetes first degree
Ethnicity with a high prevalence of diabetes (south Asian, Black Caribbean and Middle Eastern)
9
Q
What is the test of choice for gestational diabetes and when should it be done?
How is this different for women who have had previous gestational diabetes?
A
Oral glucose tolerance test
24-28 weeks
For women who’ve previously have gestational diabetes OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommends early self-monitoring of BG as an alternative
10
Q
Risk factors for preeclampsia?
A
High risk factors:
Previous history of pre-eclampsia or hypertension in pregnancy.
CKD
Autoimmune disease such as SLE or antiphospholipid syndrome.
Type 1 or type 2 diabetes.
Chronic hypertension
Moderate risk factors:
Nulliparity.
Age 40 years or older.
Pregnancy interval of more than 10 years.
Body mass index 35 kg/m2 or above.
Multiple pregnancy.
Family history of pre-eclampsia.
> =1 high risk factors
=2 moderate factors
11
Q
At booking what should you do if a woman is at risk of pre-eclampsia?
A
Refer for consultant-led care at booking
Advise to take aspirin 75-150mg daily from 12 weeks gestation until the birth
12
Q
Investigations at booking
A
Height and weight for BMI
Blood pressure and urine dipstick for proteinuria
Blood tests - FBC, blood group, rhesus D status
13
Q
What should be screened for at booking?
A
Hep B
Syphilis
HIV
Sickle cell and thalassaemia
14
Q
Immunisations in pregnancy?
A
Whooping cough
Flu
Others e.g. Covid-19
15
Q
When is the dating scan?
A
11+2 - 14+1 weeks
16
Q
Purpose of the dating scan?
A
Determine gestational age.
Detect multiple pregnancies.
Confirm viability.
Detect any fetal abnormalities that might be visible early in pregnancy (such as anencephaly).
Provide a component of screening for Down’s syndrome, Edwards’ syndrome, and Patau’s syndrome (if the woman chooses to be screened).
17
Q
What is the standard test for testing for Down’s syndrome? what does it entail?
A
The combined test - nuchal translucency measurement + serum B-HCG + Pregnancy-associated plasma protein A
18
Q
When is testing for Down’s syndrome done?
A
11-13+6 weeks
19
Q
Combined test results for Down syndrome positive result?
A
Raised HCG
Thickened nuchal translucency
Low PAPP-A
20
Q
If women book later in pregnancy when should screening for downs, Edward’s and Pataus be tested? And with what test?
A
Quadruple test - alpha-fetoprotein, unconjugated oestriol, HCG, inhibin A
21
Q
Results of combined test for positive Edward’s syndrome?
A
Low AFP
Low HCG
Low PAPP-A
Thickened nuchal translucency
22
Q
How to interpret results of combined or quadruple tests?
A
Lower chance results mean 1 in 150 chance or more
Higher chance results mean 1 in 150 chance or less
23
Q
What happens if a woman has a ‘higher chance’ from her results of combined/quadruple test?
A
Offer them a second screening test - either non-invasive screening test or a diagnostic test e.g. amniocentesis or CVS
24
Q
What is non-invasive prenatal screening test?
A
A test that analyses small DNA fragments that circulate in the blood of pregnant women - cell free foetal DNA
This cffDNA derives from placental cells and is usually identical to foetal DNA so analysis of this allows for the early detection of certain chromosomal abnormalities
Its sensitivity and specificity are very high for trisomy 21 (>99%) and similar for other chromosomal abnormalities
(Note: private companies offer it from 10/40)
25
What is done at 16 week antenatal appointment?
Update history
Check for domestic abuse if alone
Address any concerns
Measure bp and urine dipstick
Reassess risk of pre-eclampsia
Reassess risk of foetal growth restriction
Reassess the plan of care for the pregnancy
Discuss and give information on changes, resources etc
Start discussing birth preferences and the implications, benefits and risks of these
Discuss any results of blood or screening tests from previous appointments
Update antenatal records
26
What is done at the 25 week appointment for nulliparous women?
Update history
Check for domestic abuse if alone
Address any concerns
Measure bp and urine dipstick
Measure and plot SFH
Discuss baby’s movements with the woman
Continue discuss on birthing preferences, any changes, support between partners, resources and bonding with baby
Discuss any results of blood or screening tests from previous appointments
Update antenatal records
27
What is done at the 28 week antenatal appointment?
Update history
Check for domestic abuse if alone
Address any concerns
Measure bp and urine dipstick
Measure and plot SFH
Offer anti-D prophylaxis to rhesus negative women
Discuss baby’s movements
Advise woman to avoid sleeping on their back from 28 weeks onwards
Discuss and give information on preparing for lavour and birth, recognising active labour ans the postnatal period
Discuss and give information on changes, resources etc
Discuss any results of blood or screening tests from previous appointments
Update antenatal records
28
What happens at the 31 week antenatal appointment for nulliparous women?
Update history
Check for domestic abuse if alone
Address any concerns
Discuss baby’s movements
Measure bp and urine dipstick
Measure and plot SFH
Continue discussions on any changes, sleep position, support between partners, resources, bonding with baby, preparing for labour and birth, the postnatal period
Discuss any results of blood or screening tests from previous appointments
Reassess the plan of care for the pregnancy
Update antenatal records
29
What happens at the 34 week antenatal appointment?
Update history
Check for domestic abuse if alone
Address any concerns
Measure bp and urine dipstick
Discuss baby’s movements
Reassess the plan of care for the pregnancy
Measure and plot SFH
If following the 2-dose regimen of antenatal anti-D prophylaxis, offer the second dose to rheusus-negative women
Continue discussions on any changes, sleep positions, support between partners, resources, bonding with baby, preparing for labour and birth, the postnatal period
Discuss any results of blood or screening tests from previous appointments
Reassess the plan of care for the pregnancy
Update antenatal records
30
What happens at the 36 week antenatal appointment?
Update history
Check for domestic abuse if alone
Address any concerns
Measure bp and urine dipstick
Abdominal palpation to check baby’s position. If breech suspected offer USS to determine presentation
Discuss baby’s movements
Reassess the plan of care for the pregnancy
Measure and plot SFH
Continue discussions on any changes, sleep positions, support between partners, resources, bonding with baby, preparing for labour and birth, the postnatal period
Discuss any results of blood or screening tests from previous appointments
Reassess the plan of care for the pregnancy
Update antenatal records
31
What happens at the 38 week antenatal appointment?
Update history
Check for domestic abuse if alone
Address any concerns
Measure bp and urine dipstick
Blood tests - FBC, blood group and antibodies
Abdominal palpation to check baby’s position. If breech suspected offer USS to determine presentation
Discuss baby’s movements
Discuss prolonged pregnancy and options on how to manage it
Reassess the plan of care for the pregnancy
Measure and plot SFH
Continue discussions on any changes, sleep positions, support between partners, resources, bonding with baby, preparing for labour and birth, the postnatal period
Discuss any results of blood or screening tests from previous appointments
Reassess the plan of care for the pregnancy
Update antenatal records
32
What happens at the 40 week antenatal appointment for nulliparous women?
Update history
Check for domestic abuse if alone
Address any concerns
Measure bp and urine dipstick
Abdominal palpation to check baby’s position. If breech suspected offer USS to determine presentation
Discuss baby’s movements
Reassess the plan of care for the pregnancy
Measure and plot SFH
Discuss prolonged pregnancy and options on how to manage it
Continue discussions on any changes, sleep positions, support between partners, resources, bonding with baby, preparing for labour and birth, the postnatal period
Discuss any results of blood or screening tests from previous appointments
Reassess the plan of care for the pregnancy
Update antenatal records
33
What happens at the 41 week antenatal scan?
Update history
Check for domestic abuse if alone
Address any concerns
Measure bp and urine dipstick
Abdominal palpation to check baby’s position. If breech suspected offer USS to determine presentation
Discuss baby’s movements
Reassess the plan of care for the pregnancy
Measure and plot SFH
Discuss prolonged pregnancy and options on how to manage it
Continue discussions on any changes, sleep positions, support between partners, resources, bonding with baby, preparing for labour and birth, the postnatal period
Discuss any results of blood or screening tests from previous appointments
Reassess the plan of care for the pregnancy
Update antenatal records
34
When should you start measuring SFH in the antenatal appointments?
From 25 weeks (for multiparous women the first time will likely be at her 28 week appointment)
35
When should anti-D prophylaxis be given to rhesus-negative women?
28 weeks
34 weeks
36
What should you do if you have any concerns about the symphysis fundal heigh measurement?
Consider an USS for foetal growth and wellbeing
37
When should you take blood tests for anaemia, blood group and antibodies?
At booking
At 28 weeks
38
When should women start to avoid sleeping on their backs and why?
After 28 weeks
There may be a link to sleeping on the back and stillbirth in late pregnancy
39
When should abdominal palpation to check baby’s position happen?
Every appointment from 36 weeks
40
What should you do if on abdominal palpation you suspect breech position after 36 weeks?
Use USS to determine the presentation
41
What are the symptoms of pre-eclampsia?
Severe headache.
Problems with vision, such as blurred vision, flashing lights, double vision, or floating spots.
Severe epigastric pain
Vomiting.
SOB
Sudden swelling of the face, hands, or feet.
42
What foods should you advise women to avoid as they may put her or her foetus at risk?
Soft mould-ripened cheeses, unpasteurized milk or cheese, and pate (including vegetable pate) - risk of listeria infection
Uncooked or undercooked ready-prepared meals, uncooked or cured meat, raw shellfish - salmonella risk
Liver and liver products - contain high levels of vitamin AA
Shark, swordfish, marlin, and no more than 4 medium-sized cans of tuna or 2 fresh tuna steaks a week - risk of high levels of methylmercury
43
Listeria infection in pregnancy?
Listeriosis - risk of miscarriage, stillbirth or severe illness in newborn baby
44
Eggs and salmonella risk
Eggs stamped with the red lion are very low risk even if eaten raw or partially cooked - British lion code of practice
45
Vitamin A in pregnancy
Too much vitamin A (>700 micrograms) can increase risk of birth defects in the baby
46
High levels of methylmurcury in pregnancy?
Can affect the nervous system of the foetus - potentially increases the risk of learning or behavioural problems
47
Caffeine intake in pregnancy
<200mg a day
Remind pt caffeine is in coffee, tea, chocolate, colas
E,g. 1 mug instant coffee - 100mg
1 mug filter coffee - 140mg
1 mug tea - 75mg
1 cola - 40mg
1 can energy drink - 80mg
1 bar of plain chocolate - 50mg (milk chocolate 25mg)
48
High caffeine levels in pregnancy?
Associated with LBW of baby
49
Nutritional supplements during pregnancy
Folic acid 400mcg a day starting 1 month prior to conception and throughout first 12 weeks (higher dose 5mg for women at higher risk)
Vitamin D (10mcg a day) throughout pregnancy
AVOID VITAMIN A
50
Why should pregnant women take folic acid during the first 12 weeks of pregnancy?
To reduce the risk of neural tube defects in the baby
51
Which women are at higher risk of conceiving a child with a neural tube defect, and therefore should take a higher daily dose of folic acid for the first 12 weeks of pregnancy?
Women who previous had an infant with a neural tube defect
Those taking certain antiepileptic medications
Women with diabetes, coeliac disease, sickle cell, thalassaemia
Women with BMI >30
52
Which groups of women is it particuarly important to take vitamin D during pregnancy?
Women with darker skin
Those who have limited exposure to sunlight - housebound, confined indoors for long periods
Those who cover their skin for cultural reasons
53
Exercise in pregnancy?
Moderate exercise may be continued/started during pregnancy
Vigorous activity is not recommended for previously inactive women
Avoid sports that may cause abdominal trauma e.g. contact sports
Avoid scuba diving
54
Sexual intercourse during pregnancy?
Reassure women it is thought to be safe
55
Toxoplasmosis infection in pregnancy?
Can cause stillbirth, miscarriage, intracranial anomalies, visual impairment and developmental delay
56
Air travel advice in pregnancy
No evidence that air travel is harmful for healthy women with an uncompcated pregnancy
Most airlines dont allow women to fly after 37/40
Risk of developing a DVT is increased
57
What is the Healthy Start Scheme?
A government scheme that aims to improve the health of pregnant women and families with children aged under 4 years
Provides free vouchers or payments every 4 weeks that can be spent on cows milk, fresh/frozen/tinned fruit and veg, infant formula milk and fresh/tried./tinned pulses
It also provides free Healthy Start vitamins
You have to apply for this scheme
58
Advice on employment rights?
Pregnant women have a right to:
Paid time off for antenatal care — e.g. medical appointments or even antenatal or parenting classes if they’ve been recommended by a doctor/midwife.
Maternity leave — 26 weeks of ordinary maternity leave and 26 weeks of additional maternity leave, making 1 year in total. Maternity leave may be taken no matter how long the woman has been with an employer, how many hours she works, or how much she is paid. She may be entitled to take some of this leave as Shared Parental Leave. A woman is not legally permitted to return to employment in the 2 weeks following childbirth (or 4 weeks if they work in a factory).
Maternity pay or maternity allowance.
Protection against unfair treatment, discrimination, or dismissal.
59
What is statutory maternity pay?
Payments made for up to 39 weeks:
90% of average weekly earnings for the first 6 weeks
£172.48 or 90% of average weekly earnings (whichever is lower) for the next 33 weeks
Paid in the same way as your weekly earnings
60
When is the foetal anomaly scan done and what is the purpose?
18+0 to 20+6 weeks
To locate the placenta, assess amniotic fluid and identify 11 specific conditions:
- anencephaly
- open spinal bifida
- cleft lip
- diaphragmatic hernia
- gastroschisis
- exomphalos
- serious cardiac abnormalities
- bilateral renal agenesis
- lethal skeletal dysplasia
- Edward’s syndrome
- pataus syndrome
61
First, second and third trimester weeks
-12 weeks
13-26 weeks
27-birth
62
How is an accurate gestational age calculated at the dating scan?
Measures the crown-rump length (+/-5 days with 95% CI)
63
When would the effects of drinking during pregnancy have the greatest impact?
In the first 3 months
64
What can drinking alcohol during pregnancy cause?
Miscarriage
Small for dates
Preterm delivery
FAS
65
What does smoking in pregnancy increase the risk of?
FGR
Miscarriage
Stillbirth
Preterm labour and delivery
Placental abruption
Pre-eclampsia
Cleft lip or palate
SIDS
66
Who gets screened for sickle cell and thalassemia at booking?
All pregnant women get offered the screening for thalassaemia
In areas where haemoglobinopathies are more common women will be offered a blood test for SCD but in areas where it is less common, a questionnaire is used to identify the family origins of the baby’s parents
67
What is the definition of foetal growth restriction?
Estimated foetal weight or abdominal circumference <3rd centile
EFW or AC <10th with evidence of placental dysfunction: either abnormal uterine artery Doppler at 20-24 weeks OR abnormal umbilical artery Doppler
68
Risk factors for foetal growth restriction?
Moderate:
Previous SGA
Previous stillbirth
Current smoker or drug misuse
Women >=40 at booking
High:
Maternal medical conditions e.g. CKD, hyptn, autoimmune diseases or cyanotic HD
Previous FGR
Hypertensive disease in previous pregnancy
Previous SGA stillbirth
PAPPA <5th centile (hormone made by placenta)
Foetal echogenic bowel - associated with lots of conditions
Significant bleeding
EFW <10th centile
69
Whats the difference between uterine and umbilical artery Doppler and when would we use them?
Uterine artery Doppler is used to assess blood flow in the uterine arteries which supply blood to the uterus. Abnormalities in this suggest impaired placental perfusion. Often used in early pregnancy as a a tool for women at right of developing hypertensive disorders e.g. pre-eclampsia.
Umbilical artery Doppler assesses blood flow in the umbilical arteries which carry oxygenated blood from the placenta to the foetus. Abnormalities suggest impaired foetal blood flow. Often used later in pregnancy when concerns about foetal well-being arise.
Both used for foetal growth restriction
70
Management when woman has moderate risk factors for foetal growth restriction, provided anomaly scan and estimated foetal weight >10th centile?
Consider aspirin 150mg at night <16 weeks
Serial USS from 32 weeks every 4 weeks until delivery
71
Management when woman has high risk factors for foetal growth restriction + normal uterine artery Doppler?
Consider aspirin 150mg at night <16 weeks
Serial USS from 32 weeks every 2-4 weeks until delivery
72
Management when woman has high risk factors for foetal growth restriction + abnormal uterine artery Doppler but estimated foetal weight >=10th centile?
Consider aspirin 150mg at night <16 weeks
Serial USS from 28 weeks every 2-4 weeks until delivery
73
Management when woman has high risk factors for foetal growth restriction + abnormal uterine artery Doppler + estimated foetal weight <10th centile?
Discuss with foetal medicine
74
2 categories of causes of SGA
Constitutionally small
FGR/IUGR
75
What are the 2 categories of causes of foetal growth restriction
Placenta mediated growth restriction
Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality
76
What are causes of placenta-mediated growth restriction?
Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions
77
What are causes of non-placenta-mediated growth restriction?
Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism
78
Complications of foetal growth restriction
Foetal death/stilbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
Increases risk of CVD, T2DM, obesity and mood/behvaioural problems
79
Management of SGA
Aspirin for those at risk of pre-eclampsia
Treat modifiable risk factors e.g. smoking
Serial growth scans to monitor growth
Early delivery when growth is static or other problems are identified e.g. abnormal Doppler results. Reduces risk of stillbirth
Investigtaions to identify underlying cause:
BP and urine dip for pre-eclampsia
Uterine artery Doppler
Detailed foetal anatomy scan by foetal medicine
Karyotyping for chromosomal abnormalities
Testing for infections - CMV, syphilis, etc
80
Thickened nuchal translucency - what thickness?
>6mm
81
What is chorionic villus sampling? when is it done?
US guided biopsy of placental tissue
11-14 weeks of pregnancy (but can be done later)
82
What is amniocentesis?
US-guided aspiration of amniotic fluid using needle and syringe
15-20 weeks (can be done later) - later than CVS as there must be enough amniotic fluid to make it safe to take the sample
83
Risks of CVS and amniocentesis?
Not always possible to get a result from the first attempt - 6% will be offered a second procedure
1 in 200 will miscarry
Less than 1 in 1,000 will cause a serious infection
Note more risk associated with twin pregnancy - risk of miscarriage is twice as high
84
How should you advise a woman to manage constipation?
Adequate fibre - whole grains, fruits high in sorbitol e.g. apricots, grapes, peaches, plums, prunes, and vegetables - aim for 30g a day
Adequate fluid intake
Increase activirty levels
If lifestyle measures dont work, you can offer short-term oral laxataives
If response is still inadequate then tou can consider prescribing a glycerol suppository
85
What oral laxatives are best to use in preganncy?
Bulk forming laxative first line e.g. ispaghula
If stool remains hard, add or switch to an oesmotic laxative e.g. lactulose
If stools are soft but diffiuclt to pass, or Tenesmus consider a short course of a stimulant laxative e.g. senna
86
why does pregnancy cause constipation?
Increased progesterone levels inhibits gastrointestinal tract motility
87
Why are varicose veins common in pregnancy?
The uterus causes compression of the pelvic veins which can allow blood flow to be disrupted
88
Management of varicose veins in pregnancy ?
Reassure women they’re common, not harmful to baby and improve considerably after pregnancy
Consider Tx with compression stocking to improve symptoms
89
Why is dyspepsia common in pregnancy?
GOR:
Increased progesterone cause reduced gastric tone, motility and decrease the lower oesophageal sphincter pressure
Increased GI transit time
Increased intra-abdominal pressure due to growing uterus
90
Management of reflux in pregnancy?
Eat small meals frequency, dont eat 3 hours before bed, avoid known irritants
Keep a food diary to identify triggers
Avoid excessive weight gain and maintain regular physical activity
Try raising head off bed by 10-15cm
Try to sleep on the left side
Avoid meds that may worsen symptoms
Stop smooth
If not controlled by lifestyle…
Antacids and alginates are first line
If symptoms are very severe and persist consider pressing an acid-suppressing drug e.g. famotidine or omeprazole - not neither have solid evidence on their safety in pregnancy
91
Why is vaginal thrush more common in pregnancy?
Increased oestrogen levels increase the susceptibility
Note recurrent episodes may also be a sign of gestational diabetes
92
why are hemorrhoids common in pregnancy?
At the uterus expands it puts increased pressure on the pelvic veins which can lead to swelling of veins in the rectum and anus
Progesterone can cause the walls of blood vessels to relax making them more prone to swelling and inflammation
Constipation is common and can contribute to the development of haemorrhoids
93
Managing haemorrhoids in preganncy?
Offer advice on minimising constipation and straining - increase fibre, fluid and exercise it
Advise women about perianal hygiene to relive symptoms and prevent perianal dermatitis
If symptoms remain troublesome… consider topical treatment - no topical heamorrhoidal preparations are licenced for use in preganncy so women wishing to use these products should be made aware of the lack of data regarding pregnancy outcomes
94
What should be discussed with the woman if breech presentation is confirmed after 36+0 weeks in an uncomplicated singleton preganncy?
Discuss the different options:
External cephalic version
Breech vaginal birth
Elective caesarean birth
95
What is gestational transient thyrotoxicosis?
A condition limited to the first trimester of pregnancy where there is direct stimulation of the maternal TSH receptor by hCG
96
Risks of untreated thyrotoxicosis in pregnancy?
Risk of foetal loss, maternal HF and premature labour
97
Risks of untreated hypothyroidism in pregnancy?
Miscarriage
Anaemia
SGA
Pre-eclampsia
Adverse neonatal outcomes - preterm, LBW, neonatal resp distress, congenital abnormalities, congenital hypothyroidism etc
98
Management of thyrotoxicosis in pregnancy?
Propylthiouracil for the first trimester
Carbimazole for the second and third trimester
Maternal free thyroxine levels should be kept in the upper 1/3rd of the normal reference range to avoid foetal hypothyroidism
99
In women with thyrotoicosis, what should be checked and when to determine the risk of neonatal thyroid problems?
Thyrotrophin receptor stimulating antibodies
At 30-36 weeks gestation
100
Management of hypothyroidism in preganncy?
Measure serum TSH in each trimester and 6-8 weeks post-partum
Increased dose of levothyroxine by up to 50% as early as 4-6 weeks of pregnancy - treatment is titrated based on TSH level, aiming for a low-normal level
101
Which antihypertensives can be used in preganncy?
Labetalol - note other beta-blockers may have adverse effects
Calcium channel blockers e.g. nifedipine
Alpha blockers
102
Why may pregnancy worsen seizure control in women with epilepsy?
Due to the additional stress, lack of sleep, hormonal changes and altered medication regimes
(Note: seizures are not known to be harmful to the pregnancy, other than the risk of physical injury)
103
Management of epilepsy in pregnancy?
Levetiracetam, lamotrigine and carbamazepine are the safer anti-epileptic medications in pregnancy
Women should take folic acid 5mg daily from before conception to reduce the risk of neural tube defects
104
Risks of sodium valproate in pregnancy
Neural tube defects
Neurodevelopmental delay in children
105
Phenytoin in pregnancy risk
Cleft palate
Congenital heart disease
106
Rheumatoid arthritis in pregnancy
Management
Often symptoms improve and women will go into remission but they may flare up after delivery
It must be well controlled for at least 3 months before becoming pregnant
Hydroxychloroquine is considered safe - first line
Sulfasalazine is considered safe
Corticosteroids may be used during flare ups
Methotrexate is contraindicated!
107
Methotrexate in pregnancy
women should avoid pregnancy for at least 6 months after treatment has stopped
the BNF also advises that men using methotrexate need to use effective contraception for at least 6 months after treatment
Can cause miscarriage and congenital abnormalities
108
NSAIDs and preganncy
Generally avoided unless really necessary
Particularly avoided in the third trimester as they can cause premature closure of the ductus arteriosis of the foetus
They can also delaye labour
(As they block prostaglandins)
109
Beta blockers and preganncy
Can cause FGR, hypoglycaemia and bradycardia in the neonate
Labetalol is most frequently used in preganncy
110
ACEi and ARBs in pregnancy
Oligohydramnios - as they affect the kidneys and reduce production of urine
Miscarriage or fetal death
Hypocalvaria (incomplete formation of the skull bones)
Renal failure in the neonate
Hypotension in the neonate
111
Opiates in pregnancy
Can cause withdrawal symptoms in the neonate after birth - neonatal abstinence syndrome
Presents 3-72 hours afetr birth with irritability, tachypnoea, fever and poor feeding
112
Warfarin and preganncy
Can cause foetal loss, congenital malformations (particuarly craniofacial problems), and bleeding during pregnancy/PPH/foetal haemorrhage/intracranial bleeding
113
Lithium and pregnancy
Avoid in pregnancy unless all other options have failed
Particularly avoided in the first trimester as linked to congenital cardiac abnormalities - in particular Ebstein’s anomaly
If it is used the levels must be monitored every 4 weeks, and then weekly from 36 weeks
Should be avoided in breast feeding!!
114
SSRIs and preganncy
First-trimester use has a link with congenital heart defects
First-trimester use of paroxetine has a stronger link with congenital malformations
Third-trimester use has a link with persistent pulmonary hypertension in the neonate
Neonates can experience withdrawal symptoms, usually only mild and not requiring medical management
Can be used if benefits outweigh the risks
115
Isotretinoin in pregnancy
Highly teratogenic - miscarriage and congenital defects
Women must be on reliable contraception before during and for 1 month after taking isotretinoin
116
Naegele’s rule?
Begin on 1st day of LMP - 3 months + 7 days and + 1 year
117
Role of USS in diagnosing intrauterine pregnancy?
Confirms location of pregnancy
Confirms foetal viability by demonstrating cardiac activity
Establishes number of foetus
Assessment of gestational age by measurement of crown-rump length
Screening by measuring nuchal translucency
Can assess placental location and cord insertion
Assess amniotic fluid
118
What is the lambda sign on USS?
the triangular appearance of the chorion insinuating between the layers of the intertwin membrane and strongly suggests a dichorionic diamniotic twin pregnancy
119
What is the T sign on USS?
the absence of a twin peak sign (or lambda (λ) sign) and is used in ultrasound assessment of a multifetal pregnancy. It refers to the lack of chorion extending between the layers of the intertwin membrane, denoting a monochorionic pregnancy.
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Explain normal fundal height in relation to weeks?
Gestational age in weeks +/-2cm is fundal height - after 20/40
At 12 weeks fundus at pubic bone
A 20 weeks fundus at belly button
At 36 weeks fundus at xiphoid sternum
Fundal height may actually decrease after this due to head engement causing baby to drop
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When is it normal to start noticing foetal movements? When is it worrying if they haven’t?
From 16-20 weeks
Should be regular from 24/40 and worry if haven’t felt any
Note quickening is the term for the fast foetal movement that feel like flutters or tiny pulses at 16-20 weeks
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What is melasma?
a common skin problem caused by brown to gray-brown patches on the face. Most people get it on their cheeks, chin, nose bridge, forehead, and above the upper lip
Common in pregnancy 2nd/3rd trimester and in sun exposure
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how often should you monitor women with monochorionic multiple pregnancy for feto-foetal transfusion syndrome?`
USS every 14 days from 16 weeks-> birth
if any concerns about differences in babies' amniotic fluid levels in the 2nd/3rd trimester then change to weekly
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what is twin anaemia polycythemia sequence?
Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute. One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).
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antenatal care for dichorionic diamniotic twin pregnancy?
at least 8 antenetal appointments - at least 2 of these with a specialist obstetrician
additional scans to monitor for FGR, unequal growth and twin-twin transfusion syndrome - 4 weekly from 20 weeks
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antenatal care for monochorionic diamniotic twin preganncy
at least 11 antenetal appointments - at least 2 of these with a specialist obstetrician
additional scans to monitor for FGR, unequal growth and twin-twin transfusion syndrome - 2 weekly from 16 weeks
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complications of monochorionicity in twin and triplet pregnancies?
feto-foetal transfusion syndrome
foetal growth restricted
advanced-stage twin anamia polycythemia sequence
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what is a worrying estimated foetal weight discordance?
25% or more - refer to tertiary level foetal medicine centre
(note also refer if EFW of any of babies is <10th centile for gestational age)`
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how to estimate gestational age in a multiple pregnancy?
in first trimester
estimate gestational age from largest baby in the pregnancy to avoid risk of estimating it from a baby with early growth pathology
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how to determine the chorionicity and amnionicity of a multiple pregnancy
USS look for:
the number of placental masses
the presence of amniotic membranes and membrane thickness
the lambda or T-sign
discordant fetal sex
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what does dichorionic diamniotic twins mean?
babioes have their own placenta and amniotic sac
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what does monochorionic monoamniotic twins mean?
Both babies share a placenta and amniotic sac.
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timing of embryo division and twin pregnancy
division within 3 days of fertilisation - dichorionic diamniotic
4-8 days - monochorionic diamniotic
9-12 days - monochorionic monoamniotic
>12 days - conjoined twins (rare)
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dizyopgotic meaning
non-identical twins - develop from 2 separate ova that were fertilised at the same time
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monozygotic meaning
identical twins (from a single zygote)
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which type of twins have the best outcomes and why?
diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.
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lamda sign on USS
aka twin peak sign
a triangular appearance where the membrane between the twins meets the chorion, as the chorion blends partially into the membrane. This indicates a dichorionic twin pregnancy
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T sign on USS
where the membrane between the twins abruptly meets the chorion, giving a T appearance. This indicates a monochorionic twin pregnancy
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complications of multiple pregnancy: risks to mother
Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous preterm birth
Instrumental delivery or caesarean
Postpartum haemorrhage
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complications of multiple pregnancy: risks to foetus
Miscarriage
Stillbirth
FGR
Prematurity (mean age for twins 37/40 and triplets 33/40)
Twin-twin transfusion syndrome
Twin anaemia polycythaemia sequence
Congenital abnormalities
malformation x3 increased risk
perinatal mortalit x5 in twins and x10 in triplets
cord prolapse
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what is twin-twin transfusion syndrome called when its a pregnancy with >2 foetuses?
feto-foetal transfusion syndrome
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what is twin-to-twin transfusion syndrome?
When there is a connection between the blood supplies of the two fetuses (i.e. monochorionic), the recipient foetus may receive the majority of the blood from the placenta, while the the donor foetus is starved of blood.
The recipient gets the majority of the blood, and can become fluid overloaded, with HF and polyhydramnios.
The donor has growth restriction, anaemia and oligohydramnios.
There will be a discrepancy between the size of the fetuses.
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management of diagnosed feto-foetal transfusion syndrome?
refer to tertiary specialist foetal medicine centre
laser Tx may be needed to destroy the connection between the 2 blood supplies
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incidence of twins and triplets?
twins - 1 in 105
triplets - 1 in 10,000
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why is the incidence of dizygotic twins increasing?
due to infertility Tx
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predisposing factors for dizygotic twins
previous twins
family history
increasing maternal age
multigravida
induced ovulation and in-vitro fertilisation
race e.g. Afro-Caribbean
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Foetal growth restriction definition?
when a pathological process has restricted genetic growth potential. This can present with features of fetal compromise including reduced liquor volume (LV) or abnormal doppler studies.
The likelihood of FGR is higher in a severe SGA fetus.
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SGA definition?
Foetus measuring below the 10th centile for gestational age
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Measurements used to assess foetal size on USS?
Estimated foetal weight
Foetal abdominal circumference
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What is severe SGA?
Foetus EFW or Abdominal circumference below 3rd centile for their gestational age
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2 categories of SGA?
Constitutionally small 50-70%
Foetal growth restriction
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2 categories of causes of FGR?
Placenta mediated growth restriction
Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality
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Causes of FGR: Placenta mediated growth restriction
Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol or substance misuse
Anaemia
Malnutrition/low pre-pregnancy weight
Infection
Maternal health conditions - renal disease, autoimmune disease, diabetes with vascular disease, chronic hypertension
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Causes of FGR: Non-placenta mediated growth restriction
Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism
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Complications of SGA?
Short term complications of fetal growth restriction include:
Fetal death or stillbirth
Birth asphyxia
Meconium aspiration
Neonatal hypothermia
Neonatal hypoglycaemia
Polycythemia
NEC
Growth restricted babies have a long term increased risk of:
CVD, particularly hypertension
Cerebral palsy
T2 diabetes
Obesity
Mood and behavioural problems
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Minor risk factors SGA?
Maternal age >=35
Smoker 1-10 a day
Nulliparity
BMI <20 or 25-34.9
Previous pre-eclampsia
IVF singleton
Pregnancy interval <6 or >60 months
Low fruit intake pre-pregnancy
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Major risk factors SGA?
Maternal age >40
Smoker >=11 a day
Previous SGA baby
Maternal or paternal SGA
Previous stillbirth
Cocaine use
Daily vigorous exercise
Maternal disease - chronic hypertension, renal impairment, diabetes with vascular disease and antiphospholipid sudnrome
Anterpartum haemorrhage
Low PAPP-A
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Investigations for foetal growth restriction
Low risk women - SFH at every antenatal appointment from 24/40 - plot on a customised growth chart. If <10th centile…
Serial growth scans with umbilical artery Doppler (offer if 3 or more minor risk factors, 1 or more major risk factors or issues measuring SFH e.g. large fibroids of BMI >35)
Women at risk or with SGA monitor closely with serial USS measuring:
EFW and abdominal circumference
Umbilical arterial pulsatiility index - repeat every 14 days
Amniotic fluid volume - may show oligohydramnios
PAPP-A
Check for echogenic bowel
To identify cause:
Blood pressure and urine dipstick for pre-eclampsia
Detailed foetal anatomical survey by foetal medicine
Uterine artery Doppler scanning
Karyotyping is severe, with structural abnormalities and those detected <23/40
Screen for infections: CMV & toxoplasmosis (+ syphilis and malaria in high risk populations)
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Potential indications of SGA?
APH
Low PAPP-A
Small SFH measurements
Oligohydramnios
Abdnormal Doppler studies
Reduced foetal movements
Abnormal CTGs
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What can a low level of PAPP-A be associated with?
LBW baby
Increased chance of prematurity
Stillbirth
Increased risk of pre-eclampsia
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What is the likely cause of foetal growth restriction if the onset is before 23/40?
Chromosomal abnormalities
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Definition of suboptimal foetal growth?
Increase in EFW <20g per day or <280g over 14 days, from 34/40
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Management of FGR?
Monitoring: check liquor volume and umbilical artery Doppler weekly, growth scans fortnightly and continue monitoring for pre-eclampsia
High risk of pre-eclampsia - 75mg aspirin from or before 16 weeks
Tx modifiable risk factors e.g. smoking cessation and optimise maternal disease
Early delivery where growth is static or if other problems are identified e.g. abnormal Doppler - to reduce risk of stillbirth. If this is going to be preterm then consider giving corticosteroids.
Aim to deliver at 37 weeks!
Note if FGR and absent or reverse end diastolic volume seen on umbilical artery Doppler then deliver sooner if >32 weeks, otherwise send to foetal medicine
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Uterine vs umbilical artery Doppler studies?
Uterine artery Doppler studies are used at the USS at 20-24 weeks. Will be offered if thought to be more at risk of having a small baby or developing pre-eclampsia. It tells you about the blood flow to the uterus so issues may suggest inadequate placental perfusion. It indicates whether you are at increased risk of these.
Umbilical artery Doppler studies are used in the growth scans, which tend to be later in pregnancy. High resistance or absent end-diastolic flow may suggest compromised foetal circulation.
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Screening pathway for FGR
Moderate risk factors + EFW >10th centile - serial USS from 32 weeks every 3 weeks
If women is unsuitable for monitoring of growth by SFH -> anomaly scan Normal and EFW >10th centile -> serial USS from 32 weeks every 3 weeks
High risk factors + EFW >10th centile and normal UAD - serial USS from 32 weeks every 3 weeks
High risk factors + EFW >10th centile but abnormal UAD - serial USS from 28 weeks every 3 weeks
High risk factors + EFW <10th centile and normal UAD - serial USS from 26 weeks every 3 weeks
High risk factors + EFW <10th centile and abnormal UAD - discuss with foetal medicine!
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LGA baby definition
Newborn weight >4.5kg at birth
During pregnancy an EFW >90th centile
167
Causes of LGA baby
Constitutional
Maternal diabetes
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Male baby
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Risks to mother with an LGA baby?
Shoulder dystocia
Failure to progress
Perineal tears
Instrumental delivery or caesarean
Postpartum haemorrhage
Uterine rupture (rare)
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Risks to baby that is LGA
Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
Neonatal hypoglycaemia
Obesity in childhood and later life
Type 2 diabetes in adulthood
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Investigtaions for a LGA baby?
Ultrasound to exclude polyhydramnios and estimate the fetal weight
Oral glucose tolerance test for gestational diabetes for mother
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What can cause raised AFP?
Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy
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What can cause decreased AFP?
Down’s syndrome
Trisomy 18 - Edward’s syndrome
Maternal DM
