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P2 > Antenatal care > Flashcards

Antenatal care Flashcards

1
Q

Aim of fetal anatomy scans

A

To optimise ANC by providing accurate diagnostic information

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2
Q

Indications for earlier scans (before routine anomaly scan)

A

Abnormal first trimester scan
Parent with congenital anomaly
Prev fetal anomaly
Teratogenic drugs
High risk first trimester screening
Consanguinity
Two inconclusive NIPS

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3
Q

When would a single repeat scan be done

A

Done if optimal images not seen by 26/40
Can be due to:
- increased BMI
- large fibroids
- abdominal scarring
- suboptimal fetal position
* if second USS doesn’t give clear images, should be referred for fetal med review

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4
Q

NB things to be noted on anomaly scan

A

Fetal biometry: BPD, HC, AC, FL. Discrepancy >10-14/7, rescan in 2/52
Amniotic fluid: DVP <2= oligo, >8 - poly
Number of pregnancies
Placenta location including leading edge
Cardiac function
Placental cord insertion

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5
Q

Definition and management of low-lying placenta

A

<20mm from os
Repeat USS at 34/40
If low-lying and > PAS –> fetal med reivew

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6
Q

Risk factors for vasa praevia

A

Velamentous cord insertion
Placenta dysmorphology
Low lying or bilobed placenta
Multiple pregnancy
IVF

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7
Q
A
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8
Q

When to give prophylactic progesterone

A

Hx of spontaneous PTL <34/40
Pregnancy loss from 16/40
Cx length </= 25mm on TVUS from 16-24/40

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9
Q

When to stop PV progesterone

A

34/40

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10
Q

When to do cerclage

A

Cx <25mm
PPROM in prev pregnancy
Hx cervical trauma

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11
Q

Dx and mx PPROM

A

Spec +/- amniosure
Erythromycin 250mg QDSx 10/7
Screen for infection - FBC, CRP, VS, MSU
CTG

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12
Q

When NOT to do cerclage

A

infection
Active PVB
Uterine ctx

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13
Q

When to consider cerclage

A

Between 16-24/40
Dilated cx + unruptured membranes

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14
Q

Management of PTL with intact membranes

A

Suspected labour </=29+6
- tocolysis
- maternal corticosteroids
At 30+
- TVUS for cx length
— >15mm: unlikely PTB
— < 15mm: tocolysis and steroids

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15
Q

Use of fetal fibronectin

A

Likelihood of birth within 48 hours
+= tocolysis and steroids

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16
Q

Considerations for tocolytics

A

Consider:
- suspected/ dx labour
- gestational age
- likely benefit of corticosteroids
- NICU availability
Consider nifedipine 24 - 33+6 if intact membranes and suspected PTL
Oxytocin receptor antagonists if nifedipine contraindicated

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17
Q

When to give maternal corticosteroids

A

Offer 24 - 35+6
Consider single repeat dose if <34/40
- already had corticosteroids > 7/7 ago AND
- very high risk birth
Do not give more than 2 doses for PT babies

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18
Q

When to use MgSO4 in PTL

A

23 - 23+6 and delivery within 24 hours
Offer from 24 - 29+6 if established PTL or planned PTB within 24 hours
Consider from 30 - 33+6 if established PTL or planned PTB within 24 hours

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19
Q

Dosing of MgSO4

A

4g IV bolus over 5 minutes then 1g/hr until birth or for 34 hours
* if oliguric or renal failure, monitor Mg

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20
Q

Invasive fetal monitoring in PTL

A

Do not use FSE <34/40
Can use FSE if 34+0 - 36+6
Do not use FBS < 34/40

21
Q

High risk patients for PTL

A

Prev PTL
Prev cone biopsy, multiple LLETZ procedures
Prev fully dilated section
Short cx/ open cx at anatomy scan
Mid trimester ROM
Third trimester ROM

22
Q

Incidence of PPROM

A

2% pregnancies
40% of PTL

23
Q

PPROM complications leading to NND

A

Prematurity
Sepsis
Pulmonary hypoplasia

24
Q

Signs of chorioamnionitis

A

Maternal tachy
Pyrexia
Leucocytosis
Uterine tenderness
Malodourous PV discharge
Fetal tachy
Labs: raised WCC, CRP

25
Q

Ix in PPROM

A

SSE +/- amniosure to dx/ confirm
Weekly FBC and HVS
Fetal monitoring
USS
Home monitoring can be considered after 72 hours observation
- twice daily temp checks

26
Q

Management of PPROM

A

Erythromycin 250mg QDS x 10/7
Steroids if 24-34/40
If chorio suspected- broad spectrum IV ab to cover GBS, E coli, listeria, anaerobes
- co-amox not recommended d/t risk of NEC
- Delivery
Consider delivery after 34/40, no later than 36+6
- increased risk of chorio
- decreased risk of resp problems

27
Q

Risk factors for PAS

A

Prev CS (7x inc risk)
Increased risk with more CS (67% w 4+ CS)
Uterine surgery - myomectomy, D&C
AMA
ART
Placenta praevia and CS

28
Q

Maternal morbidity assoc w. PAS

A

MOH
Median loss >2000ml
80% require RCC

29
Q

Incidence of PAS

A

1 in 2000 pregnancies

30
Q

Diagnosis of PAS

A

Clear documentation of placenta site at anatomy scan if prev CS
Suspicious features –> US by fetal medicine
Standardised reporting for PAS ultrasound features
MRI for suspicious USS

31
Q

2D grayscale features suspicious for PAS

A

Loss of clear zone - loss/ irregularity of hypoechoeic plane in myometrium under placental bed
Abnormal placenta lacunae
Bladder wall interruption
Myometrial thinning - myometrium overlying placenta <1mm or undetectable
Placental bulge - deviation of uterine serosa away from expected plane
Focal exophytic mass - placental tissue breaking through serosa and extending beyond it

32
Q

2D colour doppler features of PAS

A

Uterovesical hypervascularity
Subplacental hypervascularity
Bridging vessels - often perpendicular to myometrium, extend from placenta across myometrium and beyond serosa
Placental lacunae feeder vessels

33
Q

3D USS +/- doppler features of PAS

A

Complex irregular arrangement of numerous placental vessels, exhibiting tortuous courses and varying calibres

34
Q

Antenatal care of PAS

A

MDT: fetal med, anaestetics, surgeon w expertise in complex pelvic surgeries (onco-gynae)
? PAS <24/40 - review at 24/40
? PAS > 24/40 - review within 7/7

35
Q

Outpatient ANC for PAS

A

Suitable for PAS with no bleeding
Clearly documented delivery plan in chart
Routine FBC
Small risk of FGR - US for growth at 28, 32 and 34/40
Physio referral
Antenatal eduction

36
Q

Delivery considerations in PAS

A

If recurrent APH, admit until delivery, XM available
Delivery at 34 - 36+6 (individualised)
Consent with senior
Decision for hyst vs conservative: MDT decision; consider woman’s preference, severity and surgical expertise
IR on case-case basis
Aortic balloon

37
Q

Postnatal considerations in PAS

A

VTE
Fe 6/52 if anaemic antenatally
Physio
PNMH
Debrief at 6/52
Specimen for pathology to be reported as per FIGO
Final histo r/v at MDT

38
Q

Risk factors for placenta praevia

A

Prev CS (incr w number of CS)
sTOP
Multiple pregnancy
AMA
Smoking
ART
Deficient endometrium: MROP, endo, curettage, fibroids

39
Q

Diagnosis placenta praevia

A

low lying: <20mm from internal os on TV or TA USS after 16/40
Covering os = praevia

40
Q

Complications of placenta praevia

A

Maternal:
- anaemia
- infection
- mat shock
- coagulopathy
- incr hospital stay
- psych trauma
- blood transfusion
Fetal:
- hypoxia
- SGA/ IUGR
- prematurity (SOL/ iatrogenic)
- fetal death

41
Q

DDx APH

A

Abruption
Praevia
Vasa praevia
Ca cxS

42
Q

Screening for placenta praevia

A

Placental localisation at anomaly scan
Low-lying at anomaly –> rpt at 32/40
Still low-lying at 32/40 –> TVUS at 36/40 if no PVB

43
Q

Ix if ? praevia

A

SSE
USS: placenta location, FH
FMH: Kleihauer
CTG

44
Q

Management placenta praevia if active bleeding

A

MDT
Admit, consider d/c if no bleeding for >48 hours
IV access, bloods, G+XM, coag +. fibrinogen
USS
SSE
Dexa if <34/40
MgSO4 if <32/40
+/- antiD

45
Q

Delivery of placenta praevia

A

Hx bleeding: 34- 36+6
No bleeding: 36 - 37
Deliver in unit w onsite transfusion service
Senior obs and anaesthetics present
Rapid infusion and warming devices available
Consider vertical skin +/- uterine. if transverse lie to avoid placenta, esp <28/40

46
Q

Placenta praevia grades

A

Minor:
- 1. Low lying, not reaching os
- 2. reaches os, doesn’t cover
Major:
- 3. Covers int os asymmetrically
- 4. Covers internal os symmetrically

47
Q

Teratogenic drugs

A

TERATOWA
T- Thalidomide, Tobacco
E- Epileptic meds (valproate, phenytoin)
R - Retinoids (vit A, tretinoin, isotretinoin)
A- ACE inibitors, ARBs
T- The third element, lithium
O- oral contraceptives, hormones
W- Warfarin
A- Alcohol

48
Q
A

P2 (11 decks)

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