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Obs & Gynae > Antenatal Care > Flashcards

Antenatal Care Flashcards

1
Q

Describe what the terms Gravidity and Parity mean.

A 
Gravidity = the number of pregnancies, of any outcome 
Parity = x + y 
x = live births, still births and neonatal deaths
y = miscarriages, terminations and ectopic pregnancies
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2
Q

What are you inspecting for on the pregnant abdomen?

A 
Symmetrically Distended consistent with pregnancy 
Striae Gravidarum 
Linea Nigra
Umblicius - pigementation, eversion
Scars - DO NOT MISS PAST C-SECTION SCAR 
Dilated Veins
Fetal Movements 
Rashes
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3
Q

What is an appropriate fundal height measurement?

A

The same as the number of weeks gestation +/- 2 weeks

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4
Q

Where do you listen for the fetal heartbeat?

A

Over the anterior shoulder

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5
Q

Whats a normal fetal heart beat?

A

110-160bpm

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6
Q

What should the position of a pregnant lady be during examination and why?

A

Propped up to 30 degrees, or tilted to the left

To avoid aorto-caval compression

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7
Q

How do we describe the level of engagement of the fetal head?

A

In terms of fifths palpable

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8
Q

What do you comment on when palpating the pregnant abdomen?

A

Symphisis-Fundal Height
Number of poles and therefore fetuses
Lie of the fetus - longitudinal, transverse, oblique
Back of the fetus - which side?
Determine presenting part - cephalic or breech
Engagement - fifths palpable
Any areas of tenderness

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9
Q

What dose of folic acid should women take in pregnancy and for how long?

A

400 microg daily

Ideally one month before to 12 weeks gestation

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10
Q

What are the core features of Fetal Alcohol Syndrome

A

Growth Retardation
Mental Retardation
Facial Anomalies
Behavioral Problems

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11
Q

What complications is smoking during pregnancy associated with?

A

IUGR
Miscarriage and Stillbirth
Premature Delivery
Placental Problems

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12
Q

What does the combined screening test for Downs Syndrome consist of? When can it be carried out?

A

Nuchal Translucency Measurement
Serum Test
Can be carried out between 11 and 14 weeks

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13
Q

If a woman misses the window for the combined screening test, what other test can she get done?

A

Quadruple Serum Screening Test up to 20 weeks gestation

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14
Q

What scans does the average woman have antenatally?

A

10-13 weeks - gestational age scan
18-20 weeks - anomaly scan
(if placenta praevia is found at 18-20 week scan, it should be repeated at 36 weeks)

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15
Q

What is done at the 28 week appointment.

A

BP and urinalysis
Screen for anaemia and atypical red cell allo-antibodies
Offer anti-D prophylaxis for all Rhesus Negative Women
Offer Pertussis Vaccination

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16
Q

What is done at the 36 week appointment?

A

BP and urinalysis
Checking for position of the fetus - can attempt ECV if baby is breech
If placenta praevia is was discovered previously this should be checked

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17
Q

if a woman of reproductive age presents with lower abdominal pain and bleeding, what is your differential diagnosis?

A

Ectopic Pregnancy

Miscarriage

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18
Q

Describe the features of a threatened miscarriage.

A

Bleeding - but fetus is still alive
Uterine size consistent with gestation, cervical os is closed
Only 25% will go on to miscarry

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19
Q

Describe the features of an inevitable miscarriage.

A

Bleeding usually heavy, with associated pain
Although fetus may still be alive on US, the cervical os is open
Miscarriage is about to occur

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20
Q

Describe the features of an incomplete miscarriage.

A

Heavy bleeding and pain
Some fetal parts have been passed, but the os remains open
Needs medical or surgical evacuation

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21
Q

Describe the features of a complete miscarriage.

A

All fetal tissue has been passed

Bleeding has diminished, the uterus is no loner enlarged and the cervical os is closed.

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22
Q

Describe the features of a missed miscarriage.

A

The fetus has not developed or dies in utero but it is not recognised until either
Bleeding at a later date
Ultrasound scan
Uterus is smaller than expected for dates and the cervical os is closed
Medical or surgical evacuation of uterus is needed.

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23
Q

What drugs are used for ERPC

A

Anti-progestogen - Mifepristone (sensitises uterus to effects of prostaglandins)
Prostaglandin e.g. gemeprost, misoprostol

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24
Q

What is the definition of recurrent miscarriage and how common is it?

A

When 3 or more miscarriages occur in succession

1% of couples are affected

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25
Q

What Investigations would you do in a couple who presented with recurrent miscarriages.

A

Anti-phosphlipid antibody screen
Karyotype both parents to check for chromosomal incompatibility
Pelvic US, hysterosalpingogram to check anatomy

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26
Q

What are the aetiological factors for developing an ectopic pregnancy?

A 
Previous Ectopic Pregnancy
Previous Pelvic Surgery
Previous Pelvic/Abdo Infections
Use of Copper IUD/ IUS 
Infertility and assisted conception
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27
Q

How might an ectopic pregnancy present?

A

Lower abdo pain and/or PV bleed
Shoulder tip pain and peritonism if bleeding into abdomen
SHOCK - syncope, low BP, tachycardia, increased RR

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28
Q

What different ways are there to manage an ectopic pregnancy?

A

Conservative
Medical - Methotrexate
Surgical - laparoscopic salpingostomy or salpingectomy

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29
Q

Discuss the changes you may see in a serum beta hCG level over two days and what they might mean?

A

An increase in >2/3 indicates a normal pregnancy
A significant decrease indicates a miscarriage
If it stays approximately the same indicates an ectopic pregnancy

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30
Q

What investigations would you do in a fertile woman presenting with lower abdo pain and bleeding?

A

Pregnancy test
Ultrasound scan of abdomen
Serum hCG
May do laparoscopy as a last resort

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31
Q

What is Hyperemesis Gravidarum?

A

When nausea and vomiting in early pregnancy are so severe as to cause severe dehydration, weight loss or electrolyte disturbance.

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32
Q

Describe what gestational trophoblastic disease, and the three different classifications of it.

A

Trophoblstic Tissue (part of the blastocyst which normally invades the endometrium) proliferates in a more aggressive way than is normal.
Hydatidiform mole - proliferation is local and non-invasive
Invasive Mole - Invasive, but localised to ueterus
Choriocarcinoma - if metastases occur

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33
Q

How might a woman with a molar pregnancy present?

A

Vaginal Bleeding - may be heavy
Severe vomiting may also occur
Early pre-eclampsia and hyperthyroidism may also occur

34
Q

How is a trophoblastic pregnancy managed?

A

Trophoblastic Tissue removed by suction curettage and diagnosis is confirmed histologically
In UK women are registered with a supraregional centre who will guide management and follow up
Pregnancy and COCP should be avoided until hCG levels return to normal as it can increase the need for chemotherapy
After every future pregnancy hCG levels should be checked to exclude disease recurrence (reoccurs in 1 in 60)

35
Q

What investigations would you do in a woman in whom you suspected GTD and what would you expect to see?

A

Ultrasound - snowstorm appearance
Bloods - serum hCG can be extremely high
Diagnosis may only be confirmed histologically

36
Q

Describe the Booking Appointment in Antenatal Care

A

Should occur before 12 weeks of pregnancy
Should cover lifestyle topics, social circumstances weight, BP, urine dip
Screening of mother for -
Hep B, HIV, Rubella, Syphilis
Anaemia and RBC allo-antibodies

37
Q

State the difference between pregnancy induced hypertension and pre-eclampsia.

A

Pre-eclampsia - Hypertension AND proteinuria after 20 weeks gestation
Pregnancy Induced Hypertension - Hypertension WITHOUT proteinuria

38
Q

What factors put you at a higher risk for pre-eclampsia?

A

Nulliparity, Increased Maternal Age
Previous Hx, Family Hx, Existing Hyppertension,
Diabetes, Obesity
Twin Pregnancies

39
Q

What are the fetal complication of pre-eclampsia?

A

IUGR, Hypoxia, Placental Abruption, Preterm Birth

40
Q

What are the maternal complications of pre-eclampsia?

A 
Eclampsia
CVA
HELLP syndrome
Renal Failure
Pulmonary Oedema
41
Q

What does HELLP stand for? How do the problems manifest themselves?

A

Haemolysis
Elevated Liver Enzymes
Low Platelets
Get DIC and Liver Failure

42
Q

What is the management of Pre-Eclampsia?

A

Anti-hypertensives e.g. lebetalol
Magnesium Sulphate to prevent seizures
Steroids - to promote fetal lung maturity if baby

43
Q

What are the fetal complications of diabetes in pregnancy?

A

Congential Abnormalities e.g. heart, NTD
Preterm Labour
Macrosomia
Polyhydraminos
Birth Trauma e.g. instrumental delivery, should dystocia due to macrosomia
Fetal compromise, fetal distress and sudden fetal death are more common (particularly related to poor glucose control in third trimester)

44
Q

What are the maternal complications of gestational diabetes?

A 
Hypoglycemia
Increased infection risk 
Increased risk of pre-eclampsia
Trauma from instruments /C-Section due to marosomia/fetal distress
Diabetic Neuropathy, Retinopathy
45
Q

Why do pre-existing diabetics get more complications than getational diabetics

A

Complications are directly related to glucose levels, so pre-existing diabetics will have had higher glucose levels for longer.

46
Q

What can be done in pre-existing diabetics to reduce the risk of pre-eclampsia?

A

Aspirin 75mg daily is advised from 12 weeks.

47
Q

What Risk Factors are there for developing gestational diabetes?

A 
Previous Hx of GD
Previous fetus >4.5kg, Previous unexplained stillbirth
BMI >30 
Racial Origin
1st degree relative with DM
Persistant glycosuria
48
Q

How do we manage Gestational Diabetes?

A

Diet and Exercise
Oral hypoglycemia agent e.g. metformin
Insulin if still poorly controlled

49
Q

What are the risks from obesity in pregnancy?

A

Maternal - Increased risk of VTE, pre-eclampsia, gestational diabetes, caesarean section, wound infections, surgical complications, post-partum haemorrhage and maternal death
Fetal - Increased risk of congenital abnormalities, plus risks associated with pre-eclampsia, diabetes and macrosomia

50
Q

What extra-precautions need to be taken in the care of an obese pregnant woman?

A

High dose folic acid
Vit D supplementation
Pregnancy should be considered high risk, screening for GD and PE should be more frequent
Anaesthetic risk assessment is recommended if BMI > 40
Thromboprophlaxis is frequently used

51
Q

What are the risk factors for VTE in pregnancy?

A 
Previous VTE
Increased BMI
C-section in labour
Prolonged hospitalisation
Increased age, increased parity
Smoker 
Pre-Eclampsia
52
Q

What additional supplementation are epileptic women given in pregnancy?

A

High Dose folic acid (as anti-epileptics increase risk of NTDs)
Oral Vitamin K given from 36 weeks (as haemorrhagic disease of the newborn is increased due to anti-epileptic drugs)

53
Q

What is the best way to manage women with epilepsy if they are of reproductive age.

A

Best to treat them all as if they are contemplating pregnancy, and put them on drugs that are safe in pregnancy. Lamotrigine and Carbamezepine are safest.
As pre-conceptual care is so important (increased folic acid and altering meds - plus people often reluctant to change epilepsy meds in case of recurrence of seizures and driving ban)

54
Q

Describe the core clinical features of obstetric cholestasis.

A

Typically in third trimester
Intense itching - affecting any part of the body but particularly palms and soles. Often worse at night - may interfere with sleep
Some women may develop pale stools, dark urine, jaundice
ABNORMAL LFTs

55
Q

What are the significant risks associated with Obstetric Cholestasis?

A

Associated with increased risk of sudden still birth, fetal distress and preterm delivery

56
Q

How is Obstetric Cholestasis managed?

A

Regular monitoring of LFTs
Ursodeoxycholic acid (UDCA) is medical treatament (shown to improves outcomes for mum and baby and also help itch), topical emollients can also be used for itch.
Vit K can be given from 36 weeks, as there is minimal evidence that mum and baby are at increased risk of haemorrhage, check PT time.

57
Q

In which situation does red blood cell isoimmunisation?

A

Mother is Rhesus Negative and Baby is Rhesus Positive

58
Q

How do we screen fr RBC iso-immunisation and how do we manage it?

A

Mothers blood group and presence of RBC allo-antibodies are checked at booking and again at 28 weeks.
If mum is Rhesus Negative she is given anti-D at 28 weeks and after any potentially sensitizing event

59
Q

What fetal pathology is associated with RBC isoimmmunisation?

A

In order of increasing severity:
Neanatal Jaundice only
Neonatal Anaemia (haemolytic disease of the newborn)
In-utero anaemia - as this worsens causes cardiiac failure, ascites and hydrops and ultimately fetal death.

60
Q

What are the TORCH infections?

A

TORCH infections are a group of congenitally acquired infections that cause significant morbidity and mortality in neonates. These infections are acquired by the mother and passed either transplacentally or during the birth process.
Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes infections

61
Q

What neonatal symptoms might make you consider a TORCH infection?

A

Intrauterine growth restriction (IUGR), microcephaly, intracranial calcifications, conjunctivitis, hearing loss, rash, hepatosplenomegaly, or thrombocytopenia

62
Q

How do we define an Antepartum Haemorrhage?

A

Bleeding from the genital tract after 24 weeks gestation.

63
Q

What are the common causes of APH?

A

Placenta Praevia

Placental Abruption

64
Q

What is the differenc between placenta accreta and placenta percreta?

A

Accreta - placenta implants through a c-section scar so deep the placenta will not seperate from the uterus.
Percreta - Placenta penetrates through the uterine wall and into surrounding structures such as the bladder.

65
Q

How might placenta praevia present?

A

Typically there are intermittent painless bleeds, which increase in frequency and intensity over several weeks. (however 1 in 3 women have not experienced bleeding before delivery)

66
Q

Why do we never perform a vaginal examination in a woman who is bleeding vaginally until praevia has been excluded?

A

Vaginal examination can provoke massive bleeding.

67
Q

In a pregnant woman who presents with vaginal bleeding, what investigations would you carry out?

A

CTG - to check for fetal distress
Bloods - FBC, clotting studes, cross match
Ultrasound scan to look for praevia

68
Q

Why is intra-operative OR post-partum haemorrhage so common with placenta praevia?

A

As lower segment of the uterus cannot contract easily if placenta is there, therefore can’t stop the bleeding.

69
Q

What is a placental abruption?

A

Where part (or all) of the placenta seperates from the uterine wall before delivery of the fetus.

70
Q

How might a placental abruption classically present?

A

Painful Bleeding
Pain - due to blood behind the placenta and in the myometrium
Bleeding - often dark, amount of blood does not relate to severity of abruption as some blood may not escape from the uterus.
Pain or bleeding may occur alone.
Maternal collapse can also be the first presentation

71
Q

What is the difference between a SFD fetus and an IUGR fetus.

A

SFD fetus often determined by constitutional factors e.g. low maternal height and weight, asian ethnic group and female fetal gender - are all associated with smaller babies
IUGR is pathological associated with maternal disease, maternal smoking and alcohol and congenital abnormalities.

72
Q

What investigations are done in babies who are SFD or possibly IUGR?

A

Serial ultrasound scanning to monitor babies growth more carefully
Serial umbilical artery doppler scanning

73
Q

Discuss the different types of twins.

A

Dizygotic twins - 2/3 of all multiple pregnancies, fertilisation of different oocytes by different sperm, no similar than siblings
Monozygotic - results from mitotic divison of a single zygote into “identical” twins. Can have DCDA, MCDA, MCMA twins.

74
Q

What are the most important aetiological factors determining multiple pregnancies?

A

Assisted Conception
Genetic Factors
Increasing maternal age and parity

75
Q

What are all multiple pregnancies at increased risk of?

A

Miscarriage - early (one of a twin can vanish), late miscarriage also more common due to TTTS
Preterm Labour - the main cause of perinatal mortality
IUGR much more common

76
Q

Describe what happens in Twin to Twin Transfusion Syndrome?

A

Occurs in MCDA twins (15% of these twins)
Unequal blood distribution through the shared placenta
One twin the donor is volume depleted and develops aneamia, IUGR and oligohydraminos
The other recipient twin gets volume overloaded and may develop polycythemia, carciac failure and massive polyhydraminos

77
Q

What risks are associated with TTTS?

A

Both twins are at very high risk of in-utero death or severely pre-term delivery
Even with optimal treatment survival of both twins only occurs in about 50%, with one twin in 80%
And about 10% of survivors have neurological disability

78
Q

What problems arise in MCMA twins?

A

In-utero demise is common due to the cords always being entangled and sudden acute shunting of blood between anastemoses between close cord insertions.

79
Q

In what cases is selective reduction of pregnancy appropriate and at what gestation? What are the benefits of it?

A

Can offer it at 12 weeks for women with triplet or higher order pregnancies
It decreases the chance of preterm delivery and cerebral palsy
Can be offered in twins, if one twin has a congenital abnormality (offered before 14 weeks)

80
Q

When is a pregnancy considered prolonged?

A

When >42 weeks gestation are completed.

81
Q

What risks are associated with prolonged pregnancy?

A

Increased risk of stillbirth
Neonatal Illness
Meconium Passage more common
Diagnosis of Fetal Distress increased

Obs & Gynae (6 decks)

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