Antenatal Care Flashcards
Which 3 features of female pelvis should be palpable O/E
Ischial spines, sub-pubic arch, sacrospinous ligament base
What important features of Hx (5) /Ex (3) are taken at booking?
LMP Sexual Hx Ob Hx PMH(/Surgical) FH + SH*
Smear (if overdue)
Obs
Abdo exam
What other (blood) tests are done on booking?(4)
HIV/Hep/Syphilis
Rubella immunity
FBC
Rh Grp/sickle/thalass
What is done at 9-12wks?
Dating scan (+ if twins)
Trisomy blood tests (+poss CVS)
Nuchal translucency
What is done at 20wks?
Anomaly USS
Counsel if any abns
List some anomalies scanned for at 20wks (6)
Gastroschisis Exopthalmos ToF/Cardiac Diaphragmatic hernia Duodenal fistula (Down's + polyhydramnios) Neural tube defects
What may USS’s later (>20wks) be done for?
Breech
Suspected IUGR
Polyhydramnios
Most common neural tube defects + Incidence (%)
Spina bifida + Anacephaly
0.5%
Incidence of cardiac defects
Commest type
How/when Dx
1%
VSDs commonest
increased nuchal translucency 9-12wk USS
3 RFs for cardiac defects
Congenital cardiac disease/structural/csomal abn
Previous affected offspring (3% recurrence)
DM
Describe difference b/wn exopthalmos + gastroschisis
Exopth: abdo extrusion in peritoneal sac - 50% csomal prob
Gastro: free bowel loops in amniotic cavity (rarely csomal)
What do diaphragmatic hernia babies usually die of
other structural abns / plum hypoplasia
Incidence of polyhydramnios + RFs (5)
1% Idiopathic DM Renal Failure Twins Fetal anomaly (structural/ e.g. dystrophy)
4 clinical features of polyhydramnios
maternal discomfort
unpalpable fetus
symphisis fundal height >90th centile
liquor pool >10cm
2 complications of polyhydramnios
preterm
abnormal lie
When/how is polyhydramnios managed?
<34wks + severe
Amnioreduction
NSAIDs (reduce fetal urine output) / Steroids
What are some causes of fetal hydrops (Immune/Non-immune)
Immune: haemolytic anaemia
Non imm: csomal, structural, cardiac, cardiac failure assoc anaemia, twin-twin transfusion syndrome
Indicators/RFs for Trisomy 21 (5)
Maternal age Prev affected baby (+risk 1%) Carriers of genetic translocation Thickened NT Structural abns
What tests (+ in which trimesters) used for risk assessment of Downs
1st T: age + B-hCG + PAPP-A (= risk assessment - 75% sensitivity)
2nd T: Oestriol +hCG-B + AFP (= triple test)
What % people Rh-ve?
What are diff subtypes of Rh Grps
15%
C, D + E (only D bio active)
% Rh-ve mothers carry Rh+ve baby? (thus % of all preg woman risk developing anti-D Abs)
2/3rd Rh-ve mums carry Rh+ve
= 10% all preg woman
Describe the pathophysiology of Rhesus disease
initial exposure -> small IgM response (doesn’t cross placenta)
subsequent exposure -> larger IgG response (does cross)
RBC destrcution + anaemia (unless sufficient haemopoeisis from BM/liver/spleen)
-> hypoxia + acidosis (-> hepatic/cardiac func)
-> fetal hydrops
What is fetal hydrops
Generalised oedema of skin/ascites
Pleural/pericardiac effusion
Other effects of rhesus disease (other than feral hydrous)
Postnatal jaundice (increased haemolysis/bilirubin) thus can -> kernicterus
What kind of immunity does IM anti-D give
Passive immunity in non-sensitised woman
What dose of anti-D given (+ within what hours after event)
<20wks = 250iu within 72hrs >20wks = 500iu
What test should be done after delivery in Rh-ve woman
Fetal cord sample - Rh Grp of baby
if baby Rh+ve -> blood film of mum’s for Kleihauer test (quantifies antiD dose needed)
What causes of placental bed disruption can -> feto-maternal haemorrhage (7)
Birth
Miscarriage / ectopic
APH
Spontaneous bleed
Trauma
Amniocentesis
EVC
What 3 factors would mediate an immune response from feto-maternal haemorrhage in a Rh-ve woman
Blood volume
Maternal responsiveness
Antigenic potential
Why would ABO incompatibility paradoxically be able to offer some protection against Rh disease?
Transfused cells are likely to be haemolysed by circulating maternal Abs (reducing risk of Rh immunisation)
What 2 features may present with Rhesus disease of newborn
Reduced fetal movements
Polyhydramnios
What fetal assessments may be done in Rh-ve women
Cerebral aa doppler + CTG + fetal movements
abnorm parameters -> fetal blood sample
Risk of fetal blood sample / cordocentesis
Cord haematoma
Fetal bradycardia
Intrauterine death
Further maternal sensitisation
At what IU/ml antibody is classed as significant
> 15IU/ml (or a sudden rise)
if Rh intra-utero transfusion (IUT) occurs, how is delivery done?
induce at 35wks: mild - NVD, hydropic - C-sec
Survival rates for non-hydropic/hydropic fetuses
non-hydropic = >90% hydropic = 75%
Indicators for high-risk pregnancy / consultant-led care
6 prepregnancy RFs + 5 antenatal RFs
Poor Ob Hx Prev small baby Maternal disease Assisted conception Extremes of repro age Drugs/smoking
Hypertension/proteinuria Vag bleeding SGA baby Prolonged preg Multiple preg
Increased PAPP-A suggests…?
Decreased PAPP-A suggests…?
increased = abnormal no/ csomes decreased = placental problems
What are the criteria for glucose tolerance testing
FH DM
Persistent glycosuria
Previous LGA baby
Maternal smoking is associated with: (5)
Low birth weight / IUGR Placental abruption Emotional/Intellectual impairment Pre-term labour SIDS
Incidence of breech presentation at:
20wks
32wks
Term ?
20wks = 40% 32wks = 25% Term = 3%
What 5 conditions are assoc w. breech presentation
Fibroids Multiple preg Bicornuate uterus Placenta praevia Poly/oligohydramnios
What Fe level / MCV would be indication for Fe supplements
Fe < 10.5 g/dl
MCV < 80fl
What 3 things associated with Prolonged pregnancy increase the perinatal mortality rate?
unexplained intrauterine death
meconium aspiration syndrome
intrapartum hypoxia
What 4 parameters assessed in Fetal Biophysical Profile (BPP)?
+ 2 advantage/disadvantages over other fetal assessments
Breathing Movements
Movements
Tone
Liquor
Useful in high-risk (where CTG/Dopp ambiguous)
Not useful in low-risk + time consuming
What does Umbilical aa Doppler assess/ correlate with?
What does the graph look like
Downstream placental vascular resistance
Reduced blood flow correlates with fetal compromise
End-disastolic flow may stop/reverse
What is Umbilical aa Doppler good for assessing?
Pregnancies at risk of hypoxia (due to impaired placental func)
No use in low-risk preg
Which Abx should be avoided/cautioned in pregnancy?
Avoid: Tetracycline + Trimethoprim
Caution: Metronidazole + Augmentin
What psychiatric drugs should be avoided in preg?
What anticonvulsants should be avoided in preg?
Lithium, Paroxetine
Lamotrigine, Valproate (carbamazepine best)
What antihypertensives/anticoag drugs should be avoided in preg? + why?
ACEis - teratogenic + fetal renal failure
Warfarin - teratogenic
When can USS most accurately determine gestation + why?
+ what are the most reliable measurements taken from USS? (+when)
<20wks - presumed all foetuses same size til then
Crown-rump length: 8-14th wk
Biparietal diameter: 16-20th wk
What genetic factors can lead to a small baby?
Ethnicity (asian)
Csome abns (Trisomy)
Female
Structural abns
What fetal infections can lead to a small baby?
CMV, Toxoplasmosis, Malaria, Rubella
What maternal factors can lead to small baby? (8)
Extreme starvation Oxygen supply: high altitude, congenital heart disease (chronic hypoxia) Tobacco + alc Maternal chronic disease Pregnancy complications (pre-ec) Low maternal ht/wt Maternal nulliparity
How does a fetes with congenital heart disease + chronic hypoxia (partly) compensate for better oxygen supply?
Placental hypertrophy
How does the placental normally develop in the 1st + 2nd Trimester?
1stT: trophoblast cells invade spiral aa’s in decidua
2ndT: trophoblast extends invasion along spiral aa’s into myometrium
How to maternal vessels change within placenta in 2ndT?
Thick muscular vessels w/ high resistance
Flaccid thin-walled vessels w/ low resistance
How may failure of 2nd stage (e.g. pre-eclampsia) of placental development actually → placental vasoconstriction?
Placental ischaemia ⇒ endothelial cell damage → reduced prostacyclin (vasodil) + raised thromboxane (vasocon) → net placental vasocon
How does the fetus compensate for hypoxia (NB not chronic - placental hypertrophy)
How does this present in the baby?
How is this phenomena investigated/Dx?
Increased erythropoesis (to increase O2 carrying capacity)
Reduced flow to peripheral circ + redistributed to heart/brain/adrenals
Normal length / brain development but little glycogen stores / subcutaneous fat
Middle cerebral aa Doppler shows head sparing (increased end-diastolic in MCA)
How is a SGA baby managed?
How is IUGR baby managed at:
36+wks?
34-36wks?
<34wks?
2wk serial growth scans w/ umbilical aa Dopplers - no Ix required
36+ wks → deliver
34-36wks → regular umbilical aa Doppler + CTG + consider delivery
<34wks → same as 34-36wks but with steroids
What incidence of hypertension in pregnancy?
+ 3 diff types?
15% pregnancies
Pre-existing (identified <20wks)
Pregnancy-induced
Pre-eclampsia
What BP changes happen in normal pregnancy?
Increased AT2
Decreased peripheral vascular resistance
→ Net reduction in BP (1st T up, 2nd T down, 3rd T rise again)
How is pre-eclampsia Dx?
BP >140/90
Proteinuria >0.3g/24hrs
What are the parameters/criteria for Mild/Moderate/Severe pre-eclampsia?
Mild: >140/90 + proteinuria (>0.3g/24hrs)
Moderate: >150/100 + proteinuria (>0.3g/24hrs) + no maternal complications
Severe: >160/100 + proteinuria + maternal complications
Risk Factors for Pre-Eclampsia (9)
Nulliparity DM Autoimmune disease Extreme repro ages Twins Renal disease PMH/FH Chronic hypertension Obesity
List 5 Maternal Complications of severe Pre-eclampsia
HELLP syndrome Eclampsia CVA (haemorrhagic) Renal Failure Pulm Oedema
How does eclampsia occur + how treated?
Vasospasm → grand-mal seizures
Magnesium sulphate
How does CVA occur in pre-eclampsia?
+ how is it prevented?
Failed cerebral flow autoregulation
Anti-HT meds should prevent
What does HELLP syndrome consist of?
What clinical signs seen?
What is a further complication of HELLP?
Haemolysis: dark urine, raised LDH, anaemia
Elevated Liver Enzymes: epigastric pain, liver failure, abnormal clotting
Low Platelets
Can → DIC
How is renal failure (as a complication of pre-eclampsia) managed?
Monitor fluid balance + creatinine
Haemodialysis for severe
How does pulmonary oedema occur as a pre-eclampsia complication?
What condition may it further →?
How is it managed?
Fluid overload
→ ARDS
Give O2 + Furosemide
What fetal complications may occur from pre-eclampsia
IUGR
Hypoxia
Preterm
Placental abruption
What maternal blood tests can be done to monitor pre-eclamspia complications?
LDH ↑
LFTs ↑
Platelets ↓
Uric acid ↑
Hb ↑
Creatinine ↑
What fetal investigations can be done to monitor pre-eclampsia complications?
USS
Umbilical aa Doppler
What 3 measures can be done to screen/prevent pre-eclampsia?
all women: regular BP / urinalysis
Uterine aa Doppler at 23wks
Low-dose aspirin
List some signs/symptoms that may indicate pre-eclampsia
Hyperreflexia + ankle clonus Frontal headaches Agitation Visual disturbances Epigastric pain (v bad) Fluid retention + ↓ urine output Retinal oedema/haemorrhage, papilloedema
What is the management for pre-eclampsia if <34wks and >34wks?
<34wks: conservative best if BP / blood tests/ fetal condition stable
If not then LSCS
> 34wks: induction (+ epidural + antihypertensives)
(epidural to avoid pushing - esp if >160/100)
What are the 5 main principles in pre-eclampsia management?
Control maternal BP (DBP < 100) using antihypertensives
Fluid balance (too much = plum oedema; too little = renal failure) → CVP monitoring can differentiate b/wn renal failure + intravascular fluid depletion
Prevent seizures
Consider delivery
Post-delivery - continue monitoring complications
How must eclampsia be managed?
L side tilt (to avoid aortocaval compression)
High flow 02
Magnesium sulphate
How + why must magnesium sulphate be regularly monitored?
Causes neuromuscular toxicity
Check tendon reflexes (patellar)
What BP classifies as gestational HT?
What are its RFs
> 140/90
RFs same as pre-eclampsia
What are some causes of pre-existing hypertension in pregnancy? (CV ERODE)
Coarc of Ao Vascular disease Essential HT Renal disease Obesity Diabetes Endocrine
Complications of pre-existing hypertension (3)
Super-imposed pre-eclampsia
IUGR
Placental abruption
Why can’t normal antihypertensives be used in pregnancy?
Which ones are used instead?
Diuretics = contraindicated ACEis = teratogenic
Labetolol, Nifedipine, Methyl Dopa
What are the RFs for superimposed pre-eclampsia? (ABCDR)
Age >40 BP >160/100 Connective tissue disease Diabetes Renal disease
How is pregnancy ‘diabetogenic’
+ How does it cause macrosomia?
Altered carb metabolism + antagonistic hormonal effects = ↓ GTT (glucose tolerance test)
↑ fetal blood glucose = hyperinsulinaemia = ↑ fat deposition = macrosomia
What are some fetal complications of gestational diabetes? (5)
Congenital abns (neural tube/cardiac) Macrosomia Preterm labour (+lung immaturity) (natural/induced in 10%) Polyhydramnios (↑ fetal urine) Shoulder dystocia / birth trauma
Maternal complications of gestational diabetes (7)
↑ insulin requirement + Hypoglycaemia (in attempt to control)
Hypertension (Pre-Ec / assoc w/ pre-existing)
Pre-existing IHD worsens
UTI
Wound/endometrial infection
LSCS/Instrumental
Neuropathy/Retinopathy
What pre-conceptual (2) + antenatal (5) management/monitoring taken for pre-existing maternal diabetes?
Preconceptual:
Assess/manage retinas/renal/BP (e.g. low-dose aspirin)
Max folic acid
Antenatal: HbA1c, reg glucose levels Fetal ECHO Umb aa doppler Serial growth scans (inc liquor vol)
How should delivery be managed in pre-existing diabetes?
39wks
Insulin + dextrose infusion during labour
What neonatal complications often seen post-delivery? (other than macrosomia etc)
Resp distress (even >38wks) Hypoglycaemia
Screening Qus / RFs for gestational diabetes (9)
Prev large baby
Prev stillbirth
Prev gestational diabetes
1st degree relative diabetic
South-Asian/Caribb/Middle Eastern
BMI >30
PCOS
Persistent glycosuria
Polyhydramnios
Any +ve to screening Qus/RFs for gestational diabetes indicates for what investigation?
28wk GTT
What is the stepped management for gestational diabetes?
And what would indicate moving up a step?
- glucose monitoring / Diet+Exercise
- Oral hypoglycaemics
- Insulin/treat as normal DM
If >6mmol after each, move up a step
What cardiac changes happen in pregnancy?
What signs commonly seen? (2)
↑CO + ↓Resistance
Ejection systolic murmur in 90% (due to ↑ blood flow)
ECG changes: L axis deviation + inverted T waves
What are the 4 main principles of managing maternal cardiac disease
Regular anaemia checks
Thromboprophylaxis (LMWH)
Monitor fluid balance in labour (epidural ↓ afterload)
Abx in labour to prevent endocarditis
How are these maternal cardiac conditions managed ?
Mild abnormalities (eg VSD) - usually fine
Pulm hypertension (eg Eisenmengers, VSD) - ToP (40% maternal mortality)
Aortic stenosis - ideally correct before preg (allow ↑CO)
Mitral disease - treat before preg
What respiratory changes occur in pregnancy?
↑ Tidal Vol by 40%
No change RR
What changes, if any, are made for asthma management in pregnancy?
None - drugs safe and no perinatal effects if well controlled
If steroids used, ↑ requirement for labour
What changes are made for epilepsy management in pregnancy?
Manage seizure control before pregnancy
As few anticonvulsants as poss w/ max folic acid (neural tube defects risk ↑ 4%)
What is postpartum thyroiditis? What can it further lead to?
What is its incidence?
RFs
Transient hyperthyroidism for 3m then hypothyroidism 4m (20% permanent)
Can lead to postnatal depression
Occurs in 5-10%
RFs: Antithyroid Abs + T1DM
What obstetric complication is at increased risk in hypothyroidism?
Pre-eclampsia (Antithyroid Abs)
Why rare to have pregnant lady with untreated thyroid disease?
What thyroid symptom commonly seen in pregnancy?
What effect on fetus if mother on thyroxine?
Both hyper/hypo cause anovulation
Goitre common
Fetus dependant on thyroxine until 12wks
Intrahepatic cholestasis: Incidence/Recurrence rate Why does it occur Signs/Symptoms 2 Complications
How managed
0.7% but 50% recurrence Cholestatic effect of oestrogens Abnorm LFTs + pruritis w/o rash 1% risk stillbirth due to toxic bile salts Risk haemorrhage (mum&baby)
VitK at 36wks + Induced at 39wks
List some of the clinical criteria for antiphospholipid syndrome (4), must have 1+
Vascular thrombosis
3+ losses at <10wks (unexplained)
1+ loss >10wks
Early pre-eclampsia / IUGR needing delivery <34wks
List some of the lab criteria for antiphospholipid syndrome
Lupus anticoagulant
High cardiolipin Abs
High anti-B2-glycoprotein I Ab
What obstetric risks with SLE?
What condition is SLE assoc w.?
Same as Hypertension + Renal disease: Pre-Eclampsia IUGR Placental Abruption Polyhydramnios Preterm
SLE assoc w. antiphospholipid syndrome
What maternal (1) + fetal (4) possible complications can occur in pre-existing renal disease?
Maternal renal function may deteriorate
Fetal: Pre-Eclampsia, IUGR, Polyhydramnios, Preterm
Why is asymptomatic bacteruria treated in pregnancy?
20% likelier to lead to pyelonephritis (1-2% risk)
Symptoms of pyelonephritis
Treatment
Common organism + resistance
Fever/Rigors Vomiting Abdo pain / Loin tenderness Dysuria Tachycardia
IV Abx
E.Coli (75%) - usually amoxicillin resistant
Why is pregnancy / post-natal considered prothrombotic? Explain the physiology
↑ Clotting factors
↓ Fibrinolytic activity
Mechanical obstruction to flow
Immobility
What is the incidence of DVT in pregnancy?
Where is a DVT most likely to occur
How Dx?
1%
Iliofemoral, and more likely L side
Doppler + poss venogram
How is PE diagnosed?
CXR, CT, ABG ± VQ
ECG (but mimics normal pregnancy ECG changes)
What 4 measures of thromboprophylaxis can be taken?
General - mobility/hydration
Compression stocking
Antenatal LMWH (for high risk; stopped during labour)
Postnatal LMWH prophylaxis
What factors are considered high risk for VTE (2)
and its management
Previous VTE
LMWH used antenatally
→ 6wks LMWH
What factors are considered intermediate risk for VTE (6)
and its management
BMI > 40 C-Section in labour (not elective) Prolonged hospitalisation Medical Illness Thrombophilia (screen before Tx) IVDU
→ 1wk LMWH if 1+ factor
What factors are considered moderate risk for VTE (12)
And its management
Age > 35 BMI > 30 Parity ≥3 Smoker Elective C-Section Immobility Varicose veins Pre-Eclampsia PPH Current systemic infection Labour >24hrs Forceps delivery
→ 1wk LMWH if 2+ factors
What is the prevalence of obesity in pregnancy?
20% have BMI > 30
What are some of the maternal risks (6)
VTE Pre-Eclampsia Diabetes C-Section needed (+difficult surgery / wound infections) PPH Maternal death
What is the basic management of Obesity in pregnancy?
What BMI is classed as high-risk
What BMI is classed as an anaesthetic risk
Preconceptual wt loss advised (not advised during pregnancy)
Max-dose Folic Acid + VitD
BMI ≥ 35 = high-risk
BMI ≥ 40 = anaesthetic risk
Which SSRI should be avoided in pregnancy and why?
Which anti-psychotics should be avoided in pregnancy? (2)
Paroxetine → cardiac defects
Olanzapine + Clozapine
What is the incidence of Fe defc anaemia in pregnancy?
What Hb levels do symptoms appear + treatment given
What changes also seen on FBC?
10%
Symps at Hb<9, treat with Fe/Folic acid at Hb<11
MCV (initially norm) and ferritin both reduced
How is Fe defc anaemia differentiated from Folate/VitB12 defc anaemia?
Increased MCV - consider when anaemia w/o microcytic
What dietary advice is given to avoid anaemia?
Foods rich in iron: meat, eggs, green veg
Foods rich in folic acid: Green veg. fish
Sickle cell anaemia: common ethnicities, common features
Thalassaemia: common ethnicities, common features
Sickle: Afri-Caribb, crisis of chest pain/fever
Thalassaemia: SE Asian + Mediterranean, Fe overload/Chronic anaemia
Prevalence of HIV in pregnancy in UK
↑ Risk of what maternal conditions ?
1000/yr
Pre-Eclampsia + Gestational DM commoner
Maternal HIV has an ↑ risk of what fetal effects? (4)
Pre-Eclampsia
IUGR
Premature
Stillbirth
What pregnancy problems can occur with drugs used in HIV?
Antiretrovirals increase risk of pre-eclampsia (but not teratogenic)
Co-trimoxazole (for PCP) is folic-acid antagonist
What periods is there biggest risk of vertical transmission of HIV? (3)
What conditions make this risk even greater?
> 36wks
Intrapartum
Breastfeeding
Low CD4 / High viral load
Premature
ROM >4hrs
What 4 principles in management reduce the risk of HIV vertical transmission?
Maternal antiretrovirals
Neonatal antiretrovirals
Elective C-Section
Avoidance of breastfeeding
What is the prevalence of Chlamydia + Gonorrhoea in pregnancy?
What complications are they assoc w.?
Chlamydia - 5%
Gonorrhoea - 0.1%
Assoc w. preterm + neonatal conjunctivitis
What symps seen in BV ?
What pregnancy complications can BV cause?
Asymp or offensive vaginal discharge
Increased risk of preterm / late miscarriage
Fetal effects of Opiate use in pregnancy (4)
Neonatal effects (3)
Preterm labour
SGA
Anaemia
Multiple Gestation
Neonatal withdrawal syndrome
Higher risk of SIDS
Higher perinatal mortality
Fetal effects of Cocaine use in pregnancy (3)
Neonatal effect(s)
Placental abruption
Preterm delivery
SGA
Increased cerebral infarction risk
Fetal effect(s) of cannabis use in pregnancy
Preterm delivery
