Antenatal Care

Question 1

PRECONCEPTUAL CARE

Answer 1

1. Health check before conception
   - previous pregnancies
   - cervical smear abn.
2. Rubella status. Immunize if needed
3. Folic acid 0.4mg/d
4. Optimise glucose control in diabetics
5. Optimise antiepileptics ie lamotrigine is safer.
6. Lifestyle advice: smoking, alcohol, drugs

Question 2

BOOKING APPOINTMENT

Answer 2

• 8-12w(Ideally <10w)
• Info on lifestyle: work, nutrition(folic acid 400 mcg/d till 12w, avoid vit A, supplements, vit D 10 mcg/d), food-acquired infections ie listeriosis and salmonella, alcohol, sex, smoking, air travel, moderate exercise
• BP, urine dipstick, BMI
• FBC, blood group, rhesus, red cell alloantibodies, haemoglobinopathies.
• Hep B, HIV(offered to all), Syphilis, rubella
• Urine culture for asymptomatic bacteriuria(risk of pyelonephritis)
• CO testing(NHS Lothian)
• introduce antenatal classes

Question 3

TIMETABLE

Answer 3

1. 10-13+6w
   - USS confirm dates, exclude multiple pregnancy
2. 11-13+6w
   - Offer Down’s syndrome screening w nuchal scan
3. 16w
   - discuss results
   - Consider Fe if Hb<11g/dl
   - BP and urine dipstic
4. 18-20+6w
   - elective anomaly scan
5. 24-25w(if primip)
   - BP, urine dipstick, SFH
   - exclude early-onset pre-eclampsia
6. 28w
   - BP, urine dipstick, SFH
   - 2nd screen for anaemia and atypical red cell alloantibodies. consider Fe if Hb<10.5 g/dL
   - 1st dose anti-D if indicated
7. 31w(if prim)
   - BP, urine dipstick, SFH
   - discuss results of 28w scan.
8. 34w
   - BP, urine dipstick, SFH
   - 2nd dose anti-D if indicated
   - Discuss labour and birth plan
9. 36w
   - BP, urine dipstick, SFH
   - Check presentation, ECV if needed
   - Info on neonatal care, postnatal care, breastfeeding
10. 38w
    - BP, urine dipstick, SFH
11. 40w(if prim)
    - BP, urine dipstick, SFH

• > 42w
• if IOL declined, CTG 2x/week and USS of maximum amniotic pool depth

12. 41w
    - BP, urine dipstick, SFH
    - Discuss labour, membrane sweeping and IOL.

Question 4

IMPORTANT RISK F.

1. History
2. Examination

Answer 4

1. a) Age: <17 and >35 increased risk of complications
   b) Recurrence risk: PPH, GDM, Pre-eclampsia, IUGR, SGA, preterm labour, rhesus disease
   c) FHx: Diabetes(first degree relative), pre-eclampsia, autoimmune disease, hypert., thromboembolism
   d) Gynae: Fertility drugs, assisted conception, prev. uterine surgery, cervical smear
   e) PMH: diabetes, hypert., autoimmune, haemoglobinopathy, thromboembolic disease, cardiac and renal disease. ask about depression.
2. • uterus usually palpable from 12w onwards.
     - baseline BP, BMI

Question 5

MINOR ASSOCIATED CONDITIONS

Answer 5

1. Itching
   - check LFTs
   - liver complications rare
2. Heartburn
   - extra pillows, antacids
3. pelvic girdle pain/symphysis pubis dysfunction
   - physiotherapy, corsets, analgesia
4. Abdominal pain
   - usually benign unexplained
   - caution appendicitis, pancreatitis. UTI, fibroids are also causes.
5. Backache
   - Physiotherapy, posture
6. Constipation
   - exacerbated by oral iron
   - stool softeners, high-fibre
7. Ankle oedema
   - Common
   - Caution if sudden increase
8. Carpal Tunnel syndrome
9. Vagnitis
   - due to candidiasis
   - more diff to treat
   - imidazole vaginal pessaries(clotrimazole) for symptomatic relief

Question 6

PRENATAL TESTING FOR CONGENITAL ANOMALIES:

1. 11-13+6w
2. Late booking 15-20w
3. Diagnostic tests

Answer 6

1. Combined test:
   - Nuchal translucency
   - β-hCG, PAPP-A
   - screening fro trisomies 13, 18, 21
2. Triple test: β-hCG, AFP, unconjugated estriol

Quadruple test: β-hCG, AFP, unconjugated estriol, inhibin A

3. Amniocentesis/CVS w US-guidance
   - most common abn. can be Dx. within 48h usually

*Polyhydraminos warrants repeat detailed USS

Question 7

DOWN SYNDROME RISK F.

Answer 7

1. High maternal age
2. Previous pregnancy(1% risk)
3. Balanced chromosomal translocation
4. Thickened nuchal translucency
5. Tricuspid regurgitation
6. High β-hCG, inhibin
7. Low PAPP-A, oestriol, AFP
8. Absence/shortened nasal bone

Question 8

POLYHYDRAMINOS

1. Definition
2. Epidemiology
3. Aetiology
4. Complications
5. Management

Answer 8

1. Deepest liquor pool >10cm
2. 1% of pregnancies
3. Idiopathic, maternal disorders: diabetes, GDM, renal failure; fetal anomaly(20%) esp upper GI obstructions; chest abn.; myotonic dystrophy
4. Preterm labour, maternal discomfort, abn. lie and malpresentation
5. Detaile US for detecting fetal anomaly; Maternal blood glucose testing to Dx. diabetes; amnioreduction if severe and <34w; NSAIDS to reduce fetal urine output; consider steroids if <34w