Antenatal Care Flashcards
Common modes of inheritance
Autosomal D/r
X-linked D/r
Codominant
Mitochondrial
3 commonest severe congenital abnormalities
Heart Defects
Neural Tube Defects
Downs
4 General considerations for perscribing in pregnancy
1) Pre-pregnancy counselling optimises medication
2) Balance risk to fetus with benefit to mother
3) Assess on individual basis, give information so that an informed decision can be made
4) LOWEST POSSIBLE DOSE FOR SHORTEST TIME POSSIBLE
3 Physiological changes in pregnancy relevant to perscribing
Affects distribution
1) Increase in total body water
2) Increase in fat stores
Affects metabolism
1)Increaase in cardiac output
Pharmokinetic changes in pregnancy
Absorption
- Dec due to n & v (nausea + vomiting)
Distribution
- Inc plasma volume
- Dec plasma binding
Metabolism
- Cyt P450 induction
- Increase eGFR
Elimination
- No change
Generally dec drug conc due to haemodilution, inc distridution + metabolism
Teratogenic drugs in pregnancy
Thalidomide
Diethylstilboestrol (used in breast and prostate cancer and recurrent miscarriage)
Warfrin
Phenytoin
Lithium
Methotrexate
Testosterone
Progesterone
Valproate
Benzodiazopine
Most anti-psychotics except: quetiapine, olanzapine, or risperidone
All AED except (Lamotrogine + levetricetam)
Time line of antenatal screening
What happens at a booking appointment
First contact with midwife
- Information gathered
- General info taken (name, age gestation)
- Risk assessed (obs hx, drug use, domestic abuse, PMH, )
- Baseline obs taken - BP, temp, weight
- Bloods taken - Hb, iron, rhesus, blood group, downs, spina bifida, HIV, syphillis, thalasaemia, Hep B,
- Urine dip
- Information given
- Pregnancy plan initiated
Standard antenatal screening offered to women
8-12 weeks - Bloods for infectious disease Syphilis, Hep B + HIV (usually done at booking apt)
>10 weeks - Bloods for Sickle and Thalesaemia (usually done at booking apt)
10 weeks - Booking appointment
10-14 weeks - Combined test Bloods for T21 (downs), T18 (edwards) and T13 (Pataus)
11-14 weeks - Dating scan and early anomoly scan (the same scan aka Nuchal Translucency), supports combined test and looks for other defects
14-20 weeks - Quadruple test Bloods for T21 and spina bifida (not offered to everyone)
18-21 weeks - Anomoly scan detailed USS for structural abnormalities incl T18 T21, supports quadruple bloods
Main reasons to be CLC
- <16/>40 years
- Grand multip >6
- >35 BMI
- Won’t take blood products
- Cervial suture/LLETZ
- HTN
- Familial genetic abnormalities
- Drug user
- Alcoholic
- STI e.g. herpes
- If only risk is smoking MLC, but need serial growth scans in 3rd trimester
- Pre-eclampsia
- Gestational diabetes
- Shoulder distocia
- 3/4th degree tear
- Previous C section
- Epilepsy
- Multiple pregnancy
- Antepartum haemorrhage
- Recurrent UTI
full list at: https://www.nuh.nhs.uk/handlers/downloads.ashx?id=62572
Aim of screening
Monitor normal pregnancy
Identify complicated pregnancy
Identify risks and requirements of mother and fetus
Risks of and management of VBAC
Risks
- 0.5% scar dehiscence
- Think about future pregnancies, no more than 3 c-sections recommended + risk of placenta accreta
- Emergency c-section
Management
- CLC
- Counsell for risks before (70% successfull)
- Should be done in hospital access to c-section
- Pain between contractions can indicate rupture
- Continuous CTG
- Maternal pulse changes can indicate rupture
- Check for bleeding can indicate rupture
- Induction caries 1.5 increase risk of rupture
Risks of and management of Group B strep infection
Risks (fetal)
- Septicaemia
- Pneumonia
- Meningitis
Management
- Intrapartum antibiotic prophylaxis (IAP)
- If in urine given treatment at time of diagnosis not indicated for vaginal/rectal
- IAP not needed in c-section if membranes have not ruptured
- Once membranes ruptured induction is recommended at 37w
Risks of, risks for and management of breech
Risks for
- High parity
- Uterine/pelvic abnormalities
- Previous breech
- Placenta abnormalities
- Fetal abnormalities
- Multiple pregnancy
- Low birth weight/pre-term
- Polyhydramnious
- Space occupying lesion
Risks of
- Cord Prolapse
- Hypoxia to baby
- Head entrapment
Managment
- Counsell mother with risks + create a birth plan
- Terms breech trial says planned c-section has better outcomes, recent studies conflict. Green top says women should be told c-section has small decrease in perinatal mortality but vaginal is better for mum + normal counselling for c-section and vaginal birth Re-read green top http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.14465/full
- ECV (check contraindications)
- Labour in hospital access to c-section
- Induction not recommended
- Continuous CTG
- Consider c-section if descent is delayed in 2nd stage of labour
- If 2nd twin = breech can do total breech extraction
Types of breech, best and worst
- Frank/extended breech- crossed legs next to ears
- Complete breech-crossed legs above buttock
- Footling breech-presenting part is foot WORST
Contraindications and risks of ECV
Contraindications
- Preterm
- Multiple pregnancy
- Significant third trimester bleeding
- IUGR
- Oligohydramnion
- PROM
- PIH(pregnancy induced HTN)/PET
- Nonreassuring foetal monitoring patterns
- All contraindications to vaginal birth
Risks
- Umbilical cord entanglement
- Abruptio placenta
- Premature rupture of the membranes (PROM)
- Severe maternal discomfort
- Doesn’t work
Complications of breech that contraindicate vaginal birth
- Hyperextended neck on ultrasound.
- High estimated fetal weight (more than 3.8 kg)
- Low estimated weight (less than tenth centile).
- Footling presentation.
- Evidence of antenatal fetal compromise.
- Normal contraindications to vaginal birth
Risk of and management of epilepsy in pregnancy
Risks
- SE of medication (valproate, phenytoin, phenobarbitone)
- Increase risk of seizure: tiredness, stress, labour + stopping meds
- Risks to mum
- Falls
- Trauma
- Possible brain injury
- Lack of freedom e.g. driving
- Death (SUDEP)
- Risks to baby
- Hypoxia
- Trauma
- Lactic acidosis
- Placental abruption
- Miscarriage
- Preterm labour
- Premature birth
- Risks to mum
Management
- CLC
- Pre-conception counselling
- Monotherapy, least effective dose, not valproate, phenytoin, phenobarbitone. Preferably lamotrogine + levetracitam
- High dose folic acid 5mg PO/day
- Good pain control in labour
Risks for, of and mangement of multiple pregnancy
Risks for having multiple pregnancy
- FH
- Advanced age
- IVF
Risks of having multiple pregnancy
- Anaemia
- PET
- Assisted deliver/c-section
- PPH
- Premature birth
- IUGR
- Twin-to-twin transfusion syndrome
Management
- CLC
- DCDA USS every 4 weeks
- MCDA/MCMA USS every 2 weeks after 16w
Types of twins
Dichorionic diamniotic DCDA - two placentas, two chorions, two amniotic sacs
Monochorionic diamniotic MCDA(identical) - one placenta, one chorion, two amniotic sacs
Monochorionic monoamniotic MCMA - one placenta, one chorion, one amniotic sac
Layers of placenta
Aetiology of, risks for, risks of and management of pre-eclampsia
Aetiology
- Absence of secondary trophoblastic invasion of placenta
- Therefore thin, elastic spiral aa’s are not converted to high vol, low resistance aa’s
- Leads to IUGR + eclampsia
- Only cure is to remove placenta (and hopefully baby)
Risks for PET
- Primip/new partner
- Diabetic
- Multiple pregnancy
- Previous PET
- HTN
- CKD
- <16/>40
- Family history
- BMI >30
Risks of PET
- DIC/HELLP syndrome
- High BP, causes a lot of these
- CVA
- Renal nephropathy
- IUGR
- Eclampsia (convultions)
Management
- CLC
- Admit to assess severity, consider outpatient if mild/moderate
- Monitor BP, urine, symptoms, fetal movements, epigastric pain/vomiting
- Control BP, seizures (anti-hypertensives + magnesium sulphate)
- Plan delivery date + method based in stability
- Post partum fluid management
Causes of, risks of and management of antepartum haemorrhage
APH is classed as bleeding after 24w
Causes of APH
- Placenta abruption
- Placenta previa
- Local causes (vagina, vulva)
- Unexplained
Risks of APH
- Pre-term delivery
- Infection
- Anaemia
- Fetal hypoxia
- IUGR
Management of APH
- Woman should report to their care provider e.g. midwife
- Admit for assessment
- If severely compromised: acute appraisal + resus prioritise mother
- Take full history: pain, extent of bleeding, cardiovascular state of mother, risk factors for possible causes, smear history, rupture of membranes + fetal wellbeing
- Examination: Auscultate fetal heart, maternal pulse, mat. BP, abdo palpation, speculum, VE
- Investigations: USS, rhesus status, FBC, co-ag screen, u+e, LFT, group + save, CTG
- All women with bleeding more than spotting should remain in hospital until bleeding has stopped
Risks for Placenta abruption
- Tobacco
- Cocaine
- Amphetamine
- Previous abruption
- Pre-eclamp
- IUGR
- Prematue ROM
- Trauma/domestic violence
Risks for placenta previa
Can’t have VEs, PR and sex
- Previous placenta previa
- Previous c-section
- Previous TOP
- Multip
- >40 yrs
- Multiple pregnancy
- Smoking
Causes of, risks for, risks of and mangaement of UTI in pregnancy
Causes
- Growing uterus puts pressure on bladder = stagnant urine
Risks for
- Sex
- Anatomy anomaly
- Catheter
- Pregnancy
Risks of
- Recurrent UTI
- Acute pyelonephritis
- Kidney damage
- Sepsis
- Prematurity
- SFD baby
- Mental retardation
- Developmental delay
- Miscarriage
Management
- Fluids
- Antiobiotics: penicillins and cephalosporins e.g. Cephalexin, Ampicillin
Risks for, risks of and managment of DVT in pregnancy
Risks for (see pictures)
- Previous VTE
- Thrombophilia
- Several co-morbidities
Risks of
- Embolism (PE, stroke, MI)
Management
- Score >4 consider thromboprophylaxis from first trimester. If 3 consider from 28 weeks. If 2 or under consider for 10 days. Consider if admitted to hospital.
- Diagnosed with history and ultrasound
- Treated urgently with Low Molcular Weight Heparins e.g. enoxaparin until proven to not be DVT
Risks for, risks of and management of 3/4th deg tears
Risks for
- Primip
- South asain ethnicity
- Prolonged second stage labour
- Assisted delivery
- LFD baby
- Previous tear
Risks of
- Infection
- Incontinence
Management
- Pain relief
- Repair
- Give antibiotics
- Laxatives
Stages of labour
First stage
- Cervix going from 0-10
- Last 6-36 hours
- Established labour: contractions are 5 mins apart and last at least a minute
Second stage
- Baby going down birth canal and being born
- Lasts 30 mins-hour (epidural slows it)
- This is the pushing part
Third stage
- Placenta delivery, two methods
- Physiological management: wait for it to come out naturally, can take up to an hour, breast feeding helps
- Active management: given syntoncinon in leg as shoulders are delivered, to help placenta seperate and decrease blood flow
Difference between syntocinon, ergometrine and syntometrine
Syntocinon
- artificial oxytocin
- Can be given IV for induction of labour, PPH prevention or established and incomplete, inevitable or missed miscarriage
- Intramuscular for active management of third stage of labour (unliscenced)
Ergometrine
- Ergot alkaloid works non-specifically as 5-HT agonist and vasoconstrictor
- Used to prevent PPH (generally with syntroncinon i.e. oxytocin as syntometrin) and for active management of third stage of labour
- Can’t be used in women with hypertension/pre-eclampsia
Syntometrine
- Combo of syntocinon and ergometrine
- Prevention of PPH, active management of third stage of labour and bleeding due to incomplete abortion/miscarriage
- Can’t be used in hypertension/pre-eclampsia
Risks for, risks of and management of anaemia in pregnancy
Risks for
- Mulitple pregnancy
- Excessesive vomiting
- Young or old maternal age
- Anaemia before pregnancy
- Bad diet
Risks of
- Preterm
- SFD baby
- Blood transfusion
- Post partum depression
- Folate deficiency = neural tube defects
- Increased susceptibility to infection
- PPH
Managment
- All women screened at booking and 28 weeks
- Dietry advice should be given to all
- If <110 Trail iron for diagnostic and therapeutic reasons check in three weeks if unsuccessfull check serum ferritin and refer to consultant obstetrician
- If <90 higher dose of iron and refer to obstetrician if symptomatic
- If <70 refer urgently to obstetrician, offer transfusion if actively bleeding/symptomatic
- If uncontrolled at delivery decrease risk of bleeding: CLC, IV access, group and save, active third stage labour, prompt management of PPH, prophylactic syntoncinon infusion
Aetiology of, risk for developing, risks of and management of gestational diabetes
Aetiology
- Body is not able to produce suffiecient insulin to keep up with pregnancy demands
Risks for developing
- BMI >30
- Previous >4.5 kilo baby
- Previous gestational diabetes
- FH diabetes
Risks of
- LFD baby therefore increased risk of induction, instrumental and c-section
- Polyhydramnios
- Premature birth
- Pre-eclampsie
- Neonate jaundice and hypoglycaemia
- Still birth
Management
- Screened at 18-12 weeks
- If at risk/random glucose in urine will be ofered oral glucose tolerance test
- Fasting >5.6 or 2 hour >7.8
- Review in antenatal/diabetic clinic within a week
- Educate: implication of diagnosis, importance of control, how to self-test, diet and excersice.
- Use same glucose targets as for non-pregnant diabetics
- Refer to dietitian
- If diet and excerise doesn’t make targets in 1-2 weeks offer metformin
- If metformin contra-indicated/unacceptable offer insulin
- Use a mix of diet, exercise, metformin and insulin to women who are difficult to control
- If metformin doesn’t work and woman can’t/won’t take insulin offer glibenclamide
- CARE IS VERY DIFFERENT IF YOU ALREADY HAVE DIABETES SEE https://www.nice.org.uk/guidance/ng3/chapter/1-Recommendations#gestational-diabetes-2
Risks of and management of high BMI in pregnancy
Risks of high BMI in pregnancy
- Gestational diabetes
- Pre-eclampsia
- Sleep apneoa
- Miscarriage
- Neural tube defects
- Macrosomia
- Stillbirth
- Preterm birth
- Anaesthetic complications
- VTE
- Slow labour progression
- Shoulder distocia
- PPH
Management
- Asses VTE, pre-eclampsia, gestational diabetes risk
- Counsell risks high BMI posses
- Counsell how to decrease said risks
- CLC during labour
contraindication to vaginal birth
- Cephalopeliv disproportion
- Brown presentation
- Cord/limb prolapse
- Untreated HIV
- Severe space occupying lesion
- High birth weight
- Placenta previa
- Persistent fetal distress
- High number c-sections
- Maternal distress
- Active herpes
- Failure to progress
- Acreta
