Antenatal care Flashcards
What information/ checks are done by week 10 of gestation? i.e. what is done at the very first appointment?
Firstly advice is given to mother:
- smoking/ alcohol cessation
- healthy eating = healthy start programme and food hygiene
- which medications must be stopped (if not already)
- what to expect / pregnancy care pathway
- start folic acid if not done already
- discuss place of birth
- info on pelvic floor exercises, breast feeding work shops
Screening for problems:
- BP, BMI, proteinuria - detects pre-eclampsia + now have a baseline, also identifies those at risk
- FBC - anaemia is common in pregnancy and can be corrected early with folate and iron
- blood group, rhesus antigen and other antigen - identifies those at risk of haemolytic disease of newborn
- screen for haemoglobinopathies - sickle cell/ thalassemia
- vaccinations up to date? (esp rubella, varicella and pertussis)
- HIV? Rubella? Hep B testing., syphilis
book in for: (if mother wishes)
- dating scan
- anomaly scan and downs syndrome screening
detailed obstetric Hx and examination
- when was their last period
- symptoms of early pregnancy?
- planned/ unplaned?
- last smear?
- previous problems in pregnancy?
- mental health screen?
- examination at this stage just looks at overall health of mother to identify any at risk. important to address any signs of domestic violence or female genitalia mutilation.
How much folic acid is recommended and when should women take this? What is the purpose of folic acid?
400U of folic acid for 1 month prior to becoming pregnant and then 3 months into pregnancy
to prevent neural tube defects.
why may some women require a larger dose of folic acid?
obesity, Anti epileptic drugs, history of NTDs, diabetes
when is a dating scan performed? What is used to estimate gestational age?
can be performed between 10 weeks and 13 + 6 weeks
however most accurate between 11 and 13 + 6 weeks
uses crown rump length and head circumference
when should vaccines be given to pregnant women?
should be vaccinated against rubella, varicella and pertussis
influenza vaccination should be given to anyone planning on getting pregnant or who is pregnant
live vaccines should be avoided in pregnancy and thus should be administered 28 days prior to pregnancy
what checks are performed after baby is born?
baby check within 72 hours - examination, weight, height, head circumference
baby check at GP again within 8 weeks
new born heel prick test - on day 5
hearing test by 5 weeks
immunisations
screen for vision and hearing around 4-5 yrs
What are the normal symptoms/ complications during pregnancy?
N+V Heart burn constipation haemorrhoids varicose veins backache vaginal discharge head aches appetite changes
how can advice / basic management be given for the following pregnancy symptoms: N+V heart burn constipation and haemorrhoids varicose veins backache vaginal discharge
N+V - reassure, should resolve by week 20, antihistamine and ginger can help
heart burn - lifestyle and antacids
constipation and haemorrhoids - fibre and water
backache - exercise, massage
vaginal discharge - reassure, treat any thrush
how can we educate pregnant women about diet?
plenty of fruit, veg, dairy and protein
avoid unpasteurised cheese/ milk - listeria monocytogenes
avoid uncooked means
not too much fish and tuna is small amounts
avoid too much vitamin A (affects folic acid absorption)
Caffeine is associated with low birth weight
vitamin D supplements are recommended
if obese before pregnancy - try to loose weight
if obese but already pregnant - weight loss is not recommended (but thromboprophylaxis may be offered)
which medications are teratogenic that need to be checked at antenatal visit?
paroxetine - SSRI - fetal heart defects lithium - heart defects/ ebstein anomaly warfarin retinioids antiepileptic - NTDs
Can women still work during pregnancy?
yes but advice women to reduce work load - jobs involving long periods on feet are associated with prematurity, HTN and pre-eclampsia
When is the second antenatal appointment? What happens in this?
at 16 weeks
gives women opportunity to raise issues
BP, proteinuria
review and identify anyone who needs more help
when is a foetal anomaly scan normally performed?
18 to 20 weeks
offered to all women to check for any structural abnormalities such that care after birth can be planned e.g. may require tertiary centre for CHD
Who is the 25 week appointment for?
scheduled for nulliparous women
BP and urine checked
measure and plot symphysis fundal height
what happens at the 28 week antenatal appointment?
BP and urine check
measure and plot symphysis fundal height
check Hb, rhesus and other antigen
if Hb <10.5 - investigate and consider iron supplements
offer anti-D prophylaxis to rhesus negative women - first dose
what happens at the 31 week appointment?
BP and urine - pre-eclampsia
plot symphysis fundal height
when testing the urine for proteinuria what else can be tested for?
UTI and glucose
pregnant women are prone and often asymptomatic
what occurs at the 34 week antenatal appointment?
second dose of anti-D prophylaxis to those rhesus negative women
screen for anaemia
BP, urine, symphysis fundal height measurement
what occurs at the 36 week antenatal appointment?
BP, urine, symphysis fundal height measurement
discuss care of newborn, breast feeding, vit K administration at birth and awareness of post natal depression
check baby position and for those in breech offer external cephalic version (ECV)
what occurs at the 38 and 40 week antenatal appointment?
BP, urine, symphysis fundal height again
what should be offered at 41 weeks?
offer membrane sweep
offer induction of labour
BP, urine, fundal symphysis height
what should be done for those who have not given birth by 42 weeks and refuse induction ?
biweekly USS and CTG
overall how many appointments should uncomplicated:
a) nulliparous women
b) parouss women
have?
a) 10
b) 7
what is checked at every antenatal appointment?
BP , urine = pre-eclampsia - from the beginning
from 24 weeks: fundal symphysis height and recorded = to assess foetal growth
who performs antenatal checks?
uncomplicated cases - GP or midwife
What are the main 3 things screened for during antenatal appointments using maternal risk factors?
maternal diabetes
pre-eclampsia
VTE
what support should be offered to mother postnatally?
assess physical and emotional well being
coping and support available to mother?
breast feeding advice
look for signs of mental health problems.
what does the foetal anomaly screening detect?
structural defects:
- Abdominal wall defects - Gastrochisis, exomphalus
- Diaphragmatic hernia
- Cleft lip - linked to chromosomal abnormalities
- CHD
- skeletal dysplasia
- NTDs
- Acephaly
also check placental position and amniotic fluid index (oligohydramnios or polyhydramnios) and estimate fetal weight
what anomalies does the USS scan pick up best?
CNS, renal, cardiac and skeletal. in order from best to worst
what is the purpose of the foetal anomaly scan?
offers parents an opportunity to terminate OR allows time to prepare e.g. book in for delivery at a specialist tertiary centre.
what are the maternal risk factors for downs syndrome?
age high BMI diabetes previous child with downs syndrome consanguinity drugs - epileptic
these are risk factors for most chromosomal problems.
what are the two screening tests available to test for Downs syndrome? which is most accurate?
Combined test - more accurate and offered between 11 +2 weeks and 14 + 1 weeks.
- Nuchal translucency - blood test - PAPP A and BHCG
Quadruple test - less accurate but offered if the above is missed
- 4 markers tested in blood: UE3, AFP, Inhibin A and hCG
These screening tests combine all this information + the maternal age to give an overall risk of the fetus having down syndrome. calculated by e.g. 1 in 300
what is nuchal translucency? What value is the cut off?
Using USS the fluid thickness behind the neck is measured.
the larger this is the more likely there is to be chromosomal defects e.g. downs
it should be <3.5mm
how are PAPP-A, B-HCG and aFP, uE3 and inhibin A levels related to down syndrome?
PAPP A - reduced in downs BHCG - increased in downs aFP - reduced in downs UE3 - reduced in downs Inhibin A - increased in Downs
what cells produced PAPPA and BHCG?
Syncytiotrophoblasts
what produces uE3 ?
placenta and fetal adrenals
What happens to women who are calculated at high risk of down syndrome from combined or quadruple test?
Those who are calculated to have more than 1 in 250 chance are offered further investigations by chorionic villus sampling or amniocentesis.
do all chromosomal defects increase in incidence with age?
no Turners does not.
when gestational age is amniocentesis offered and when is chorionic villus sampling offered?
amniocentesis - >15 weeks gestation
chorionic villus sampling 10-13 weeks
what is the most accurate way of testing for downs syndrome?
look at foetal DNA in maternal circulation
not available on NHS
what are the risk factors for VTE in pregnancy? i.e. how is VTE risk assessed in pregnant women?
pre-existing:
- previous VTE history - 3 points
- thrombophilia - 2 points
- age >35 - 1 point
- comorbidities - 2 points
- obesity - 2 points
- smoking - 1 point
- varicose veins - 1 point
- paraplegia - 1 point
- parity 3 or more - 1 point
obstetric:
- pre-eclampsia - 1 point
- C section - 2 points
- PPH - 1 point
- prolonged labour - 1 point
others: all below are 1 point
- infection
- dehydration
- immobility / long distance travel
- hyperemesis
when should LMWH be offered in pregnancy or after?
if the risk is calculated to be:
3 or more in pregnancy = LMWH
2 or less in pregnancy = mobilisation and hydration
3 or more after pregnancy = LMWH for 6 weeks
2 after pregnancy = LMWH for 7 days
1 or less after pregnancy = mobilise and hydrate
use enoxaparin e.g. clexane
which infections are screened for in pregnancy?
HIV, syphilis, rubella, parvovirus, Hepatitis B, group B streptococcus and UTIs
why are rubella, parvovirus,and HIV screened for in pregnant/ soon to be pregnant women?
rubella - screened prior to pregnancy and offered vaccination atleast 1 month before pregnancy. Associated with rubella syndrome of child. However do not vaccinate in pregnancy because live vaccine
HIV - screened for such that measures can be put in place to reduce transmission e.g. C section, antivirals during pregnancy and to fetus after, no breast feeding.
parvovirus - associated with fetal anaemia and heart failure. not a problem for the mother but, identification, especially if in contact with someone infected, can allow close monitoring and support of fetus
why do we screen for group B streptococcus? when do we screen for this?
about 1/4 of preganant women have group B strepto colonising vagina.
during delivery it can be transmitted to fetus and result in neonatal sepsis (mortality/ morbidity)
more over it increases chance of preterm or rupture of membranes
can reduce transmission by use of intrapartum IV Ab - IV penicillin
why is hepatitis B screened for?
Allows us to put measures in place to reduce fetal transmission e.g. vaccine and Abs to fetus
why are UTIs in pregnancy screened for?
associated with Preterm and miscarriage
What are the risk factors for diabetes in pregnancy?
- age above 30
- previous gestational diabetes/ glucose intolerance
- previous macrosomic baby > 4.5kg
- BMI >35 or maternal weight >100kg
- repeated episodes of glycosuria
- 1st degree relative with diabetes
- previous unexplained still birth
- HTN
- Pre - eclampsia
- other endocrine problems
assess for such risk factors in antenatal appointment to guide as to weather further screening is required.
what people are screened for gestational diabetes?
those who have risk factors for diabetes - cost effective
if there are any risk factors then the individual is screened at first appointment and 28 weeks
if previous gestational diabetes then also screened at 18 weeks
how is gestational diabetes screened for?
glucose tolerance test
what is offered to those patients who are shown to be diabetic?
induction of labour at 38 weeks - to reduce chance of still birth.
how is pre-eclampsia screened for?
BP and urine checked at every antenatal appointment
at first appointment assess for risk factors
can also check LFTs - rise in pre-eclampsia
educate patients on symptoms of pre-eclampsia and when to seek advice
what are the risk factors for pre-eclampsia?
>40yrs nulliparity pregnancy interval >10yrs FHx of pre-eclampsia previous pre-eclampsia BMI >30 pre-existing vascular disease e.g. HTN pre-existing renal disease multiple pregnancy
what BP recording is worrying when assessing pre-eclampsia at antenatal appointments?
single systolic >110mmHg or 2 consecutive >90mmHg (more than 4 hours apart) +/- proteinuria = prompt increased surviellence
systolic BP >160 on 2 consecutive readings at least 4 hours apart = consider treatment.
what are the symptoms of pre-eclampsia that should be made aware to patients?
severe headache visual problems - blurring, flashing severe pain just below ribs vomiting sudden swelling of face, hands, feet
tell them to seek advice if any of the above
how is pregnancy dated?
calculate the days since last menstrual period (beginning of period) = gestational age = Naegele’s rule
can confirm by USS - look at size of embryo and compare to reference values - use crown rump length. more accurate the earlier the pregnancy. usually measured between 10+0 and 13 +6 weeks
what are the difficulties with dating pregnancy?
women don’t remember first day of their last period
some babies are large/ small for gestational age so hard to determine by USS
what is amniocentesis?
A procedure whereby a sample of amniotic fluid is taken to examine foetal cells within it
what are the indications for amniocentesis?
high risk after antenatal screening for downs syndrome or fetal anomaly.
previous child with chromosomal/ congenital abnormalities
risk of recessively inherited diseas
parent with balanced chromosomal translocation
how is amniocentesis performed?
around 15 to 16 weeks
give anti D prophylaxis to any rhesus negative mothers
needle inserted through abdomen, USS guidance, into amniotic sac and fluid aspirated
tested:
- AFP an acetylcholinesterase levels - for NTDs
- Billirubin levels - for haemolysis
- Test lung maturity
- enzyme analysis
- obtain fetal cells and assess chromosomes by microarrays/ FISH
what are the risks / complications of amniocentesis?
discomfort vaginal bleeding amnionitis rhesus sensitisation miscarriage (mainly if in T3)
how is chorionic villus sampling performed?
a catheter is inserted into vagina and needle into chorionic villi to sample it.
more commonly performed transabdominally
rhesus prophylaxis given before in rhesus negative women.
what are the indications for chorionic villus sampling?
same as for amniocentesis however performed earlier at 11 to 13 weeks.
what are the contraindications to chorionic villus sampling?
active vaginal bleeding infection cervical polyps fibroids fundal placenta retroverted uterus and posteriorly placed placenta
(only contraindicated in transcervical route)
what are the risks/ complications of chorionic villus sampling?
sampling failure
miscarriage
vaginal bleed
infection
what is safer out of chorionic villus sampling and amniocentesis?
amniocentesis in T2 is safer and less likely to result in lab failures
what are the indications for clexane (enoxaparin) during pregnancy?
risk factors for DVT
antiphospholipid syndrome
acute VTE
valvular heart disease
how can we predict the date of delivery?
Naegele’s rule:
- first day of last menstrual period + 9 months + 7days
what is meant by Gravidity and parity?
Gravidity - total number of pregnancies regardless of outcome
Parity - total number of pregnancies carried over the threshold of viability (24 weeks)
if pregnant G2 P1 +1
one previous successful pregnancy and currently pregnant
what does G2 P1 mean?
pregnant twice and one viable post 24 weeks (the other miscarried)
what is the TORCH screen and when is it routinely performed?
toxoplasmosis, other (parvovirus), rubella, CMV, hepatitis
all these infections are routinely screened at 28 weeks
what does a growth scan involve?
measurement of abdominal circumference, fetal head circumference, femur length , umbilical cord blood flow
