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Obstetrics > Antenatal care > Flashcards

Antenatal care Flashcards

1
Q

What information/ checks are done by week 10 of gestation? i.e. what is done at the very first appointment?

A

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.
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2
Q

How much folic acid is recommended and when should women take this? What is the purpose of folic acid?

A

400U of folic acid for 1 month prior to becoming pregnant and then 3 months into pregnancy
to prevent neural tube defects.

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3
Q

why may some women require a larger dose of folic acid?

A

obesity, Anti epileptic drugs, history of NTDs, diabetes

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4
Q

when is a dating scan performed? What is used to estimate gestational age?

A

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

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5
Q

when should vaccines be given to pregnant women?

A

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

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6
Q

what checks are performed after baby is born?

A

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

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7
Q

What are the normal symptoms/ complications during pregnancy?

A 
N+V
Heart burn 
constipation 
haemorrhoids 
varicose veins 
backache 
vaginal discharge 
head aches
appetite changes
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8
Q 
how can advice / basic management be given for the following pregnancy symptoms:
  N+V
  heart burn
  constipation and haemorrhoids 
  varicose veins 
  backache 
  vaginal discharge
A

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

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9
Q

how can we educate pregnant women about diet?

A

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)

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10
Q

which medications are teratogenic that need to be checked at antenatal visit?

A 
paroxetine - SSRI - fetal heart defects
lithium  - heart defects/ ebstein anomaly 
warfarin 
retinioids 
antiepileptic - NTDs
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11
Q

Can women still work during pregnancy?

A

yes but advice women to reduce work load - jobs involving long periods on feet are associated with prematurity, HTN and pre-eclampsia

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12
Q

When is the second antenatal appointment? What happens in this?

A

at 16 weeks
gives women opportunity to raise issues
BP, proteinuria
review and identify anyone who needs more help

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13
Q

when is a foetal anomaly scan normally performed?

A

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

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14
Q

Who is the 25 week appointment for?

A

scheduled for nulliparous women
BP and urine checked
measure and plot symphysis fundal height

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15
Q

what happens at the 28 week antenatal appointment?

A

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

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16
Q

what happens at the 31 week appointment?

A

BP and urine - pre-eclampsia

plot symphysis fundal height

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17
Q

when testing the urine for proteinuria what else can be tested for?

A

UTI and glucose

pregnant women are prone and often asymptomatic

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18
Q

what occurs at the 34 week antenatal appointment?

A

second dose of anti-D prophylaxis to those rhesus negative women
screen for anaemia

BP, urine, symphysis fundal height measurement

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19
Q

what occurs at the 36 week antenatal appointment?

A

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)

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20
Q

what occurs at the 38 and 40 week antenatal appointment?

A

BP, urine, symphysis fundal height again

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21
Q

what should be offered at 41 weeks?

A

offer membrane sweep
offer induction of labour

BP, urine, fundal symphysis height

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22
Q

what should be done for those who have not given birth by 42 weeks and refuse induction ?

A

biweekly USS and CTG

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23
Q

overall how many appointments should uncomplicated:

a) nulliparous women
b) parouss women

have?

A

a) 10

b) 7

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24
Q

what is checked at every antenatal appointment?

A

BP , urine = pre-eclampsia - from the beginning

from 24 weeks: fundal symphysis height and recorded = to assess foetal growth

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25
Q

who performs antenatal checks?

A

uncomplicated cases - GP or midwife

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26
Q

What are the main 3 things screened for during antenatal appointments using maternal risk factors?

A

maternal diabetes
pre-eclampsia
VTE

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27
Q

what support should be offered to mother postnatally?

A

assess physical and emotional well being
coping and support available to mother?
breast feeding advice
look for signs of mental health problems.

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28
Q

what does the foetal anomaly screening detect?

A

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

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29
Q

what anomalies does the USS scan pick up best?

A

CNS, renal, cardiac and skeletal. in order from best to worst

30
Q

what is the purpose of the foetal anomaly scan?

A

offers parents an opportunity to terminate OR allows time to prepare e.g. book in for delivery at a specialist tertiary centre.

31
Q

what are the maternal risk factors for downs syndrome?

A 
age 
high BMI
diabetes
previous child with downs syndrome
consanguinity 
drugs - epileptic

these are risk factors for most chromosomal problems.

32
Q

what are the two screening tests available to test for Downs syndrome? which is most accurate?

A

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

33
Q

what is nuchal translucency? What value is the cut off?

A

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

34
Q

how are PAPP-A, B-HCG and aFP, uE3 and inhibin A levels related to down syndrome?

A 
PAPP A - reduced in downs 
BHCG - increased in downs
aFP - reduced in downs
UE3 - reduced in downs
Inhibin A - increased in Downs
35
Q

what cells produced PAPPA and BHCG?

A

Syncytiotrophoblasts

36
Q

what produces uE3 ?

A

placenta and fetal adrenals

37
Q

What happens to women who are calculated at high risk of down syndrome from combined or quadruple test?

A

Those who are calculated to have more than 1 in 250 chance are offered further investigations by chorionic villus sampling or amniocentesis.

38
Q

do all chromosomal defects increase in incidence with age?

A

no Turners does not.

39
Q

when gestational age is amniocentesis offered and when is chorionic villus sampling offered?

A

amniocentesis - >15 weeks gestation

chorionic villus sampling 10-13 weeks

40
Q

what is the most accurate way of testing for downs syndrome?

A

look at foetal DNA in maternal circulation

not available on NHS

41
Q

what are the risk factors for VTE in pregnancy? i.e. how is VTE risk assessed in pregnant women?

A

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

42
Q

when should LMWH be offered in pregnancy or after?

A

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

43
Q

which infections are screened for in pregnancy?

A

HIV, syphilis, rubella, parvovirus, Hepatitis B, group B streptococcus and UTIs

44
Q

why are rubella, parvovirus,and HIV screened for in pregnant/ soon to be pregnant women?

A

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

45
Q

why do we screen for group B streptococcus? when do we screen for this?

A

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

46
Q

why is hepatitis B screened for?

A

Allows us to put measures in place to reduce fetal transmission e.g. vaccine and Abs to fetus

47
Q

why are UTIs in pregnancy screened for?

A

associated with Preterm and miscarriage

48
Q

What are the risk factors for diabetes in pregnancy?

A
  • 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.

49
Q

what people are screened for gestational diabetes?

A

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

50
Q

how is gestational diabetes screened for?

A

glucose tolerance test

51
Q

what is offered to those patients who are shown to be diabetic?

A

induction of labour at 38 weeks - to reduce chance of still birth.

52
Q

how is pre-eclampsia screened for?

A

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

53
Q

what are the risk factors for pre-eclampsia?

A 
>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
54
Q

what BP recording is worrying when assessing pre-eclampsia at antenatal appointments?

A

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.

55
Q

what are the symptoms of pre-eclampsia that should be made aware to patients?

A 
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

56
Q

how is pregnancy dated?

A

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

57
Q

what are the difficulties with dating pregnancy?

A

women don’t remember first day of their last period

some babies are large/ small for gestational age so hard to determine by USS

58
Q

what is amniocentesis?

A

A procedure whereby a sample of amniotic fluid is taken to examine foetal cells within it

59
Q

what are the indications for amniocentesis?

A

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

60
Q

how is amniocentesis performed?

A

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

61
Q

what are the risks / complications of amniocentesis?

A 
discomfort 
vaginal bleeding 
amnionitis 
rhesus sensitisation
miscarriage (mainly if in T3)
62
Q

how is chorionic villus sampling performed?

A

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.

63
Q

what are the indications for chorionic villus sampling?

A

same as for amniocentesis however performed earlier at 11 to 13 weeks.

64
Q

what are the contraindications to chorionic villus sampling?

A 
active vaginal bleeding
infection
cervical polyps 
fibroids 
fundal placenta 
retroverted uterus and posteriorly placed placenta

(only contraindicated in transcervical route)

65
Q

what are the risks/ complications of chorionic villus sampling?

A

sampling failure
miscarriage
vaginal bleed
infection

66
Q

what is safer out of chorionic villus sampling and amniocentesis?

A

amniocentesis in T2 is safer and less likely to result in lab failures

67
Q

what are the indications for clexane (enoxaparin) during pregnancy?

A

risk factors for DVT
antiphospholipid syndrome
acute VTE
valvular heart disease

68
Q

how can we predict the date of delivery?

A

Naegele’s rule:

- first day of last menstrual period + 9 months + 7days

69
Q

what is meant by Gravidity and parity?

A

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

70
Q

what does G2 P1 mean?

A

pregnant twice and one viable post 24 weeks (the other miscarried)

71
Q

what is the TORCH screen and when is it routinely performed?

A

toxoplasmosis, other (parvovirus), rubella, CMV, hepatitis

all these infections are routinely screened at 28 weeks

72
Q

what does a growth scan involve?

A

measurement of abdominal circumference, fetal head circumference, femur length , umbilical cord blood flow

Obstetrics (8 decks)

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