Antenatal care Flashcards
Downs screening:
a) Test before 13 weeks
b) Test after 13 weeks
c) If risk > 1 in 150…?
d) Who should be offered?
a) Combined test: Nuchal translucency (see below) and two pregnancy hormones (PB: Papp-A and Beta-hCG)
b) Quadruple test (Beta-hCG, AFP, UE3 and inhibin-A)
c) Offer CVS (11 - 13 weeks) or amniocentesis (> 15 wk)
d) All women, with counsel about risk (increase with age)
Interpreting Downs screening results:
a) Hormones (which go up and which go down: mnemonic - two are raised BI down’s)
b) Nuchal translucency
c) Follow-up diagnostic tests
a) PAPP-A: produced by placental syncytiotrophoblasts; (reduced in Down’s)
Beta-hCG: produced by placental syncytiotrophoblasts; (raised in Down’s syndrome).
AFP: produced by fetal yolk sac and liver;
(reduced in Down’s syndrome)
uE3: produced by placenta and fetal adrenals;
(reduced levels in Down’s syndrome).
Inhibin-A: produced by placenta;
(raised in Down’s syndrome)
b) Increased nuchal translucency (size of the nuchal pad at nape of the neck - ?oedema) reflects fetal heart failure; it is typically seen in any serious anomaly of the heart and great arteries and strongly associated with a chromosomal abnormality
c) CVS if less than 13 weeks of gestation or amniocentesis if beyond 15 weeks of gestation
CVS and amniocentesis:
a) risks
b) what should be given before (if indicated)
c) Conditions it can diagnose
a) Miscarriage, Discomfort, Sepsi, Amnionitis, Amniotic fluid leakage
b) Anti-D Ig
c) Trisomies (13, 18, 21), Sex chromosome abnormalities (Turners, Klinefelters, etc.)
Pre-eclampsia.
a) define
b) pathogenesis
a) - Pregnancy-induced HYPERTENSION (>140/90) with onset after 20 weeks of gestation and PROTEINURIA
b) Spiral arteries become fibrous, reducing foetal blood flow, leading to inflammation
Severe pre-eclampsia:
a) BP level
b) Or what symptoms/signs?
c) Or what biochemical results?
d) Or what foetal features?
a) BP > 160/110
b) Symptoms: HEADACHE, EPIGASTRIC PAIN, sudden swelling of face, hands and feet, RUQ tenderness, visual disturbance (e.g, blurring or flashing lights in front of the eyes) and vomiting. Signs: clonus, papilloedema
c) Low platelets, raised liver enzymes
d) IUGR, distress (reduced movements)
Pre-eclampsia: risk factors
a) Patient details
b) Obstetric
c) Pre-existing comorbidities
d) Who should be screened?
a) Age > 40, BMI > 35
b) 1st pregnancy, 10 years or more since the last pregnancy. Family history of pre-eclampsia (in mother or sister). Multiple pregnancy
c) HTN, DM, CKD, SLE
d) Screen anyone with RFs and all nulliparous women at 24 weeks
Pre-eclampsia: complications
- DRCOG
- others?
D Disseminated intravascular coagulation (DIC) leading to HELLP R Renal failure C Cerebral haemorrhage O Oligohydramnios G Growth retardation (IUGR)
Eclampsia
Pre-eclampsia: investigations
a) Initial bedside
b) Bloods
c) Special tests
d) If neurological symptoms
a) BP and proteinuria measurement, fundoscopy, neurological examination
b) LFTs, clotting screen, FBC
c) Foetal USS, CTG, arterial Doppler
d) Fundoscopy, CT head
Pre-eclampsia: management
a) All patients with suspected pre-eclampsia should be…?
b) Pregnancy management including tests
c) Ask about what 2 symptoms at every recording of BP ?
d) Treat above what level? 1st line? 2nd line?
e) If risk of seizures - prophylaxis
f) Prevention in at-risk patients from 12 weeks gestation
g) Delivery of baby when?
a) Admitted for assessment
b) Obstetrician led care; FBC, UEs, creatinine, LFTs, clotting
c) Headache, epigastric pain
d) 150/100 - labetalol, 2nd line: methyldopa, nifedipine
e) MgSO4
f) Aspirin
g) Between 34 and 36 weeks
Management of eclampsia
a) Initial
b) Control of seizures
c) Once seizures are controlled, severe hypertension treated and hypoxia corrected…?
d) Woman still at risk of seizures for how long?
a) A-E (airway, oxygen, intubation, ventilation, etc.), Lie mother in left lateral position Reduce BP (IV labetalol)
b) MgSO4
c) Deliver foetus (definitive treatment)
d) 6 weeks
GDM: risk factors
- BMI >30.
- Previous gestational diabetes.
- Previous baby with a weight ≥4.5 kg.
- First-degree relative with diabetes.
- Afro-Caribbean/ South Asian /Middle Eastern origin.
- Glycosuria 2+ on one occasion or 1+ on two occasions during routine antenatal care
GDM: screening
a) Who?
b) When?
c) How?
a) Anyone with risk factors
b) At 24-28 weeks
c) OGTT (7.8 or above at 2h post- 75g glucose)
GDM: antenatal management
a) Additional antenatal monitoring
b) If fasting glucose < 7, first line? Second line?
c) If fasting glucose > 7 or complications (e.g. macrosomia) - ?
d) If metformin/insulin not tolerated/contraindicated - ?
a) Glucose monitoring, USS at 28, 32 and 36 weeks to assess foetal growth and amniotic fluid volume
b) Lifestyle - weight loss (‘weight neutral pregnancy’), diet, exercise. If this fails (1 - 2 weeks), offer metformin
c) Insulin
d) Glibenclamide
GDM: intrapartum care
a) If preterm labour occurs…?
b) Delivery
c) If patient carries to 40+6…?
a) Offer maternal corticosteroids and tocolysis (e.g. terbutaline)
b) Can deliver PV but need to know the risks (especially if macrosomic)
c) Offer induction (do not let them carry past 40+6 !)
GDM: complications
a) Foetal
b) Maternal
a) Foetal - LGA, macrosomia, shoulder dystocia, neonatal hypoglycaemia. Later: obesity, intellectual impairment
b) Maternal - pre-eclampsia, birth trauma (e.g. perineal tear, complications of CS)
