Antenatal Care Flashcards
What is the purpose of antenatal care?
To identify mothers who do need medical attention, to prevent maternal and foetal mortality
What are the aims of antenatal care?
- Detect and manage pre-existing maternal disorders that may affect pregnancy outcome
- Prevent or detect and manage maternal complications
- Prevent or detect and manage foetal complications of pregnancy
- Detect congenital foetal problems, if requested by parents
- Plan, with the mother, the circumstances of pregnancy care and delivery to ensure maximum safety for mother and baby, and maximum maternal satisfaction
- Provide education and advice regarding lifestyle and ‘minor’ conditions of pregnancy
What should be considered in prenatal care and counselling?
- How previous pregnancies were; if they were traumatic the implications of this for another
- Health check; look for undetected problems like cervical smear abnormalities or cardiac disease and Tx
- Rubella status; provide immunisation
- Chronic disease optimisation; strict preconceptual glucose control in diabetics reduces incidence of congenital abnormalities
- Optimise medication; e.g. lamotrigine over sodium valproate for epilepsy
- 0.4mg/day folic acid reduces risk of neural tube defects
When should 1st antenatal visit be?
Before 10 weeks
Purpose of 1st antenatal visit?
Screen for possible complications that may arise in pregnancy, labour and puerperium
What is done in 1st antenatal visit?
- Assess ‘risk’ using Hx and examination and Ix
- Check gestation of pregnancy
- Appropriate prenatal screening discussed
- General health check
- Health advice
History to be taken in 1st antenatal visit?
- Age
- Hx of present pregnancy
- Past obstetric Hx
- Past gynaecological Hx
- Past medical Hx
- Drugs
- FHx
- Immigration and language issues
- Personal/social Hx
What age of women have an increased risk of obstetric and medical complications?
<17 and >35
When are chromosomal trisomies more common?
Advancing age
How are all pregnancies except IVF dated in the UK?
Early ultrasound (11-13 + 6 weeks) measures crown-rump length
Obstetric issues that have a high recurrence rate?
- Preterm labour
- Small-for-gestational age and ‘growth-restricted’ foetus
- Stillbirth
- Antepartum and postpartum haemorrhage
- Some congenital anomalies
- Rhesus disease
- Preeclampsia
- Gestational diabetes
Why does past gynae Hx need to be discussed?
Some previous surgeries (e.g. myomectomy) may influence delivery recommendations (e.g. loop diathermy) or increase preterm labour risk
What medical conditions put women at increased risk of pregnancy problems?
Htn Diabetes Autoimmune disease Cardiac or renal disease Other serious illnesses Past mental illness increases suicide risk
How are women at increased pregnancy risk due to medical conditions managed?
Input from appropriate specialist
What needs to be considered about drugs at 1st antenatal visit?
Contraindicated drugs should be swapped to those considered safe
What antenatal conditions can be familial?
Gestational diabetes more likely if 1st-degree-relative is diabetic Htn VTE Autoimmune disease Preeclampsia
What is important to consider in the personal or social Hx?
Domestic violence
Pre existing health conditions found on booking and issues of these?
- BMI >30 increases risk of complications
- Baseline HTN increases risk of preeclampsia
- Incidental findings e.g. breast carcinoma
What abdo exams are done at the 1st antenatal check?
Abdo exam before 3rd trimester is limited
From 12 weeks, foetal heart can be auscultated with an electronic monitor
Routine vaginal exam not appropriate
When is a smear done if woman is overdue?
3 months postnatally
What can an US detect?
- ‘Dating’ by CRL
- Screening for chromosomal abnormalities with nuchal translucency measurement, along with blood levels of human chorionic gonadotrophin beta-subunit (β-hCG) and pregnancy-associated plasma protein A (PAPPA)
Blood tests done at 1st antenatal visit and why?
- FBC = pre-existing anaemia
- Serum antibodies = those at risk of intrauterine isoimmunisation
- Glucose tolerance test = in at risk women, planned for later in pregnancy
- Syphilis = serious complications for foetus
- Rubella immunity; vaccination offered postnatally if needed
- HIV and hep B
- Haemoglobin electrohphoresis in at risk women. If positive, check partner to ID women that need prenatal diagnosis
Ethnicity at risk of sickle cell anaemia?
Afro-Caribbean women
Ethnicity at risk of thalassaemias?
Mediterranean and Asian
Routing booking investigations?
- Urine culture
- FBC
- Antibody screen
- Serological test for syphilis
- Rubella immunoglobulin G
- HIV and Hep B (offered)
- US scan
- Screening for chromosomal abnormalities
- (+ Hb electrophoresis)
Other tests that can be done at booking that are not routinely offered in UK?
- Screening for infections (e.g. chlamydia, BV) in women at increased risk
- Toxoplasmosis and CMV
Other tests routinely done at booking?
- Urine microscopy and culture = Asx bacteriuria in pregnancy commonly (20%) leads to pyelonephritis
- Urinalysis for glucose, protein and nitrites = screen for underlying diabetes, renal disease and infection, respectively
Supplements that should be taken in the UK?
- Folic acid
- Vitamin D
- Aspirin
How much folic acid should be taken and for how long?
- 4mg/day folic acid for 12 weeks. Higher dose of 5mg recommended for;
- BMI >30
- Diabetes
- Sickle cell disease
- Malabsorption
- Antiepileptics
Dose of vitamin D supplementation and who should take it?
10µg/day for all. Higher dose of 25µg/day for;
- BMI >30
- S. Asian and Afro-Caribbean
- Low sunlight exposure
- Increased risk of preeclampsia
Dose of aspirin and who should take it?
75mg for women at increased risk of preeclampsia
Immunisations that should be given?
Seasonal influenza and after 28 weeks, pertussis
Lifestyle advice that should be given?
- Diet = balanced and 2500 calories/day
- Alcohol avoidance
- Smoking advice and NRT
- Dental check up advised
- Coitus okay unless placenta is praevia or membranes have ruptured
- Avoid Listeriosis infection by drinking pasteurised or UHT milk, no soft and blue cheese, no paté, no uncooked food
- Exercise good; swimming best; no contact sports or heavy exercise
- Wear seatbelt above and below bump
- Sleep in left lateral position from 28 weeks
Who leads most antenatal care in UK?
Community midwives
When is medical input in antenatal care required?
Pre-existing illness
Increased risk of pregnancy complications and adverse maternal or foetal outcomes
Disorders checked for antenatal screening and action if high risk?
- VTE = Low molecular weight heparin
- Preeclampsia = Aspirin 75mg, increased BP monitoring
- Chromosomal abnormalities = non-invasive prenatal diagnosis or invasive testing
- Foetal growth restriction = Serial ultrasound of foetal growth
- Gestational diabetes = Glucose tolerance test
What can be used for risk assessment of preterm delivery in otherwise low risk women?
Ultrasound cervical length measurement at around 20 weeks
What can halve the risk of preterm delivery in women with a short cervix but otherwise ‘low risk’?
Progesterone administration
What can be used to screen for intrauterine growth restriction and preeclampsia?
Ultrasound measurement of uterine artery
What is NIPT?
Non-invasive prenatal testing to determine Rhesus-negative mothers carrying Rhesus-positive babies. Those with a positive baby given anti-D
Does frequency of antenatal visits increase or decrease in pregnancy and why?
Increase as complications are more common in later pregnancy
NICE recommend how many antenatal visits?
Nulliparous = 10 Multiparous = 7
What is done at each antenatal visit?
Hx briefly reviewed
Woman asked about physical and mental state
Women can ask Qs
BP taken
Urine checked for protein, glucose and nitrites (urine culture if nitrites detected)
Abdomen examined
Reassessment of pregnancy risk
What is done at 16 week antenatal check?
Review results of screening tests for chromosomal abnormalities and booking blood tests
What is done at 18-21 week antenatal check?
Anomaly scan performed. Further scan at 32 weeks if placenta is low
What is done at 25 week antenatal check (for nulliparous women only)?
Exclude early onset preeclampsia. GTT if indicated
What is done at 28 week antenatal check?
Fundal height measured
FBC and antibodies checked
Anti-D given to Rh-ve women with Rh+ve women
What is done at 31 week antenatal check (for nulliparous women only)
Fundal height measured
What is done at 36, 38 and 40 week antenatal checks?
Fundal height measured
Foetal lie and position checked
Referral for external cephalic version (ECV) offered if breech presentation
Pelvic exam only if induction is contemplated or suspicion of obstruction
What is done at 41 week antenatal check?
Fundal height measured
Foetal lie and presentation checked
Membrane sweeping offered
Induction by 42 weeks
‘Minor’ conditions of pregnancy?
Itching Pelvic girdle pain Abdo pain Heartburn Backache Constipation Ankle oedema Leg cramps Carpal tunnel syndrome Vaginitis Tiredness
Itching in pregnancy?
Check sclerae for jaundice, LFTs and bile acid assessment. Rare, but liver complications in pregnancy often present in pregnancy
TX of pelvic girdle pain?
Physiotherapy, corsets, analgesics and crutches. Care with leg abduction. Usually cured after delivery
Heartburn in pregnancy?
Affects 70%.
Worse in supine position
Extra pillow help and antacids allows
Preeclampsia can present with epigastric pain
Backache?
Almost universal and may cause sciatica
Physiotherapy, advice on posture and lifting, firm mattress and corset can help
Constipation
Common
Exacerbated by oral iron
High fibre intake
Stool softeners to be used if needed
Ankle oedema
Common Worsens at end Unreliable sign of preeclampsia Sudden increase in oedema warrants follow up BP, urinalysis Helped by raising foot of bed at night Don't give diuretics
Leg cramps?
30% affected
Tx unproven but; NaCl tablets, Ca2+ salts or quinine
Carpal tunnel syndrome
Due to fluid retention compressing median nerve
Rarely severe and usually temporary
Wrist splints can help
Vaginitis
Due to candidiasis common and difficult to Tx
Imidazole vaginal pessaries for Sx infection
Tiredness
Almost universal
Often incorrectly attributed to anaemia
