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EOY4 > Antenatal Care > Flashcards

Antenatal Care Flashcards

1
Q

Give 2 gynae symptoms and 3 signs of pregnancy before 12 weeks

A
  • AMENORRHOEA

Breast engorgement + nipple darkening

Vulva becomes more vascular

Cervix softens

Uterine body is more globular

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2
Q

Give a GI symptom of pregnancy BEFORE 12 weeks

A

Nausea and vomiting

Significantly more/hyperemesis = scan around 8 weeks to check for twins or molar pregnancy

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3
Q

Give 4 minor GI symptoms of pregnancy AFTER 12 weeks

A

Nausea and vomiting!

Abdominal Pain

Constipation

Reflux/Heartburn

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4
Q

Why do you become constipated during pregnancy and what is the management?

A

Decrease in gut motility due to mass or increased progesterone.

Don’t give stimulant laxatives as can increase uterine activity.

Ensure adequate fluid intake i.e. more lifestyle but can lead to haemorrhoids/varicose veins

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5
Q

Why do you get reflux in pregnancy? What is the management?

A

Fundus of the uterus presses on UGIT and + increase in progesterone relaxes the pyloric sphincter.

Give Ranitidine or Rennies.

Avoid smoking, spicy food and use more pillows so can sit up.

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6
Q

Give 3 MSK symptoms of pregnancy

A

Backache

Pubic symphysis dysfunction - pain as pelvic ligaments and muscle relaxation

Cramp

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7
Q

Give 4 other minor symptoms of pregnancy

A

Ankle Oedema
- - venous return
Check BP and urine dip (?pre-eclampsia)
Check for DVT

Urinary Frequency
Baby’s head presses on bladder (later on)
++ GFR and ++ urinary output - make sure it’s not a UTI

Breathlessness
Fundus of the uterus = - - space for lungs. Make sure it’s not a VTE

Headache +/- palpitations +/- fainting
Dilation of peripheral circulation due to + + progesterone
May also feel hot n sweaty

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8
Q

What is the naegele rule?

A

How to calculate the due date ASSUMING THAT the gestational age is 280 days (40 weeks)

Add 1 year. Subtract 3 months. Add 7 days to origin of gestational age.

Example: if LMP was 01/09/2019 then the due date will be 08/06/2020

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9
Q

What are 4 risks of smoking during pregnancy?

A

++ risk of miscarriage

++ risk of placenta problems
implanting in the wrong place (placenta praevia)
Coming away from the wall of uterus before labour (placental abruption)

++ risk of baby not growing enough (foetal growth restriction)

++ risk of going in to labour too soon (preterm labour)

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10
Q

What is the impact of alcohol during pregnancy?

A
  • FAS at high consumption

- Crosses placenta

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11
Q

What are the risks of recreational drug use during pregnancy?

A
  • same as smoking but also risks intrauterine death
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12
Q

What are the nutritional supplements recommended in pregnancy?

A

Folic Acid Supplementation

Vitamin D Supplementation
Darker skin = ++ risk
Limited skin exposure = ++ risk

Avoid Vitamin A
High in liver
Teratogenic

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13
Q

Why is folic acid recommended?

A

Reduces risk of neural tube defects e.g. spina bifida (helps the spinal cord to form properly) and cleft lip

Take 400mcg per day until week 13 (+before conception if trying)

OR take 5mg/day until week 13 if: previous hx, diabetic, Sickle cell disease, obese, on anti epileptics or HIV and on co-trimoxazole

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14
Q

Which foods should be avoided during pregnancy and why?

A

Reducing listeriosis risk

  • ONLY DRINK UHT/pasteurised milk
  • ripened/soft cheese
  • pate
  • undercooked meats

Reducing salmonella risk

  • partially cooked eggs/mayo
  • undercooked meats
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15
Q

Which blood tests are used for screening at booking (10 weeks)?

A
  • FBC (anaemia)
  • Infections (HIV, HEP B, Syphillis
  • Haemaglobinopathy (sickle cell and thalassaemia)
  • Blood grouping and Red Cell alloantibodies
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16
Q

Which USS findings are used for screening at booking? (3)

A
  • Dating:
    CRL if 10-14 weeks
    or head circumference if CRL >84 mm or 14+1-20 weeks

Nuchal translucency - Trisomy 21 screening

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17
Q

Which USS findings are used for screening during the 20 week scan?

A
  • Structural abnormalities
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18
Q

What happens during the week 36 visit?

A

Breastfeeding info

Labour and birth prep + baby position

Vit K prophylaxis

Care of new baby

Post natal self care

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19
Q

What is the triple/combined test?

A

Nuchal Translucency + free B-hCG + pregnancy associated plasma protein + woman’s age between 11 and 13+6 weeks. (USS + Blood test)

Detects 90% of all aneuploides

Results are as a risk factor and 2% of women will be ‘high risk’. They are then offered CVS sampling or amniocentesis.

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20
Q

What is the quadruple test and when can it be offered?

A

Blood test

for late bookers between week 15-20

4.1% false positive

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21
Q

What is amniocentesis and when can it be performed?

A

Aspiration of foetal cells from skin and gut. Needle is put transabdominally and using USS

Done >16 weeks

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22
Q

What are the positives of amniocentesis? (3)

A

can diagnose foetal infections

lower miscarriage rate [than cvs]

can get results in 3 working days for trisomies

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23
Q

What are the negatives of amniocentesis?

A

Done later in pregnancy so less thinking time if considering termination

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24
Q

What is chorionic villi sampling and when can it be done?

A

Take sample from the placenta either transabdominally or transcervically under USS

Done between week 10-13

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25
Q

What are the positives of CVS? (2)

A

Happens earlier so more time and safer if considering termination.

Results within 3 days for trisomies.

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26
Q

What are the negatives of CVS? (4)

A

miscarriage rate is 1-2%,

increased risk of BBV transmission

false positives.

Can’t have if dichorionic multiple pregnancy.

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27
Q

Give 6 sensitising events/ events where maternal and foetal blood could mix

A

Birth

Last Trimester

ECV

Amniocentesis and CVS

Termination

Late miscarriage

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28
Q

When are rhesus groups a problem?

A

If a Rh - (rr) mother + Rh + (Rr) father

Results in an Rh + baby even though mother is Rh -

This is not a problem in the first pregnancy but is definitely a problem in subsequent pregnancies.

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29
Q

What does incompatible rhesus groups between mother and foetus result in?

A

Haemolytic disease of the newborn

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30
Q

During which sensitisation events does anti-d need to be given?

A
  • ECV
  • CVS
  • Amniocentesis
  • Termination
  • Miscarriage (unless threatened and before 12 weeks)
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31
Q

Why would a Kleihauser test be performed? What is it?

A
  • See if eligible for anti-D

- Measures amount of foetal Hb in maternal supply so that amount of anti-d can be determined.

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32
Q

What are the physiological cardiovascular changes that occur during pregnancy?

A

SV up 30%, HR up 15% & cardiac output up 40%

systolic BP is unaltered

diastolic BP is reduced in the 1st and 2nd trimester, returning to non-pregnant levels by term

enlarged uterus may interfere with venous return which can lead to ankle oedema, supine hypotension and varicose veins

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33
Q

What are the physiological respiratory changes that occur during pregnancy?

A

increase in pulmonary ventilation

Increase in oxygen requirements so over breathing leads to a fall in pCO2 - this can give rise to a sense of dyspnoea that may be accentuated by elevation of the diaphragm

BMR up 15% (increase in thyroxine and adrenocorticoids)

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34
Q

What are the physiological haematological changes that occur during pregnancy?

A

Increase in blood volume in 2nd half of pregnancy

Physiological anaemia due to ↓ Hb but ↑ plasma

Increased risk of VTE due to ↓ fibrinolytic activity and ↑ in clotting factors

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35
Q

What are the physiological urinary changes that occur during pregnancy?

A

blood flow increase by 30%

GFR increases by 30-60%

Salt and water reabsorption is increased by elevated sex steroid levels

Urinary protein losses increase

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36
Q

What are the physiological biochemical changes that occur during pregnancy?

A

Increase in calcium requirements esp during T3

Calcium actively transported across placenta so serum conc falls

Gut absorption of calcium increases

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37
Q

What are the physiological uterine changes that occur during pregnancy?

A

100g → 1100g

hyperplasia → hypertrophy later
I
ncrease in cervical ectropion & discharge

Braxton-Hicks: non-painful ‘practice contractions’ late in pregnancy (>30 wks)

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38
Q

What is the definition of foetal lie?

A

Relationship between the long axis of foetus and mother

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39
Q

What is the definition of foetal presentation?

A

Part of baby that first enters maternal pelvis

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40
Q

What is the definition of foetal position?

A

Position of foetal head as it enters the birth canal (ideally occipito-anterior). Think of that lady who gave birth really quickly as occipto-posterior and got the third degree tear.

41
Q

What is the most common malpresentation?

A

Breech where baby is feet/bum first

but this normally resolves by week 36 as the baby usually turns to head first by then

42
Q

How is breech presentation diagnosed?

A

Baby is longitudinal but cannot feel head in the pelvis

Smooth round mass @ funds (head)

May have pain under ribs

USS is gold standard. Have to do to rule out placenta praevia as this is CONTRAINDICATED for breech?

43
Q

What is the management of breech presentations?

A

ECV if vag delivery is planned and is after 36 weeks

If ECV doesn’t work then elective c section at 39 weeks

44
Q

What is external cephalic version?

A

Gentle, firm pressure on the abdomen to move the baby.

Uncomfortable and sometimes painful.

Works 40% of the time in primips and 60% in multips.

Kim Kardashian had one with Saint.

45
Q

What investigations must happen before an ECV?

A

CTG (and do after)

Maternal HR and BP

46
Q

What are 5 contraindications to ECV/

A

Diagnosed placenta praevia

Uterine scars or abnormalities

Abnormal CTG

Foetal abnormality

Pre-eclapmisa/maternal HTN

47
Q

Should medications be given alongside ECV?

A

Yes

Anti-D if Rhesus NEGATIVE afterwards

48
Q

What are the risks of ECV? (4)

A

Might not work/ baby might turn back. Effective in about 40% first time mams and 60% if had baby before.

Discomfort. Shouldn’t be painful but will stop if so.

Cause some stress to baby

Risk of placenta coming away from the wall of the uterus (abruption)

49
Q

What is the definition of rupture of membranes?

A

Breakage of the amniotic say so that the baby can be born
Most women will spontaneously labour 24 hrs after ROM as PGE2 is released = uterine contractions
6% won’t be in spontaneous labour after 96 (!!!) hours and the earlier it is then this is more likely to happen

50
Q

What is the definition of premature rupture of membranes (PROM)?

A

Rupture of membranes before the onset of uterine contractions/labour

51
Q

What is the definition of pre-term premature rupture of membranes

A

PROM before 37 weeks of gestation

52
Q

What are 4 causes of PROM?

A

Cervical incompetence
Cerclage (the stitch)
Insufficiency (cervix shortens and opens too early)
Amniocentesis

Infection
Chorioamnionitis/inflammation

53
Q

Give 4 maternal risk factors for PROM

A
  • Previous hx of PPROM/ preterm delivery
  • Uterine irritation e.g. placental abruption
  • Lifestyle e.g. smoker
  • Age above 40 or below 20
54
Q

Give 3 uteroplacental risk factors for PROM

A
  • Stretched uterus e.g. multiple pregnancy
  • Cervical insufficiency
  • intra-amniotic infection
55
Q

Which investigation should you never do in a lady with PROM?

A

DO NOT DO A DIGITAL VAGINAL EXAMINATION AS THIS INCREASES RISK OF ASCENDING INFECTION

56
Q

Which investigations should be done to diagnose PROM?

A

Sterile Speculum Examination - Have a look and see if amniotic fluid is there

Nitrazine stick (checks the pH)
Can also test for:
Insulin-like growth factor binding protein-1
Placental alpha microglobin-1
Foetal fibronectin
Don’t use in isolation just help with diagnosis

USS - check gestation and liquor volume

Foetal monitoring via CTG

57
Q

When should you admit a lady with PROM?

A

Admit to hospital if PPROM or ascending infection is suspected
Need to monitor signs of infection and RFM

58
Q

What is the medical management of PROM?

A

Abx Prophylaxis:
Give to reduce complications of preterm delivery and postnatal infection
Erythromycin for 10 days

Give BenPen if GBS is isolated

IM Betamethasone at 0 and 12h if gestation is between 24-36 weeks

59
Q

When should you deliver the baby in PROM?

A 
GBS infection - ascending infection from uterus + can trigger early labour etc. Can also be passed to baby during childbirth. See later. 
HIV for vag delivery
Chorioamnionitis
Foetal stress/meconium liquor
HSV infection
60
Q

What are the maternal, placental complications of PROM?

A

Abruption

Retained placenta

PPH, SPH

61
Q

What are the other maternal complications of PROM

A
  • infection

endometritis
chorioamnionitis

62
Q

What is the relevance of GBS infections in pregnancy?

A

Ascending infection from birth canal that can lead to preterm birth/PROM/chorioamnionitis or sepsis in the baby

63
Q

What are 5 risk factors of GBS in pregnancy?

A

previous hx of a baby with GBS

current pyrexia

ROM for >24 hours

Preterm birth

suspected chorioamnionitis

64
Q

What is the management of a mother with a history of:

A previous baby with GBS
or
GBS on high vaginal swab
?

A

Give prophylactic abx

BenPen or Cephalosporins

65
Q

What is the management of a mother with PPROM?

A

give prophylactic abx during labour (infection likely cause)

66
Q

What is the management of a mother with PROM + known GBS?

A

induction of labour + give prophylactic abx

67
Q

What is the management of a mother with no GBS suspected + intact membranes?

A

no abx

68
Q

Define obstetric cholestasis

A

Pruritus during 2nd half of pregnancy

Esp on palms and soles of feet

Worse at night

No rash

69
Q

Give 3 other symptoms of obstetric cholestasis (4)

A

Insomnia

Liver stuff - pale stools/steatorrhoea, dark urine, jaundice

Malaise

Abdo pain

70
Q

What is the deal with jaundice in obstetric cholestasis?

A

Unusual

If it does happen then it’ll be around 2 weeks after pruritus develops and has quick onset with a rapid plateau.

Constant til delivery.

71
Q

What are the differentials of pruritus during pregnancy?

A

Liver disease - Acute fatty liver disease of pregnancy

Hepatitis - viral/autoimmune/drug induced

Extra-hepatic obstruction from gallstones

72
Q

What is acute fatty liver disease of pregnancy?

A

A v rare but serious condition

Get abdominal pain, jaundice, headache and vomiting +/-thrombocytopenia and pancreatitis

Associated with pre-eclampsia

73
Q

What are the Ix to diagnose obstetric cholestasis?

A

Liver USS

Bloods = LFTs!!!

LFTs - measure weekly until delivery

Moderately high transaminase

V high ALP

Increased serum total bile acid x10

Mild bilirubin increase

74
Q

Why is ALP raised in obstetric cholestasis?

A

Raised anyway in pregnancy from placenta so has to be abnormally high

75
Q

What is the foetal management of obstetric cholestasis?

A

Increased foetal monitoring

76
Q

What is the maternal management of obstetric cholestasis?

A

Conservative:

  • Inform increased risk of: passage of meconium and prematurity
  • Topical calamine lotion

Medical:

  • Oral vitamin K
  • Urseodeoxycholic acid
77
Q

What is the role of oral vitamin K in obstetric cholestasis?

A

Vitamin K is fat soluble and have fat malabsorption in liver disease

Vitamin K is needed for clotting and so is protective for PPH

78
Q

What is the role of ursodeoxycholic acid in obstetric cholestasis?

A

Displaces bile salts and protects hepatocytes

79
Q

What are the maternal complications of obstetric cholestasis?

A

PPH

Liver impairment if lasting several weeks - Reduction in vitamin K reabsorption or decreased PATIENT production = increased prothrombin time

80
Q

What are the foetal complications of obstetric cholestasis?

A

Intrauterine death

Foetal distress

Prematurity

81
Q

When should delivery be considered in a patient with obstetric cholestasis?

A

37-38 weeks

Earlier if:
Multiple pregnancy
Foetal distress
Increasing LFTs
Serum bile acids >40 mol/l
82
Q

How many antenatal appointments should uncomplicated women receive?

A

10 antenatal visits in the first pregnancy if uncomplicated

7 antenatal visits in subsequent pregnancies if uncomplicated

women do not need to be seen by a consultant if the pregnancy is uncomplicated

83
Q

How should chickenpox EXPOSURE be managed in a pregnant lady?

A

Urgent blood test for varicella antibodies

Not immune = give varicella-zoster immunoglobulin asap (can give up to 10 days after exposure)

84
Q

How should chickenpox be managed in a pregnant lady?

A

Obstetrics referral

Oral acyclovir if ?20 weeks and within 24 hours of rash

85
Q

What is the dose of folic acid that should be taken in a normal woman who wants to get pregnant?

A

400 micrograms to prevent NTD

Until 12 weeks

86
Q

What is the dose of folic acid that should be taken in a higher risk woman who wants to get pregnant?

A

5 milligrams from before conception to 12 weeks

To prevent NTD

87
Q

Which women are at higher risk of NTDs?

A
  • Previous Hx, FHx, has coeliac, diabetes or a thalassaemia

- On anti-epileptics,has a BMI of >30

88
Q

Define zygosity

A

Degree of genetic similarity between a pair of twins

89
Q

Define chorionicity

A

Number of placentae

90
Q

What are the signs and symptoms of multiple pregnancy?

A

Uterus is large for dates
Hyperemesis
Polyhydramnios

2+ poles
Multiple foetal parts
2 foetal HR

91
Q

What are the ix to diagnose a multiple pregnancy?

A

USS at 11-13 weeks - establish chorionicity

Get more monitoring as high risk

92
Q

Which chorionicity is the highest risk?

A

Monochorionic - get scans every 2 weeks from 16

Check for twin to twin transfusion and foetal growth restriction

93
Q

What are the maternal complications of a multiple pregnancy?

A

Anaemia

APH due to bigger placenta

Hyperemesis

Increased risk VTE

94
Q

What are the foetal complications of a multiple pregnancy?

A

Twin to twin transfusion syndrome

Increased risk prematurity

FGR

Increased perinatal mortality (vasa praaevia, cord entanglement, malpresentation)

95
Q

What are the complications of a multiple pregnancy during pregnancy?

A

Polyhydramnios

Pre-eclampsia

APH

Anaemia

96
Q

What are the complications of a multiple pregnancy during labour?

A

PPH

Malpresentation

Premature separation of the placenta

Cord entanglement - cuts off supply

97
Q

What is twin to twin transfusion syndrome?

A

Twins that share a placenta and blood vessels = blood can pass from one twin to the other at ~16-25 weeks

Recipient = cardiac failure and polyhydramnios
Donor = oliguria, oligohydramnios and FGR
98
Q

What is the delivery management for uncomplicated multiple pregnancy?

A

Dichorionic = elective birth @ 37 weeks

Monochorionic = elective birth @ 36 weeks

Majority need c-section but can do vaginally +/- forceps

99
Q

Which women need prophylactic antibiotics to prevent GBS and which abx would you give?

A

Previous Hx GBS sepsis
GBS on high vaginal swab (give intrapartum)
PPROM - give during labour
PROM + known GBS = induction + give

NO GBS and membranes in tact = don’t give

Give BenPen or Cephalosporin IV
Or vancomycin if anaphylaxis allergic

EOY4 (22 decks)

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