Antenatal Care Flashcards
Give 2 gynae symptoms and 3 signs of pregnancy before 12 weeks
- AMENORRHOEA
Breast engorgement + nipple darkening
Vulva becomes more vascular
Cervix softens
Uterine body is more globular
Give a GI symptom of pregnancy BEFORE 12 weeks
Nausea and vomiting
Significantly more/hyperemesis = scan around 8 weeks to check for twins or molar pregnancy
Give 4 minor GI symptoms of pregnancy AFTER 12 weeks
Nausea and vomiting!
Abdominal Pain
Constipation
Reflux/Heartburn
Why do you become constipated during pregnancy and what is the management?
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
Why do you get reflux in pregnancy? What is the management?
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.
Give 3 MSK symptoms of pregnancy
Backache
Pubic symphysis dysfunction - pain as pelvic ligaments and muscle relaxation
Cramp
Give 4 other minor symptoms of pregnancy
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
What is the naegele rule?
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
What are 4 risks of smoking during pregnancy?
++ 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)
What is the impact of alcohol during pregnancy?
- FAS at high consumption
- Crosses placenta
What are the risks of recreational drug use during pregnancy?
- same as smoking but also risks intrauterine death
What are the nutritional supplements recommended in pregnancy?
Folic Acid Supplementation
Vitamin D Supplementation
Darker skin = ++ risk
Limited skin exposure = ++ risk
Avoid Vitamin A
High in liver
Teratogenic
Why is folic acid recommended?
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
Which foods should be avoided during pregnancy and why?
Reducing listeriosis risk
- ONLY DRINK UHT/pasteurised milk
- ripened/soft cheese
- pate
- undercooked meats
Reducing salmonella risk
- partially cooked eggs/mayo
- undercooked meats
Which blood tests are used for screening at booking (10 weeks)?
- FBC (anaemia)
- Infections (HIV, HEP B, Syphillis
- Haemaglobinopathy (sickle cell and thalassaemia)
- Blood grouping and Red Cell alloantibodies
Which USS findings are used for screening at booking? (3)
- Dating:
CRL if 10-14 weeks
or head circumference if CRL >84 mm or 14+1-20 weeks
Nuchal translucency - Trisomy 21 screening
Which USS findings are used for screening during the 20 week scan?
- Structural abnormalities
What happens during the week 36 visit?
Breastfeeding info
Labour and birth prep + baby position
Vit K prophylaxis
Care of new baby
Post natal self care
What is the triple/combined test?
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.
What is the quadruple test and when can it be offered?
Blood test
for late bookers between week 15-20
4.1% false positive
What is amniocentesis and when can it be performed?
Aspiration of foetal cells from skin and gut. Needle is put transabdominally and using USS
Done >16 weeks
What are the positives of amniocentesis? (3)
can diagnose foetal infections
lower miscarriage rate [than cvs]
can get results in 3 working days for trisomies
What are the negatives of amniocentesis?
Done later in pregnancy so less thinking time if considering termination
What is chorionic villi sampling and when can it be done?
Take sample from the placenta either transabdominally or transcervically under USS
Done between week 10-13
What are the positives of CVS? (2)
Happens earlier so more time and safer if considering termination.
Results within 3 days for trisomies.
What are the negatives of CVS? (4)
miscarriage rate is 1-2%,
increased risk of BBV transmission
false positives.
Can’t have if dichorionic multiple pregnancy.
Give 6 sensitising events/ events where maternal and foetal blood could mix
Birth
Last Trimester
ECV
Amniocentesis and CVS
Termination
Late miscarriage
When are rhesus groups a problem?
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.
What does incompatible rhesus groups between mother and foetus result in?
Haemolytic disease of the newborn
During which sensitisation events does anti-d need to be given?
- ECV
- CVS
- Amniocentesis
- Termination
- Miscarriage (unless threatened and before 12 weeks)
Why would a Kleihauser test be performed? What is it?
- See if eligible for anti-D
- Measures amount of foetal Hb in maternal supply so that amount of anti-d can be determined.
What are the physiological cardiovascular changes that occur during pregnancy?
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
What are the physiological respiratory changes that occur during pregnancy?
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)
What are the physiological haematological changes that occur during pregnancy?
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
What are the physiological urinary changes that occur during pregnancy?
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
What are the physiological biochemical changes that occur during pregnancy?
Increase in calcium requirements esp during T3
Calcium actively transported across placenta so serum conc falls
Gut absorption of calcium increases
What are the physiological uterine changes that occur during pregnancy?
100g → 1100g
hyperplasia → hypertrophy later
I
ncrease in cervical ectropion & discharge
Braxton-Hicks: non-painful ‘practice contractions’ late in pregnancy (>30 wks)
What is the definition of foetal lie?
Relationship between the long axis of foetus and mother
What is the definition of foetal presentation?
Part of baby that first enters maternal pelvis
What is the definition of foetal position?
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.
What is the most common malpresentation?
Breech where baby is feet/bum first
but this normally resolves by week 36 as the baby usually turns to head first by then
How is breech presentation diagnosed?
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?
What is the management of breech presentations?
ECV if vag delivery is planned and is after 36 weeks
If ECV doesn’t work then elective c section at 39 weeks
What is external cephalic version?
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.
What investigations must happen before an ECV?
CTG (and do after)
Maternal HR and BP
What are 5 contraindications to ECV/
Diagnosed placenta praevia
Uterine scars or abnormalities
Abnormal CTG
Foetal abnormality
Pre-eclapmisa/maternal HTN
Should medications be given alongside ECV?
Yes
Anti-D if Rhesus NEGATIVE afterwards
What are the risks of ECV? (4)
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)
What is the definition of rupture of membranes?
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
What is the definition of premature rupture of membranes (PROM)?
Rupture of membranes before the onset of uterine contractions/labour
What is the definition of pre-term premature rupture of membranes
PROM before 37 weeks of gestation
What are 4 causes of PROM?
Cervical incompetence
Cerclage (the stitch)
Insufficiency (cervix shortens and opens too early)
Amniocentesis
Infection
Chorioamnionitis/inflammation
Give 4 maternal risk factors for PROM
- Previous hx of PPROM/ preterm delivery
- Uterine irritation e.g. placental abruption
- Lifestyle e.g. smoker
- Age above 40 or below 20
Give 3 uteroplacental risk factors for PROM
- Stretched uterus e.g. multiple pregnancy
- Cervical insufficiency
- intra-amniotic infection
Which investigation should you never do in a lady with PROM?
DO NOT DO A DIGITAL VAGINAL EXAMINATION AS THIS INCREASES RISK OF ASCENDING INFECTION
Which investigations should be done to diagnose PROM?
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
When should you admit a lady with PROM?
Admit to hospital if PPROM or ascending infection is suspected
Need to monitor signs of infection and RFM
What is the medical management of PROM?
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
When should you deliver the baby in PROM?
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
What are the maternal, placental complications of PROM?
Abruption
Retained placenta
PPH, SPH
What are the other maternal complications of PROM
- infection
endometritis
chorioamnionitis
What is the relevance of GBS infections in pregnancy?
Ascending infection from birth canal that can lead to preterm birth/PROM/chorioamnionitis or sepsis in the baby
What are 5 risk factors of GBS in pregnancy?
previous hx of a baby with GBS
current pyrexia
ROM for >24 hours
Preterm birth
suspected chorioamnionitis
What is the management of a mother with a history of:
A previous baby with GBS
or
GBS on high vaginal swab
?
Give prophylactic abx
BenPen or Cephalosporins
What is the management of a mother with PPROM?
give prophylactic abx during labour (infection likely cause)
What is the management of a mother with PROM + known GBS?
induction of labour + give prophylactic abx
What is the management of a mother with no GBS suspected + intact membranes?
no abx
Define obstetric cholestasis
Pruritus during 2nd half of pregnancy
Esp on palms and soles of feet
Worse at night
No rash
Give 3 other symptoms of obstetric cholestasis (4)
Insomnia
Liver stuff - pale stools/steatorrhoea, dark urine, jaundice
Malaise
Abdo pain
What is the deal with jaundice in obstetric cholestasis?
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.
What are the differentials of pruritus during pregnancy?
Liver disease - Acute fatty liver disease of pregnancy
Hepatitis - viral/autoimmune/drug induced
Extra-hepatic obstruction from gallstones
What is acute fatty liver disease of pregnancy?
A v rare but serious condition
Get abdominal pain, jaundice, headache and vomiting +/-thrombocytopenia and pancreatitis
Associated with pre-eclampsia
What are the Ix to diagnose obstetric cholestasis?
Liver USS
Bloods = LFTs!!!
LFTs - measure weekly until delivery
Moderately high transaminase
V high ALP
Increased serum total bile acid x10
Mild bilirubin increase
Why is ALP raised in obstetric cholestasis?
Raised anyway in pregnancy from placenta so has to be abnormally high
What is the foetal management of obstetric cholestasis?
Increased foetal monitoring
What is the maternal management of obstetric cholestasis?
Conservative:
- Inform increased risk of: passage of meconium and prematurity
- Topical calamine lotion
Medical:
- Oral vitamin K
- Urseodeoxycholic acid
What is the role of oral vitamin K in obstetric cholestasis?
Vitamin K is fat soluble and have fat malabsorption in liver disease
Vitamin K is needed for clotting and so is protective for PPH
What is the role of ursodeoxycholic acid in obstetric cholestasis?
Displaces bile salts and protects hepatocytes
What are the maternal complications of obstetric cholestasis?
PPH
Liver impairment if lasting several weeks - Reduction in vitamin K reabsorption or decreased PATIENT production = increased prothrombin time
What are the foetal complications of obstetric cholestasis?
Intrauterine death
Foetal distress
Prematurity
When should delivery be considered in a patient with obstetric cholestasis?
37-38 weeks
Earlier if: Multiple pregnancy Foetal distress Increasing LFTs Serum bile acids >40 mol/l
How many antenatal appointments should uncomplicated women receive?
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
How should chickenpox EXPOSURE be managed in a pregnant lady?
Urgent blood test for varicella antibodies
Not immune = give varicella-zoster immunoglobulin asap (can give up to 10 days after exposure)
How should chickenpox be managed in a pregnant lady?
Obstetrics referral
Oral acyclovir if ?20 weeks and within 24 hours of rash
What is the dose of folic acid that should be taken in a normal woman who wants to get pregnant?
400 micrograms to prevent NTD
Until 12 weeks
What is the dose of folic acid that should be taken in a higher risk woman who wants to get pregnant?
5 milligrams from before conception to 12 weeks
To prevent NTD
Which women are at higher risk of NTDs?
- Previous Hx, FHx, has coeliac, diabetes or a thalassaemia
- On anti-epileptics,has a BMI of >30
Define zygosity
Degree of genetic similarity between a pair of twins
Define chorionicity
Number of placentae
What are the signs and symptoms of multiple pregnancy?
Uterus is large for dates
Hyperemesis
Polyhydramnios
2+ poles
Multiple foetal parts
2 foetal HR
What are the ix to diagnose a multiple pregnancy?
USS at 11-13 weeks - establish chorionicity
Get more monitoring as high risk
Which chorionicity is the highest risk?
Monochorionic - get scans every 2 weeks from 16
Check for twin to twin transfusion and foetal growth restriction
What are the maternal complications of a multiple pregnancy?
Anaemia
APH due to bigger placenta
Hyperemesis
Increased risk VTE
What are the foetal complications of a multiple pregnancy?
Twin to twin transfusion syndrome
Increased risk prematurity
FGR
Increased perinatal mortality (vasa praaevia, cord entanglement, malpresentation)
What are the complications of a multiple pregnancy during pregnancy?
Polyhydramnios
Pre-eclampsia
APH
Anaemia
What are the complications of a multiple pregnancy during labour?
PPH
Malpresentation
Premature separation of the placenta
Cord entanglement - cuts off supply
What is twin to twin transfusion syndrome?
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
What is the delivery management for uncomplicated multiple pregnancy?
Dichorionic = elective birth @ 37 weeks
Monochorionic = elective birth @ 36 weeks
Majority need c-section but can do vaginally +/- forceps
Which women need prophylactic antibiotics to prevent GBS and which abx would you give?
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
