Antenatal care

Question 1

What are the aims of antenatal care?

Answer 1

1. Detect and manage pre-existing maternal disorders that may affect pregnancy outcome
2. Prevent or detect and manage maternal complications of pregnancy
3. Prevent or detect and manage foetal complications of pregnancy
4. Detect congenital foetal problems, if requested by the parents
5. Plan, with the mother, the circumstances of pregnancy care and delivery to ensure maximum mother and baby and maximum maternal satisfaction
6. Provide education and advice regarding lifestyle and ‘minor’ conditions of pregnancy

Question 2

What needs to be covered in preconceptual care and counselling

Answer 2

Previous pregnancies - trauma?

Health check - assess for CV health or cervical smear abnormalities

Rubella status - so immunisation can occur prior to pregnancy

Chronic condition check - glucose control optimised in diabetes or blood pressure control

Medication - e.g. anti-epileptics

Folic acid supplements - reduce the chances of NTD

Question 3

What is the booking visit?

Answer 3

Booking is at 10 weeks gestation. The purpose is the screen for possible complications that may rise in pregnancy, labour and the puerperium.

Risk is assessed using history, examination and standard investigations

Decisions about pregnancy care must be constantly re-evaluated as the pregnancy proceeds - the gestation pregnancy should also be checked, appropriate prenatal screening discussed and a general health check

Question 4

What things are noted on the booking visit?

Answer 4

AGE - <17 ad >35 have an increased risk of obstetric and medical complications in pregnancy - chromosomal trisomies more common with advancing age

History of presenting pregnancy - early USS (usually 11-13+6 weeks) used to date all except IVF pregnancies

Past obstetric history - disorders have recurrence rates - including preterm labour, SGA, ‘growth-restricted’ foetus, stillbirth, antepartum and postpartum haemorrhage, congenital anomalies, Rhesus disease, pre-exlampsia, gestational diabetes

past gynaecology hx
PMH
Drugs
FH

Question 5

What examinations are done on the booking visit?

Answer 5

BMI - if >30, maternal and foetal complications are more common

Baseline BP - enables comparison if hypertension occurs later in pregnancy

From 12 weeks, the fetal heart can be auscultated - abdominal palpation is hard before 3rd trimester

If a smear has not been performed for 3 years it is usually done 3 months postnatally

Question 6

What investigations should be done on a booking visit?

Answer 6

USS - 11-13+6 weeks so foetus can be ‘dated’ using crown-rump length, unless IVF pregnancy
detects multiple pregnancies, and enables screening for chromosomal abnormalities with nuchal translucency measurement in conjunction with b-hcg and pappa (combined test)

FBC - pre-existing anaemia
Serum antibodies (anti-D) - intrauterine isoimmuniation
Glucose tolerance test - in at risk women (>30BMI)

Blood tests for syphilis - serious implications on foetus

Rubella immunity - vaccination offered postnatally

HIV and HepB - counselling and screening offered

Haemoglobin electrophoresis - in at risk women (sickle cell anaemia and thalassaemias)

Screening for infections - chlamydia and BV can cause preterm labour

Urine MC&S 0 asymptomatic bacteruria in pregnancy commonly leads to pyelonephritis (20%)

Urinalysis for glucose, protein and nitrites - underlying diabetes, renal disease and infection

Question 7

What dose of folic acid should be taken in pregnancy?

Answer 7

0.4mg/day - until at least week 12 - increased doses of 5mg/day in women with BMI >30, sickle disease, malabsorption or if on anti-epileptics

Question 8

What dose of vitamin D should pregnant ladies have?

Answer 8

(10ug/day) or 25ug/day in women with BMI >30, South Asian or Afro-Caribbean origin or with low sunlight exposure or with increased pre-eclampsia risk

Question 9

What dose of aspirin should women with an increased pre-eclampsia risk take?

Answer 9

75mg

Question 10

What immunisations should pregnant ladies have?

Answer 10

seasonal flu vaccine and >28 weeks pertussis vaccine

Question 11

What diet and exercise regime should pregnant ladies follow?

Answer 11

2500 calories
No alcohol or smoking
Avoid Listeriosis by drinking only pasteurised or UHT milk - avoid soft/blue cheese, paté and uncooked/partially cooked ready prepared food

Exercise - advised
Sleeping - left lateral position from 28 weeks
Antenatal classes - prepare and educate women and partners about pregnancy and labour

Question 12

What structural abnormality tests are done routinely?

Answer 12

USS - 20 weeks: ‘anomaly scan’ - enables detection of most structural foetal abnormalities

USS cervical length measurement - around 20 weeks can be used for risk assessment of preterm delivery

USS measurement of uterine artery - can be used as screening for IUGR and pre-eclampsia

Question 13

What treatment can be given to women who have a short cervix but are otherwise ‘low risk’?

Answer 13

Progesterone

Question 14

What routine later pregnancy tests are done?

Answer 14

FBC and antibody assessment - performed at 28 weeks: FBC repeated later if treated for anaemia

NIPT - used to determine if Rhesus -ve mother is carrying a Rhesus +ve baby.
Only those with a +ve baby are given anti-D

Question 15

How many appointments does NICE recommend for uncomplicated pregnancies?

Answer 15

10 in a nulliparous woman and 7 for uncomplicated pregnancies in a multiparous woman

More frequent visits are appropriate in ‘high-risk pregnancies’

Question 16

What routine bedside tests are done at every antenatal visit?

Answer 16

Blood pressure and urine dip

abdomen examined - presentation variable and unimportant until 36 weeks - listening to fetal heart

Question 17

What things are done at 16 weeks?

Answer 17

results of screening tests for chromosomal abnormalities and booking blood tests - ‘triple test’ is offered for women who missed chromosomal abnormality testing

Question 18

What things are done at 18-21 weeks?

Answer 18

anomaly scan performed - further scan at 32 weeks if placenta is low

Question 19

What things are done at 25 weeks?

Answer 19

for nulliparous women - exclude onset of pre-eclampsia and GTT if required

Question 20

What things are done at 28 weeks?

Answer 20

Fundal height measured - FBC and antibodies checked - anti-D given to Rhesus -ve women

Question 21

What is done at 31 weeks?

Answer 21

Fundal height measured in nulliparous women

Question 22

What is done at 36, 38 and 40 weeks?

Answer 22

fundal height is measured and foetal lie and presentation are checked - referral for external cephalic version (ECV) is offered if in breech position

Question 23

What is done at 41 weeks?

Answer 23

Fundal height is measured and foetal lie and presentation check - membrane sweeping is offered as is induction of labour by 42 weeks

Question 24

Name some of the common minor conditions in pregnancy

Answer 24

Itching 
Pelvic girdle pain
Abdo pain
Heartburn 
Backache
constipation
Ankle oedema
Leg cramps
Carpal tunnel syndrome 
Vaginitis 
Tiredness

Question 25

What is checked if a woman presents with itching?

Answer 25

Sclerae - jaundice
LFTs
bile acids assessed

Obstetric cholestasis excluded

Question 26

what is the cause/mx of constipation in pregnancy?

Answer 26

common - exacerbated by oral iron - high fibre intake is needed

Question 27

What is the cause of vaginitis in pregnancy?

How is it managed?

Answer 27

candidiasis

imidazole vaginal pessaries (e.g. Clotrimazole) used for symptomatic infection