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GOSH > Antenatal care > Flashcards

Antenatal care Flashcards

1
Q

Gravidity

A

How many times a woman has been pregnant

Includes ectopics etc

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2
Q

Parity

A

How many babies have been delivered at 24+ weeks

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3
Q

Primigravid

A

First ever pregnancy

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4
Q

Nulliparous

A

No delivery of a baby >24 weeks

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5
Q

Multiparous

A

1+ Babies delivered >24 weeks

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6
Q

1st trimester

A

1-12 weeks

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7
Q

2nd trimester

A

13-27 weeks

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8
Q

3rd trimester

A

28wks- delivery

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9
Q

What happens at the booking visit?

A 
Obstetric Hx
BP, Urinalysis, BMI
Antenatal screening 
Place of birth
Advice
Access to services
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10
Q

When is the booking visit

A

8-12 weeks ideally <10

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11
Q

When is the early dating scan and what happens

A

10-13+6

Confirms dates, Excludes multiple pregnancy

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12
Q

What is the combined test?

A 
11-13+6 usually at dating scan 
Nuchal translucency 
HCG
PAPP-A
Detects 85%- Trisomies
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13
Q

What results in the combined test would suggest Down’s syndrome?

What about the quadruple test?

A

High HCG
Low PAPP-A <1
Nuchal translucency >3.5mm

Low AFP, Low oestriol, inc Inhibin-A

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14
Q

Apart from Down’s what else can thickened NT suggest?

A

Abdominal defect

Cardiac defect

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15
Q

What happens at the Anomaly/Anatomy scan?

A 
18-20+6
Quadruple test
PLACENTAL LOCATION
Assess gestational age 
Anatomic survey
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16
Q

What is the Quadruple test

A

14-17 weeks but up to 20 weeks
AFP, HCG,Oestriol, Inhibin A
75% detection 4.1% false +ves

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17
Q

From the quadruple or combined test what risk is defined as high risk?
What do you do?

A

1/150 or more

CVS or amniocentesis

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18
Q

What is CVS?

A

Chorionic villous sampling
11-14 weeks
Miscarriage rate 1-2%
LA,Large needle

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19
Q

What is amniocentesis?

A

15+ weeks
Miscarriage rate 0.5-1%
Thin needle +/- LA

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20
Q

How do you diagnose Downs/Trisomies antenatally?

A

CVS/Amniocentesis

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21
Q

What is the IONA screen?

A

99% sensitivity for Down’s
Detects free-foetal DNA in maternal circulation
Still need amnio for Dx

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22
Q

How do you calculate gestational age in the dating scan?

A

Crown rump length (mm)

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23
Q

When can you see foetal heart activity?

A

6-7 weeks

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24
Q

What happens at fetal wellbeing/growth scans?

A

Estimate foetal weight and plot (Biparietal diameter, Head circumference, Abd circumference, Femur length)

Amniotic fluid index- Sum of deepest verticle pools
Doppler studies- EDF, MCA, Pulsatile index

If high risk have these regularly

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25
Q

Minor problems in 1st trimester?

A

N+V- resolution likely 16-20wks
Urinary symptoms as GFR inc (Dec Cr and urea)
constipation (decreases with gestation)

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26
Q

Minor problems in 3rd trimester?

A 
Obstetric cholestasis 
Acute fatty liver of pregnancy
Reflux 
Stress incontinence 
Varicose veins (inc with gestation)
Backache/sciatica 
Haemorrhoids
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27
Q

Normal Vaginal discharge in pregnancy?

A

Increased vaginal and cercival blood flow results in whit/clear muccoid discharge

Infection= Offensive, coloured, Itchy
RoM- Watery + profuse

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28
Q

Thresholds for giving oral iron for anaemia antenatally?

A

1st Tm < 110g/l
2nd TM <105g/l
3rd TM <100g/l

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29
Q

How do you treat obstetric cholestasis?

A

Urosdeoxycholic acid for symptoms
Induce at 37 weeks
Weekly LFTS and Vit K supplementation

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30
Q

Key diagnostic features of hyperemesis gravidarum

A

5% pre-pregnancy Wx loss
Dehydration
Electrolyte imbalance

Exclude UTI, Thyrotoxicosis

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31
Q

Admission criteria for hyperemesis gravidarum

A

Not tolerating oral fluids and dehydrated

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32
Q

Treatment of hyperemesis gravidarum

A

Check electrolytes and LFTs
IV fluids
+/- Promethiazine or cyclizine
+/- Ondansetron, Metoclopromide

If prolonged may need vitamin supplementation and high dose corticosteroids

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33
Q

Fetal consequences of hyperemesis gravidarum

A

Growth restriction

Pre-term

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34
Q

Key risk factors for SGA ‘starved small’

A 
Pre-eclampsia 
Hx IUGR
Multiple pregnancy 
Maternal medical disorders
Drug abuse, smoking
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35
Q

Key risk factors for SGA ‘abnormal small’

A

Chr, infection, genetics

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36
Q

SGA definition

A

Newborn birth Wx <10th percentile for gestational age

Estimated foetal Wx <10th percentile for gestational age

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37
Q

IUGR vs SGA

A

IUGR a subtype of SGA

could be constitutionally small

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38
Q

Investigation of SGA

A

UA doppler
Pulsatile index
EDF
+/- MCA PI +/- CPR

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39
Q

When would you consider delivery of an SGA baby at 32 weeks?

A

Absent/Reversed EDF in UA

Would also do 2 weekly scans

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40
Q

What do you want the resistance index and pulsatile index to be?

A

<1

Suggests easy blood flow getting through in both sys and dias

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41
Q

What would you do if an SGA baby had UA PI>95th centile and +ve EDF

A

UA doppler 2X weekly
Growth every 2 weeks
Delivery at 37 weeks

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42
Q

If the doppler is normal in an SGA baby when would you consider >34 week deliver

A

Static growth for 3 weeks or MCA <5th centile

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43
Q

When should you feel foetal movements?

A

18-20 weeks

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44
Q

Priorities when someone presents with reduced foetal movements? Consider DDx

A

Rule out IUD- Doppler heart beat and CTG (24+)
Infection- Bloods
IUGR- foetal assessment, 48 hr growth scan

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45
Q

What does amniotic fluid volume tell us about fetal sufficiency?

A

Sparing effect limits non-central organ blood flow

Good indicator of fetal insufficiency

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46
Q

What is prolonged pregnancy? What investigations are important?

A

Exceeding 42 weeks from LMP

Daily CTG after 42 weeks, Report any decrease in fetal movements, initial USS for growth and liquor volume

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47
Q

Management of prolonged pregnancy

A

Estimate EDD as accurately as possible +/- induction if high risk
Stretch and sweep at 41 weeks
IoL at 41-42 weeks

48
Q

How do you estimate EDD at Booking visit?

A

LMP +7/7 +9/12

49
Q

What is PPROM?

A

Preterm Prelabour RoM <37Wks

50
Q

Investigations to do if PPROM?

A 
Bloods for infection 
Sterile Spec exam with HVS, VVS, PH
CTG and MSU 
USS for foetal presentation 
NO DIGITAL EXAM

Dx- Pooling of amniotic at the back of the vaginal fornix

51
Q

In PPROM What would suggest chorioamnionitis?

A

Fever, Abd pain, Purulent discharge,, Temp, Tachycardia (Mat or foetal), Yellow brown discharge on speculum

52
Q

Management of pregnancy if Chorioamnionitis?

A

Broad Spec Abx- Oral Eryhtromycin
Dexamethasone or Betamethasone 12mg IM
Deliver

N.B Bleeding risk is increased

53
Q

Management of PPROM if no chorioamnionitis?

A

Inform neonatal team
Admit
Abx- Oral Erythro?
Stertoids- Dex or Beta 12mg IM 2x doses 12 hour apart
Tocolytic like Nifedipine to allow time for steroids to work
Deliver at 34 weeks as the risk of chorionaminionitis increases as the pregnancy progresses but the risk of RDS decreases, so a trade-off

54
Q

What is IUGR and what causes it?

A

Wx <10th percentile

MOSTLY A FAILURE OF PLACENTA
+ multiple pregnancy, infection, APS, Maternal health, Warfarin, Anticonvulsants, Sickle cell, SMOKING, DRUGS, ALCOHOL

May need to attend consultant antenatal clinics

55
Q

Difference between dizygotic and monozygotic twinning?

A

Dizygotic- seperate ova fertilised… No more identical than normal siblings… Dichorionic and Diamniotic

Monozygotic… Identical features… Type depends on timing of division

56
Q

Why is the timing of the division in monozygotic twins significant?

A

EARLIER= BETTER

Day 0-3 Dichorionic Diamniotic… Division is before implantation so better
Day 4-8 Monochorionic Diamniotic
Day 8-13- Monochorionic Monoamniotic HIGHEST RISK

57
Q

Principles of management in Multiple pregnancy

A

Early Dx and consultant led
High dose folic acid and iron
75mg daily aspirin as 5x more likely to get pre-eclampsia
Extra growth scans

58
Q

Delivery of Dichorionic twins

A

38 weeks

Planned

59
Q

Delivery of MCDA and MCMA

A

MCDA- 36-37 Weeks

MCMA- Elective C-section 32 weeks + 2 weekly USS

60
Q

Main complication of MCMA

A

Twin-Twin Transfusion Syndrome
Recipient- Polycythaemia, HTN, Cardiac Hypertrophy, Oedema (Hydrops), Polyhydramnios
Donor- Anaemia, IUGR, Hypotension, Oligohydramnios

Can ablate anastamoses via laser

61
Q

Complications of Multiple pregnancy

A

LOTS FOR MOTHER AND BABY

IUGR, Poly, Preterm, abruption, Cord prolapse

Praevia, Placental disease, HTN, PPH

62
Q

Different types of HTN in Pregnancy

A

Chronic HTN- Pre-existing and uncommon
Gestational HTN- BP >140/90 after 20 weeks without proteinuria
Pre-eclampsia- BP >140/90 after 20 weeks + >0.3g/24hrs Proteinuria (PCR >30mg/Mol 2+ on dipstick) without UTI

63
Q

1st line treatment for Gestational HTN

What Anti-HTN should be stopped?

A

Oral labetolol, Nifedipine if asthmatic

Important to stop Thiazides, ACEi, ARBs because inc congen abnormalities

64
Q

Target BP for Gestational HTN

A

<150/90

Note the maternal BP decreases in 1st TM to inc placental Blood flow… hence why its Dx post 20 weeks

65
Q

How does pre-eclampsia present

A

Headache, Visual disturbance, Facial oedema, periorbital oedema, Hyper-reflexia, Clonus, Papilloedema, Hepatic capsule engorgement

Monitor for Pul.Oedema and IC haemorrhage

66
Q

How do you monitor pre-eclampsia

A

FBC, Cr, LFTs, U+Es (3x week if Sev, 2x if not) USS (Growth, Liquor, Doppler)… Also do a G+S
Measure BP, 4X daily if mild.mod, >4 if Sev

NOT PROTEINURIA

67
Q

What is mild, Moderate and Severe Pre-eclampsia

A

Mild >140/90
Mod >150/100
Sev >160/110 OR ALTERED HAEMATOLOGY OR SIG SYMPTOMS

68
Q

What is HELLP syndrome

A

Haemolysis
LFTS inc- Rise in Transaminase not ALP (this is raised anyway in pregnancy)
Low Platelets

69
Q

Management of pre-eclampsia

A

200mg oral labetolol (Alt= Nifedipine) try 2nd dose then IV if no effect
10mg Oral nifedipine
Mg sulphate until 24 hours post-delivery or last seizure
Hydralazine can be considered
?Steroids

70
Q

Prophylactic management of pre-eclampsia

A

75mg Aspirin from 12 weeks if high risk

71
Q

Who is high risk of pre-eclampsia

A

Hx pregnancy related HTN, Multiple pregnancy, CKD, SLE, APS, DM, Chronic HTN

Moderate= Fhx, 1st preg, BMI >30, Mat age >30

72
Q

Principles of delivery in Pre-eclampsia

A

Timing= 34+ weeks
BP MUST BE CONTROLLED BEFORE C-SECTION
Maternal steroids up to 34 weeks
Repeat scnas

73
Q

Management of eclampsia

A

ABC- 02 and intubate
Left lateral position
IV Mg Sulphate
Iv labetolol or Hydralazine

CURE= PLACENTAL DELIVERY
Can be postnatal…

74
Q

Principles of management for pre-existing DM in pregnancy

A

Serial growth scans
Induction at 38-40 weeks +/- C section if LGA
BMI>27= must lose weight
5mg folic acid and 75mg aspirin from 12 weeks
Detailed anomaly scan
Stop ACEi and Statins
Monitor BG- Fasting, Pre-meal, 1 hour post meal, Bedtime
Monitor eyes and renal function as function may deteriorate

75
Q

Diagnosis of Gestational Diabetes

A

OGTT- 75g oral glucose

2 hour venous plasma glucose >7.8 (or fasting >5.6)

No role for HBA1C

76
Q

Key RF for GDM?

Who needs screening?

A

PCOS + Obesity= OGTT at 26 weeks, Previous GDM= OGTT at 16 weeks

Screen- BMI>30, 1st relative with GDM, previous large baby >4kg, High risk ethnicity, Hx still birth (unexplained) Polyhyramnios

77
Q

Key Principles of management in GDM

A

Fasting <7mmol/l then trial diet and exercise

If target not met within 1-2 weeks then Metformin

Finally add insulin if needed

78
Q

What are the complications of GDM?

A

No increase in Miscarriage or congen abnormalities

Shoulder dystocia, Stillbirth, maternal tears, neonatal hypoglycaemia

Check maternal fasting glucose 6 weeks post-partum for underlying DM

79
Q

What prophylaxis would someone with a Hx of VTE receive?

A

Antenatal and 6 week postnatal LMWH

80
Q

When would you consider antenatal thromboprophylaxis?

A

Hospital admission, High risk thrombophilia, medical comorbidities, Any surgery, OHSS, Single VTE B/C surgery

(Previous VTE is an absolute indication for antenatal LMWH)

81
Q

4 or more of what risk factors would make you consider LMWH from 28 weeks?

A

BMI>30, 35+ yrs, parity >3, Smoker, Varicose veins, Curret pre-eclampsia, Immobility, Low risk thrombophilia, Multiple preg, IVF, FHx unprovoked oes related VTE in 1st degree

82
Q

What VTE test is useless in pregnancy?

A

D-Dimer B/C always raised

83
Q

What are the benefits of VBAC? What are the risks?

A

Less risk for mum but Increased risk of uterine rupture (0.5% in spont delivery 3% in induced)
75% success inc to 90% if 2nd VBAC
Deliver on labour ward with CTG

Always the risk of an emergency C-section which is higher risk than an elective C-section

84
Q

Risks of an LCSC

A

Infection, Bleeding, Adjacent organ injury, scalpel injury to baby, Anaesthesia risk, VTE increased therefore prophylaxis

2nd time the scar tissue is more complex

In the future- Inc rupture risk, adherent placenta, Stillbirth, VD may be higher risk

85
Q

Safest anti-convulsants in pregnancy

A

CBZ, Lamotrigine, Levetiracetam

86
Q

Principles of management in an epileptic pregnant lady?

A

5mg daily folic acid
Oral Vit K last 4 weeks
Avoid Sodium Valproate, Phenytoin, Phenobarbitone

87
Q

Managing a UTI in pregnancy

A

Nitrofuranoin preferred UNLESS 3RD TM

Avoid Trimethoprim in 1st trimester

Dont use tetracyclines as tooth discolouration

88
Q

Principles of chicken pox management in pregnancy

A

Check Ab -> Not immune-> IV IG ASAP

Presents within 24 hours of onset of rash? Oral Aciclovir

89
Q

Analgesia of choice Antenatally?

A

Paracetamol

NSAIDS inc miscarriage and malformations and premature DA closure

90
Q

When would you test for anaemia

A

Booking visit (8-12wks) give if <11g/dl, 28 weeks give if <10.5g/dl

91
Q

What antibiotic should be avoided in pregnancy?

A

Co-Amox because of NEC risk to baby

92
Q

When are the 1st and 2nd doses of Anti-D given?

A

28 and 34 weeks

IM Anti-D also given after delivery if baby is Rh +VE

93
Q

Sensitising events in pregnancy?

A

Amniocentesis, Placental abruption, Trauma, Heavy bleed <12 weeks, Any bleed >12 weeks, EVAC of retained products/Ectopic/Abortion

94
Q

When do you test for Rh status?

A

Booking visit

Give at 28 and 34 weeks if Rh -ve and not sensitised

95
Q

Pathophysiology of Rh status in pregnancy

A

R-ve mum -> R+ve child with D -antigen-> Leakage of foetal RBC into Maternal circulation -> Anti-D antibody crosses placenta in later pregnancies-> Normocytic anaemia and haemolysis, jaundice in foetus

96
Q

What does the Anti-D IG do?

A

Neutralise foetal D-antigen so no maternal Antibodies are created

97
Q

Indications for high dose (5mg) folic acid

A 
Parent with NTD, or FHx of NTD
Antiepileptic drugs 
Coeliac
DM
Thalassemia 
BMI>30
98
Q

Causes of folic acid deficiency

A

Methotrexate
Pregnancy
Alcohol excess
Phenytoin

99
Q

Sequela of folic acid deficiency

A

Macrocytic megaloblastic anaemia

NTD

100
Q

What folic acid advice should be given to all women

A

Pre-conceptual 0.4mg folic acid until 12 weeks gestation

101
Q

Key points to cover in an antenatal clinic

A 
Movements 
Previous preg
Urinalysis
BP
Abdo exam
Frequency (New-onset?)
102
Q

Causes of polyhydramanios?

A 
50% Idiopathic 
Congenital problems in foetus
Trisomy
Maternal DM
Multiple preg
Fetal anaemia
Hydrops fetalis
Substance abuse
103
Q

What does polyhydramanios increase your risk of?

A 
Prolapsed cord
Malpresentation
UTIs
Preterm
PPH
104
Q

Causes of Oligohydramnios

A

Either excess loss of fluid or
Decreased foetal urine production
-> RoM, Renal agenesis, renal obstruction, decreased renal perfusion, placental abruption

105
Q

When is anaemia screened for?

A 
Booking (<11g/Dl)
28 weeks (<10.5g/DL)
106
Q

What is the ‘dilutional effect’ in pregnancy?

A

Plasma volume increase is greater than Red cell mass increase
Decreased haematocrit is normal
Normal MCV
Low HB (Normal now ~115g/L)

107
Q

What Mean corpuscular Hb

A

MCH= Amount of HB found in RBC

108
Q

What is Mean Corpuscular Hb concentration?

A

Concentration of HB in a given volume

109
Q

What is ferritin

A

Iron stores

110
Q

What is Haematocrit

A

% of Plasma volume that is RBCs ~40%

111
Q

How does iron deficiency anaemia present on blood results

A

Microcytic hypochromic anaemia (Decreased MCV, MCH & Dec/Norm MCHC)

112
Q

How does B12 or folaye deficiency anaemia present on Blood results?

A

Macrocytic Hypochromic anaemia (Inc MCV, Dec MCH and MCHC)

113
Q

What tests should you do if there is abnormal Hb on a FBC?

A

Haematinics (Folate, B12, Ferritin, EPO)

114
Q

Management of iron deficiency anaemia

A

100-200mg elemental iron daily
For at least 3 months
+ 6 weeks post partum
Do not take with tea/coffee

115
Q

Changes to the CV system in pregnancy

A

Inc HR, inc SV, Inc CO
Inc circulating volume to compensate for blood loss in labour
PVR will be decreased (Hence fainting) but if pathology this will be inc

GOSH (5 decks)

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