Antenatal Care Flashcards
What happens in first contact with healthcare professional post conception
WHEN PRENANCY CONFIRMED
Folic acid supplementation
Vitamin D supplement
Food hygiene - avoid shellfish, unpasteurised milk/cheeses, raw eggs, undercooked meat and tuna
Lifestyle - stop smoking, recreational drugs and alcohol
Exercise - regular activity as long as you feel comfortable and slow down as pregnancy progresses
Explain about antenatal screening and Down’s screening
What happens booking visit
8-12 WEEKS
Check BP, urine dipstick (UTI and kidney disease), BMI
Booking bloods - FBC, blood group, rhesus status, RC alloantibodies, haemoglobinopathies, hep B, syphilis, rubella, HIV
Discuss LMP (work out EDD), consider iron if Hb < 110, discuss place of birth, breastfeeding, antenatal classes, antenatal screening and mental health issues
What happens at dating scan
10-13+6 WEEKS Early scan to confirm dates (CRL) Exclude multiple pregnancies Detect neural tube defects Look at placental site
What happens at Down’s syndrome screening (Nuchal combined)
11-13+6 WEEKS
Nuchal translucency - measures pad at nape of foetal neck
- foetus must be in right position
- detects 85% of Down’s cases and other cardiac abnormalities
- depth > 3mm positive result - discuss CVS/amniocentesis
Beta-hCG
PAPP-A
What happens at Down’s syndrome screening (quadruple test)
> 14 WEEKS - only late presenting mothers who missed NCT AFP Beta-hCG Unconjugated oestriol Inhibin-A
When does GDM screening occur
16 WEEKS
OGTT for women who are high risk
What happens at the anomaly scan
18-20+6 WEEKS
Gestational age based on - biparietal diameter, head circumference, abdominal circumference, femur length
Screening for - anencephaly, open spina bifida, cleft lip, diaphragmatic hernia, gastroschisis, exomphalos, cardiac abnormalities, renal agenesis, lethal skeletal dysplasia, Edward’s syndrome, Patau’s syndrome
When do specialist foetal cardiac scans ocurr
22-24 WEEKS
Only if indicated by previous scans
When does a routine care appointment occur
28, 36 AND 38 WEEKS
AND 25, 31 AND 40 WEEKS IF PRIMIP
BP, urine dipstick, symphysis-fundal height
40 WEEKS - discuss induction
When dose a plancetal scan occur
31 WEEKS
Assess for risk of placenta praevia is concerned
When is Anti-D prophylaxis given
Given to rhesus negative women at 28 and 34 weeks
What is LGA
Large for Gestational Age
Foetus is above 97th centile
Over 9 pounds 11 at birth
Causes of LGA
Large parents
Large amount of weight mother gains
Diabetes
Problems associated with LGA
Long time for delivery Difficult birth Injury to baby during birth - damage to brachial plexus Need for C-section Hypoglycaemia in baby post birth Higher risk for birth defects Maternal trouble breathing
Investigations for LGA
USS - foetal measurements
Large weight gain in pregnacy
Management for LGA
Prevented by taking care of diabetes, watching weight and following healthcare advice
Early delivery
Blood glucose testing
Define SGA
Small for gestational age
Less than < 10th centile for gestational age
Define foetal growth restriction
Pathological process has restricted genetic growth potential
- can present with features of foetal comprise including reduced liquor volume or abnormal doppler studies
Define low birth weight
Infant with birth weight of < 2500
Define a normal (constitutionally) small growth restriction
Identified by small size at all stages but growth following the centiles
No pathology present
Contributing factors include ethnicity sex and parental height
Define placenta mediated growth restriction
Growth is usually normal initially but slows in utero
Common cause of FGR
Maternal factors include low pre-pregnancy weight, substance abuse, autoimmune disease, renal disease and chronic hypertension
Define non-placenta mediated growth restriction
Growth affected by foetal factors such as chromosomal or structural anomaly, an error in metabolism or foetal infection
Risk factors for SGA
Minor - maternal age > 35 - smoker 1-10 a day - nulliparity - BMI < 20 or > 25 - IVF singleton - previous pre-eclampsia - pregnancy interval < or > 60 - low fruit intact pre-pregnancy Major - maternal age > 40 - smoker > 11/day - maternal/paternal SGA - previous SGA - previous stillbirth - cocaine use - daily vigorous exercise - maternal disease - heavy bleeding - low PAPP-A - pregnancy associated plasma protein
Diagnosis of SGA
USS for diagnosis and surveillance
- EFW and AC plotted on personalised centile charts
Ratio of HC and AC significant
- symmetrically small foetus more likely to be constitutionally small
- asymmetrically small foetus more likely to be caused by placental insufficiency
Investigations for SGA
Detailed foetal anatomical survey Uterine artery doppler Karyotyping Screening for infections - congenital cytomegalovirus - toxoplasmosis - syphilis - malaria
Management of SGA
Prevention
- smoking cessation and optimising maternal disease
- women at high risk for pre-eclampsia started on 75mg of aspirin
Surveillance
- UAD
Delivery
- if delivery considered between 24-35+6 weeks single course of antenatal steroids given
Indication of delivery for SGA
< 37 weeks if absent/reverse end-diastolic flow on doppler - c-section
By 37 weeks if abnormal UAD or MCA doppler - can offer induction
At 37 weeks if normal UAD - can offer induction
Complications of SGA
Neonatal - birth asphyxia - meconium aspiration - hypothermia - hypo/hyperglycaemia - polycythaemia - persistent pulmonary hypertension - pulmonary haemorrhage - necrotising enterocolitis Long-term - cerebral palsy - type 2 diabetes - obesity - hypertension - precocious puberty - behavioural problems - depression - Alzheimer's disease - cancer
Define red blood cell isoimmunisation
Production of antibodies in response to an isoantigen present on an erythrocyte
Pathophysiology of red blood cell isoimmunisation
Maternal isoimmunisation occurs when the mother’s immune system in sensitised to antigens on foetal erythrocytes resulting in production of IgG antibodies
- sensitising event - antepartum haemorrhage or abdominal trauma
In future pregnancies these antibodies can cross the placenta and attack foetal RBCs -> haemolysis and anaemia - haemolytic disease of newborn
Rhesus D isoimmunisation only possible when women who is RhD- with a RhD+ foetus
Use of anti-D immunoglobulin
If a sensitising event occurs maternal isoimmunisation can be prevented by administration of anti-D immunoglobulin
- binds to RhD+ cells in maternal circulation and no immune response is stimulated
Indications for use of anti-D immunoglobulin
In rhesus D negative women
- invasive obstetric testing - amniocentesis or CVS
- antepartum haemorrhage
- ectopic pregnancy
- external cephalic version
- fall or abdominal trauma
- intrauterine death
- miscarriage
- termination of pregnancy
- delivery - normal, instrument or caesarean section
Investigations for red blood cell isoimmunisation
Maternal blood group and antibody screen
- determines ABO and RhD blood groups and detects any antibodies directed against RBC surface antigens
Foeto-maternal haemorrhage test
- assess how much foetal blood has entered maternal circulation to determine how much anti-D to give
After delivery rhesus status of baby determined
Dosage of anti-D
Routine prophylaxis at 28 and 34 weeks - 500IU
Sensitising events
- less than 20 weeks = 250 IU within 72 hours
- greater than 20 weeks = 500 IU within 72 hours
Define prematurity
Baby born before 37 weeks
- late = 34-36 weeks
- moderate = 32-24 weeks
- very = less than 32 weeks
- extremely = before 25 weeks
Risk factors for prematurity
Previous premature birth Pregnancy with twins or more Less than 6 months between pregnancy IVF Smoking Infections Chronic conditions such as hypertension and diabetes Under or over weight Stress Physical injury or trauma
Complications of prematurity
Breathing problems - acute respiratory distress syndrome
Heart problems - patent Ductus arteriosus
Brain problems - haemorrhages
Immature GI system - necrotising enterocolitis
Anaemia
Neonatal jaundice
Define prolonged pregnancy
Pregnancy persists past 42 weeks gestation
Risk factors for a prolonged pregnacy
Nulliparity Maternal age > 40 Previous prolonged pregnancy High BMI FHx of prolonged pregnancies
Complications of a prolonged pregnancy
Increased risk of
- stillbirth
- placental insufficiency
- meconium aspiration in labour
- instrumental or caesarean delivery
- neonatal hypoglycaemia
Clinical features of a prolonged pregnancy
Diagnosis based on gestational age - some have no clinical features at all
Static growth or potential macrosomia
Oligohydramnios
Reduced foetal movements
Presence of meconium - signs of meconium staining on nails etc
Dry/flaky skin with reduced vernix
Management of a prolonged pregnancy
Recommend delivery by 42 weeks
- membrane sweeps - offered from 40+0 for nulliparous and 41+0 for parous women
- induction of labour - offered between 41+0 and 42+0
