Antenatal Care Flashcards
INTRAUTERINE PREGNANCY
definition
An intrauterine pregnancy (IUP) occurs when a fertilised egg implants and starts to develop within the uterus there is the presence of a gestational sac that contains either a yolk sac or a foetal pole
INTRAUTERINE PREGNANCY
How investigations can be used to diagnose pregnancy?
Ultrasonography - dating scan at 8-14 weeks
serum B-hcg
progesterone
early pregnancy factor
DIAGNOSING INTRAUTERINE PREGNANCY For the following times since last menstrual period give the expected HCG levels and landmarks seen on ultrasonography 1. 4 weeks 2. 5 weeks 3. 6 weeks
- gestational sac / 10 to 708 mIU/mL
- yolk sac / 18–7,340 mIU/mL
- foetal pole and cardiac activity / 1,080–56,500 mIU/mL
DIAGNOSING INTRAUTERINE PREGNANCY
What are the main symptoms/information that should be gained from history?
- menstrual history (pattern, date, onset of last menses, duration, flow, frequency). Atypical last menstrual period, contraceptive use, history of irregular menses can confuse diagnosis of early pregnancy and up to 25% of women bleed during first trimester
- Nausea and vomiting (common in 1st trimester, occur any time of day, can persist through pregnancy)
- Frequency of micturition (increased plasma volume and urine production, pressure effect of uterus on bladder)
- Excessive lassitude or fatigue (common in early pregnancy and disappears after 12 weeks)
- Breast tenderness (especially seen in month after first period is missed)
- Foetal movements (20 weeks in nullipara, 18 weeks in multipara)
- pica (abnormal desire to eat something not regarded as nutritive eg dirt)
DIAGNOSING INTRAUTERINE PREGNANCY
describe the classical presentation of pregnancy?
woman with regular, frequent menses who present with amenorrhea, nausea, vomiting, generalised malaise and breast tenderness
DIAGNOSING INTRAUTERINE PREGNANCY
what are the important examination findings?
- enlarged uterus after bimanual examination
- breast changes
- softening and enlargement of cervix (Hegar sign at 6 weeks).
- Chadwick sign: bluish discolouration of cervix from venous congestion observed by 8-10 weeks
- After 12 weeks uterus is palpable abdominally and fetal heart may be heard using hand held doppler
DIAGNOSING INTRAUTERINE PREGNANCY
- what secretes HCG?
- when does HCG peak?
- how can HCG be measured?
- hCG secreted by trophoblastic tissue
- 8-12 weeks - increasing levels of hCG exponentially from 8 days after ovulation and doubles every second day
- hCG can be measured in blood or urine
DIAGNOSING INTRAUTERINE PREGNANCY
what is the role of testing progesterone in early pregnancy?
- Useful for evaluation of abnormal early pregnancy
- Reflects progesterone production of corpus luteum
- Viable intrauterine pregnancy diagnosed with high sensitivity if serum greater than 25ng/mL (low levels can help diagnosis of nonviable pregnancy)
DIAGNOSING INTRAUTERINE PREGNANCY
what is the role of testing for early pregnancy factor?
- Detectable in serum 36-48 hours after fertilisation, peaking early in first trimester
- Undetectable in ectopic pregnancies, spontaneous abortions
DIAGNOSING MULTIPLE PREGNANCY
What investigations are valuable in diagnosing multiple pregnancy?
- hCG levels: quite high with multiple pregnancy
- alpha fetoprotein: protein released by fetal liver, found in mothers blood may be high when more than 1 foetus making the protein
- ultrasound: using vaginal transducer especially in early pregnancy or abdominal transducer later in pregnancy
ULTRASONOGRAPHY
what can be assessed by ultrasound in the first trimester?
- Accurate dating by measuring CRL (crown rump length) at 8-12 weeks
- Identify embryo and yolk sac
- Foetal number (number of amniotic sacs and chorionic sacs)
- Assess anatomy
- Evaluate maternal uterus, tubes, ovaries and surrounding structures
- Evaluate foetal nuchal fold
ULTRASONOGRAPHY
What can be assessed by ultrasound in the second and third trimester?
- Foetal number (number of amniotic sacs and chorionic sacs)
- Foetal cardiac activity
- Foetal position relative to uterus and cervix
- Location and appearance of placenta, umbilical cord
- Amniotic fluid volume
- Gestational age
- Foetal weight estimation
- Foetal anatomical survey
- Evaluate maternal uterus, ovaries and surrounding structures
ULTRASONOGRAPHY
How can ultrasound be used for dating and growth monitoring?
- ultrasound offers alternative to estimating gestational age, most accurately using crown rump length between 7 and 13 weeks
- after 13 weeks foetal age estimated using biparietal diameter, head circumference, femur length, crown heel length and other parameters
- dating more accurate when done earlier in pregnancy
ULTRASONOGRAPHY
How can ultrasound be used for sex discernment?
- from early as 11 weeks but only accurate after 13 weeks
- accuracy depends on gestational age, precision of sonographic machine, expertise of operator, foetal posture
ULTRASONOGRAPHY
why is it important to assess cervix on ultrasound?
- useful to assess in women at risk of premature birth
- short cervix associated with higher risk for premature delivery
ULTRASONOGRAPHY
What is the purpose of abnormality screen?
- detect defects before birth eg checking status of limbs and organs
- nuchal translucency thickness
- foetal organ anomaly done around weeks 18-23
what is the aim of antenatal care?
- provide evidence based information and support to women and their partners to make informed decisions about care
- advice on minor problems and symptoms of pregnancy
- facilitate provision of prenatal screening and management of abnormalities
- monitor foetal and maternal well being and screen for commonly occuring complications (BP, urine for pre-eclampsia and diabetes)
- determine timing and mode of delivery when complications arise or if pregnancy continues after due date
- develop partnership between woman and health professional
- increase understanding of public health issues
- provide opportunities to prepare for birth and parenthood
what publications influence antenatal care provision?
- MBRRACE-UK (mothers and babies-reducing risk through audits and confidential enquiries across the UK)
- NICE antenatal care guideline
- Evidence based practice
- Local policy/guidelines for practice
- Midwifery 2020
what was the purpose of national maternity review ‘better births’?
Personalised care, continuity of care, safer care, better postnatal and perinatal mental health care, multi-professional working, working across boundaries fairer payment system
what are the different aspects of antenatal care?
- Booking
- Regular visits
- Parentcraft education
- At every interaction a holistic approach should be used to consider physical, psychological, social and spiritual dimensions
ANTENATAL CARE
Describe the booking interview?
- NICE recommends booking appointment is done by 10 weeks
- Important opportunity to begin the relationship with the woman
- Opportunity to discuss concerns
- Detailed history and discussion of screening tests takes place
- Baseline recordings taken
- Public health advice given
ANTENATAL CARE
What information is gained in the booking interview?
- Demographic details
- Present pregnancy and menstrual history
- Previous pregnancies
- Medical history
- Surgical history
- Social and lifestyle history
- Family history
- Baseline observations
ANTENATAL CARE
how many antenatal visits will these women attend?
1. parous women
2. nulliparous
- 7
2. 10
ANTENATAL CARE
- when are the scheduled antenatal visits?
- which of these are for nulliparous women only?
- booking, 16, 25, 28, 31, 34, 36, 38, 40, 41 weeks
2. 25, 31, 40
ANTENATAL CARE
what routine blood tests are performed in pregnancy?
- FBC (anaemia)
- Blood grouping and antibody screen (identify rhesus -ve women at risk of rhesus isoimmunisation and detect abnormal antibodies)
- Rubella screen (2% nulliparous, 1% multiparous women are not immune and require post partum vaccination)
- Syphilis screen (treat to prevent congenital syphilis)
- Hepatitis B screen (at booking so effective postnatal intervention can be offered, 90% of neonates become chronic carriers and risk post infective hepatic cirrhosis and hepatocellular carcinoma)
- HIV screen (universal at booking in visit in order to reduce vertical transmission by antiretrovirals)
- Haemoglobin electrophoresis (routine in women of minority ethnic or racial origins with high incidence of haemoglobinopathies (cyprus, eastern Mediterranean, middle east, Indian subcontinent, south east asia))
- Others (thyroid function tests, HbA1c, baseline urea and creatinine)
ANTENATAL CARE
what is the purpose of the visit at 8-12 weeks (ideally <10 weeks)?
booking
information - diet, alcohol, smoking, folic acid, vit D, antenatal classes
BP
urine dip
BMI
bloods- FBC, group, rhesus, red cell autoantibodies, haemoglobinopathies, hep B, syphilis, HIV
urine culture
ANTENATAL CARE
what is the purpose of visit at 10-13+6 weeks?
early scan to confirm dates, exclude multiple pregnancy
ANTENATAL CARE
what is the purpose of the visit at 11-13+6 weeks?
Downs syndrome screening (nuchal test)
ANTENATAL CARE
what is the purpose of visit at 16 weeks?
information on anomaly and blood results
if Hb <11g/dl consider iron
routine care - BP and urine dipstick
ANTENATAL CARE
what is the purpose of visit at 18-20+6 weeks?
anomaly scan
ANTENATAL CARE
what is the purpose of visit at 25 weeks?
only if primip routine care BP urine dip symphysis-fundal height
ANTENATAL CARE
what is the purpose of visit at 28 weeks?
routine - BP, urine dip, symphysis-fundal height
second screen for anaemia and atypical red cell alloantibodies
if iron <10.5g/dl consider iron
1st dose anti-D prophylaxis to rhesus -ve women
ANTENATAL CARE
what is the purpose of visit at 31 weeks?
routine care
only if primip
ANTENATAL CARE
what is the purpose of visit at 34 weeks?
routine care
2nd dose anti D prophylaxis to rhesus -ve women
information on labour and birth plan
ANTENATAL CARE
what is the purpose of visit at 36 weeks?
routine care
check presentation- external cephalic version
information on breast feeding, vit K, baby blues
ANTENATAL CARE
what is the purpose of visit at 38 weeks?
routine care
ANTENATAL CARE
what is the purpose of visit at 40 weeks?
only if primip
discuss options for prolonged pregnancy
ANTENATAL CARE
what is the purpose of visit at 41 weeks?
routine care
discuss labour plans and possible induction
ANTENATAL CARE
describe the use of menstrual history in determining gestational age?
- The first day of the last menstrual period used to calculate gestational age and EDD
- This may be inaccurate (women not certain of day of period, ovulation not always on day 14 and proliferative phase may be shorter or longer
- EDD can be calculated using Naegele’s formula
- 40% of women deliver within 5 days of EDD and 2/3 within 10
- 11-42% of gestational age estimates from this may be inaccurate
- Day of embryo transfer used in IVF
ANTENATAL CARE
describe the role of ultrasound scanning in determining gestational age?
- Between 8 and 13 weeks
- Most accurate measure of gestational age and should be used to calculate EDD
- Unreliable before 8 weeks
- After 13 weeks other factors may affect foetal growth so estimate should be made using BPD and femur length (this may be unreliable)
ANTENATAL CARE
describe what is meant by crown rump length?
- Used between weeks 8-13
- Measured from one foetal pole to the other along its longitudinal axis in a straight line
ANTENATAL CARE
describe the principles of screening in pregnancy?
Ideally screening should be offered to all women at time of booking. Detailed, unbiased, written information provided about conditions being screened for, types of tests and implications of results. Important to explain that a negative result does not guarantee that the baby does not have that or another abnormality
ANTENATAL CARE
why is prenatal diagnosis important?
- Enabling decision on timing, mode, and place of delivery (e.g. in a unit that provides paediatric surgery).
- Preparing parents to cope with an affected child.
- Introducing parents to specialist neonatal services.
- Ensuring fetal surveillance, such as later USSs to monitor the condition and ensure the best possible outcome.
- Potentially allowing in utero treatment (rarely available at present).
- Giving parents the option of terminating the pregnancy in severe cases.
ANTENATAL CARE
describe counselling?
- How parents respond to the news that there is abnormality with foetus will vary with factors such as age, social background, and religious belief.
- Not all parents will wish to terminate the pregnancy: even in the face of abnormalities incompatible with life.
- Some parents report that the opportunity to hold their child enabled them to grieve.
- Counselling must be supportive, informative, and non-directional.
- Care must also be taken to counsel adequately before any screening tests.
- If parents have no intention of having the riskier diagnostic tests performed then there is little benefit in screening and much anxiety may be generated.
ANTENATAL CARE
describe what makes a good screening test?
- Should be cheap and widely available.
- Non-invasive, safe, and acceptable.
- Have good sensitivity (high detection rate) and specificity (low FPR).
- Provide a measure of the risk of being affected by a certain disorder
- Must have a suitable diagnostic test for those identified as ‘high risk’.
ANTENATAL CARE
what makes a good diagnostic test?
- Need to definitely confirm or reject the suspected diagnosis (e.g. the fetus does, or does not, have Down’s syndrome).
- Must be as safe as possible.
- Must have high sensitivity and specificity.
- The implications of the disorder tested for must be serious enough to warrant an invasive test.
ANTENATAL CARE
what is the combined test?
- Screening test for Down’s syndrome, Edwards’ syndrome and Patau’s syndrome
- 10-14 weeks
- Combines ultrasound with blood test
- Carried out at same time as dating scan
- Nuchal translucency: Risk similar to triple test but can pick up foetuses with other trisomies or congenital heart disease. This is done at an earlier stage so those at high risk may be offered chorionic villus sampling
- Blood tests measure hCG and PAPP-A
- Alternatives to combined test: if nuchal translucency not possible or more than 14 weeks then quadruple blood screening which only screens for downs. A mid pregnancy scan can screen for Edwards’ and Patau’s syndrome for those too far into pregnancy for combined test.
ANTENATAL CARE
what is the role of serum alpha fetoprotein?
- Neural tube defects account for 50% of congenital abnormalities
- Some hospitals offer blood test at 15-17 weeks to measure serum alpha fetoprotein
- Majority of these defects detected by ultrasound at 18-20 weeks
ANTENATAL CARE
what is the triple test?
- Blood tests at 16 weeks
- Oestriol, hCG, AFP, inhibin A (in quadruple test only)
- High alpha fetoprotein indicate neural tube defect yet low result is associated with increased risk of Down’s syndrome but this is not specific or sensitive so it combined with hCG (raised) and oestriol (lowered) in downs.
- Results are related to age and weight of the mother and is positive if the risk is greater than 1:250
- It detects 7/10 babies with Down’s
- Women with positive result are offered amniocentesis to get fetal cells and make definitive karyotypic diagnosis
ANTENATAL CARE
what is routine anomaly ultrasound scanning
- 18-20 weeks
- Establish gestational age
- Exclude structural abnormalities of the foetus
- Diagnose multiple pregnancies
- Biparietal diameter, head circumference, abdominal circumference and femur length are measured
- Placental site, anencephaly, spina bifida, double bubble of dilated stomach and duodenum in duodenal atresia, fallots tetrilogy, ventricular septal defect, atrial septal defect, hydrocephaly, renal pelvic dilatation, sacral agenesis, major limb defects
PROBLEMS IN PREGNANCY
list some common health problems in pregnancy?
constipation cramp feeling hot incontinence increased urinary frequency skin and hair changes varicose veins backache bleeding DVT bleeding gums headaches HTN pre-eclampsia indigestion and heart burn leaking nipples mental health morning sickness and nausea nosebleeds pelvic pain piles sleepiness stretch marks swollen ankles tiredness vaginal discharge
PROBLEMS IN PREGNANCY
advice to deal with constipation
Eat foods high in fibre, exercise regularly, drink plenty of water, avoid iron supplements
PROBLEMS IN PREGNANCY
advice to deal with cramp
Gentle exercise to improve circulation
PROBLEMS IN PREGNANCY
advice to deal with feeling faint
- Due to hormonal changes
- Get up slowly after sitting or lying
- Sit down when feeling faint
- If feel faint when lying on back turn onto side
PROBLEMS IN PREGNANCY
advice to deal with feeling hot
- Due to hormonal changes
- Wear loose clothing
- Keep room cool
- Wash frequently
PROBLEMS IN PREGNANCY
advice to deal with increased urinary frequency
- Cut out drinks in late evening
- Rock back and forth on toilet to lessens pressure of womb on bladder so empty fully
PROBLEMS IN PREGNANCY describe skin and hair changes
- Hormonal changes
- Nipples darker, skin darken, patchy
- Hair growth increase and hair may be greasier
PROBLEMS IN PREGNANCY
advice to deal with varicose veins
- Uncomfortable but not harmful
- avoid standing for long periods of time
- try not to sit with your legs crossed
- try not to put on too much weight, as this increases the pressure
- sit with your legs up as often as you can to ease the discomfort
- try compression tights, which you can buy at most pharmacies – they won’t prevent varicose veins but can ease the symptoms
- try sleeping with your legs higher than the rest of your body – use pillows under your ankles or put books under the foot of your bed
- do foot and other exercises such as walking and swimming, which will help your circulation
PROBLEMS IN PREGNANCY
risk factors in pregnancy
- existing health problems - HTN, diabetes, HIV
- overweight
- multiple births
- young or old maternal age
RISK FACTORS IN PREGNANCY
issues with overweight and obesity
Obesity increases the risk for high blood pressure, preeclampsia, gestational diabetes, stillbirth, neural tube defects, and cesarean delivery. NICHD researchers have found that obesity can raise infants’ risk of heart problems at birth by 15%.
RISK FACTORS IN PREGNANCY
issues with multiple births
The risk of complications is higher in women carrying more than one fetus (twins and higher-order multiples). Common complications include preeclampsia, premature labor, and preterm birth. More than one-half of all twins and as many as 93% of triplets are born at less than 37 weeks’ gestation.
RISK FACTORS IN PREGNANCY
issues with young or old maternal age
Pregnancy in teens and women age 35 or older increases the risk for preeclampsia and gestational high blood pressure.
Women with high-risk pregnancies should receive care from a special team of health care providers to ensure the best possible outcomes.
MISCARRIAGE
how common is it
- Miscarriage is common, occurring in at least 15–20% of pregnancies
- Possibly up to 40% of all conceptions.
EXAMINING A PREGNANT WOMAN
inspection
- Inspect from end of bed
- Pain
- Obvious scars: abdominal surgery
- Pallor: anaemia
- Jaundice: high bilirubin eg obstetric cholestasis
- Oedema: small amount is normal in late stages however may be sign of pre-eclampsia
- Look for mobility aids
- Vital signs
- Fluid balance
- Prescriptions
EXAMINING A PREGNANT WOMAN
inspecting hand
- Colour: pale suggests poor peripheral perfusion (hypovolaemic shock, aortocaval compression) and cyanosis (hypoxaemia)
- Peripheral oedema (normal in late pregnancy but can suggest pre-eclampsia
- Palmar erythema – normal in pregnancy
- Temperature – hands should be symmetrically warm, cool hands suggest poor peripheral perfusion
- Capillary refill time – if longer than 2 seconds suggests poor peripheral perfusion (antepartum haemorrhage, aortocaval compression)
- Radial pulse
- Heart rate: in pregnancy there is usually a higher baseline pulse (80-90bpm)
EXAMINING A PREGNANT WOMAN
inspecting face
- Jaundice (in pregnancy usually secondary to obstetric cholestasis)
- Melasma: benign dark irregular hyperpigmented macules, normal in pregnancy
- Oedema: normal but consider pre-eclampsia
- Conjunctival pallor: associated with anaemia
EXAMINING A PREGNANT WOMAN
inspecting abdomen
- Early pregnancy: 30-45°
- Late pregnancy : left lateral position tilted to 15° to avoid compression of abdominal aorta and inferior vena cava
- Abdominal shape: indication of foetal lie
- Foetal movements: visible from 24 weeks
- Surgical scars:
- Linea nigra
- Striae gravidarum
- Striae albicans
EXAMINING A PREGNANT WOMAN
palpate abdomen
- Ask for tenderness before
- Palpate lightly over 9 regions for tenderness/mass not related to pregnancy
- Palpate uterus: identify borders including upper and lateral edges
- Uterine fundus can be found at different locations depending on gestation
- Foetal lie:
- Foetal presentation:
- Foetal engagement:
- Symphyseal fundal height:
EXAMINING A PREGNANT WOMAN
symphyseal fundal height
distance between fundus and upper border of pubic symphysis and after 20 weeks it should correlate with gestational age. Palpate inferior to xiphisternum, locate fundus of uterus (firm feeling edge at upper border of bump), locate upper border of pubic symphysis, measure distance between upper uterine border and pubic symphysis with a tape measure
EXAMINING A PREGNANT WOMAN
foetal engagement
engaged when more than 50% of presenting part has descended into pelvis, divided into fifth (five fifths palpable=not engaged and entire head palpable in abdomen / zero fifths palpable = fully engaged and not able to feel the head
EXAMINING A PREGNANT WOMAN
what are the types of foetal lie
longitudinal lie (head and buttocks palpable at each end) oblique lie (head and buttocks palpable in one of iliac fossae) transverse lie (foetus lying directly across the uterus
EXAMINING A PREGNANT WOMAN
what is foetal lie
relationship between long axis of foetus with respect to long axis of mother. Place hands on either side of uterus, gently palpate each side, one side should feel full due to fetal back and the other side the fetus’s limb
EXAMINING A PREGNANT WOMAN
what is foetal presentation and how is it assessed
which anatomical part of the fetus is closest to pelvic inlet. Place hands either side of lower pole of uterus just above pubic symphysis and apply firm pressure to uterus angled medially, palpating for presenting part (hard round part suggestive of cephalic presentation), broader, softer, less defined presenting part (foetal bottom or legs) suggests breech presentation
EXAMINING A PREGNANT WOMAN
foetal heartbeat
- Using either pinard stethoscope or doppler probe
- Place pinard aiming between fetal shoulders on fetal back
- Place ear to pinard and move hand so not holding onto it
- Listen to fetal heartbeat and feel maternal pulse, if these match then likely listening to uterine vessels not fetal heartbeat
what is miscarriage and the different type
Loss or failure of early pregnancy which can be complete, incomplete, inevitable, missed, septic and threatened
MISCARRIAGE
complete
termination of pregnancy before age of viability, occurring before 20 weeks or foetus weight <500g, most occur before 6 weeks or after 14 weeks
MISCARRIAGE
incomplete
spontaneous passage of some of the products of conception, associated with uniform pregnancy loss. Pregnancy in which rupture of membranes and or cervical dilatation takes place in first half of pregnancy is labelled as inevitable abortion. Uterine contractions follow, ending in spontaneous loss of pregnancy in most cases
MISCARRIAGE
missed
retention of a failed intrauterine pregnancy for extended period
MISCARRIAGE
septic
variant of incomplete abortion in which there is infection of uterus and contents
MISCARRIAGE
threatened
pregnancy at risk for some reason, often when vaginal bleeding or uterine cramping takes place but no cervical changes have occurred.
MISCARRIAGE
risk factors
- Increasing parity
- Increasing maternal age
- Increasing paternal age
- Short interval between pregnancies
- Excessive caffeine consumption
MISCARRIAGE
general signs and symptoms
- vaginal bleeding (may be bright red to dark in colour)
- Abdominal cramping (generally rhythmic, accompanied by pelvic or low back pressure)
- Passage of tissue (complete and incomplete abortion)
- Cervical dilation (typical of all types of abortion except missed and threatened)
- Cervical dilation with tissue visible at the cervical os (diagnostic of either incomplete or inevitable abortion)
MISCARRIAGE
missed abortion signs and symptoms
- decreased or minimal uterine growth early in pregnancy
- Vaginal bleeding that changes to a dark-brown discharge that continues
- Loss of early symptoms of pregnancy, such as breast fullness or morning sickness
- Disseminated intravascular coagulopathy (DIC) can occur when an intrauterine foetal demise in the second trimester has been retained beyond 6 weeks after the death of the foetus (rare)
MISCARRIAGE
signs and symptoms off septic abortion
severe haemorrhage (vaginal)
- Midline lower abdominal pain
- Uterine and perimetric tenderness
- Bacteraemia
- Septic shock
- Renal failure
MISCARRIAGE
signs and symptoms of threatened abortion
implantation bleeding
- Cervical polyps, cervicitis
- Other causes of lower abdominal discomfort (e.g., urinary tract infection, constipation)
MISCARRIAGE
differentials
- Ectopic pregnancy
- Cervical polyps, cervicitis
- Molar pregnancy
- Possibility of trauma, perforation of uterus or vagina, when sepsis present
MISCARRIAGE
laboratory investigations
- Pregnancy test (if not confirmed)
- If serial determinations of beta hCG do not show 66% increase every 48 hours outlook is poor
- Complete blood count
MISCARRIAGE
imaging
Ultrasound may confirm loss of uterine contents, absence of fetal pole or failure to grow
MISCARRIAGE
procedures
If significant dilatation identified by speculum and bimanual examination a diagnosis of incomplete abortion is established
MISCARRIAGE
management of threatened miscarriage
- Paracetamol 500-1000mg every 4-6 hours with councelling
- WITH anti-D immunoglobulin in SOME patients
MISCARRIAGE
management of inevitable/ incomplete / missed miscarriage
- Manual evacuation or suction evacuation of uterus +/- antibiotics
- Paracetamol 500-1000mg every 4-6 hours (avoid NSAIDs)
- Misoprostol 800mcg (patients with severe vaginal bleeding)
- Anti-D immunoglobulin (some patients)
- counselling
MISCARRIAGE
management of complete miscarriage
- Paracetamol 500-1000mg every 4-6 hours with counselling
- Anti-D immunoglobulin (SOME patients)
CHRONIC RENAL DISEASE
what are the renal changes in pregnancy
- Renal blood flow increase
- GFR increases
- Increase body water and decrease in plasma osmolality
- 25% fall in serum uric acid concentration in first 2 trimesters
CHRONIC RENAL DISEASE
what factors cause worse prognosis
- Hypertension prior to pregnancy
- Proteinuria prior to pregnancy
- Active progression of renal disease
CHRONIC RENAL DISEASE
what factors influence foetal prognosis
- Normotensive with CKD have 2-3x greater risk of developing pre-eclampsia
- Women with severe renal disease have higher incidence of pre-eclamptic toxaemia and impaired fetal growth
- Pre-existing hypertension and proteinuria-fetal mortality high as 30% (preterm delivery and complications)
ACUTE RENAL FAILURE
types
Either tubular necrosis or cortical necrosis
ACUTE RENAL FAILURE
aetiology in pregnancy
- Hypovolaemia due to; pre-eclampsia, placental abruption, postpartum haemorrhage, hyperesmesis gravidarum, miscarriage
- Gram negative shock due to: pyelonephritis, chorioamnionitis, puerperal infections, septic miscarriage
- Nephrotoxins: rare
- Vomiting in late pregnancy
FOLIC ACID DEFICIENCY ANAEMIA
issues in pregnancy
- Needed for DNA production
- Increased utilisation In pregnancy which is worse in multiple pregnancy, grand multiparity, fetal haemolysis, infection
HEART DISEASE IN PREGNANCY
mitral stenosis signs
- Pulmonary oedema.
- Right-sided congestive failure.
HEART DISEASE IN PREGNANCY
aortic stenosis
- Left-sided congestive failure. Rare to start de novo, in pregnancy.
HEART DISEASE IN PREGNANCY
eisenmengers syndrome
- if right-to-left shunt —pulmonary hypertension.
HEART DISEASE
coarctation of aorta
- Risk of rupture in late pregnancy or labour. Often repaired before; if well healed, no in- creased dangers.
HEART DISEASE
fallots tetralogy
- If right-to-left shunt, risk of cardiac failure.
HEART DISEASE IN PREGNANCY
maternal morbidity and mortality
- Mortality: increased risk of death—9% of all maternal deaths in UK are associated with heart disease
- Morbidity: increased risk of deterioration of heart condition. Used to be inevitable. This is not so if proper care is taken.
HEART DISEASE IN PREGNANCY
foetal prognosis
- Little increased risk if mother kept healthy. Watch for fetal risks from anticoagulation if relevant.
ASTHMA IN PREGNANCY
Often emotional factors are involved so asthma may worsen if pregnancy is resented. Continue all treatments started before pregnancy. Be careful of new therapies, e.g. budesonide teratogenic to some species; not known to be so in humans. Therefore use well-established drugs.
PULMONARY TB IN PREGNANCY
-Needs to be delivered by most expeditious route (baby may be large)
DIABETES
what are the effects of poorly controlled diabetes on pregnancy
- Diabetes is associated with an increased risk of first trimester miscarriages.
- Second trimester miscarriages, due to fetal death.
- Congenital abnormalities. By x3, 50% neural tube defects, 30% cardiac abnormalities. Diabetics tend to show a predominance of multiple malfor- mations and caudal regression appears exclusively in diabetics.
- Pregnancy-induced hypertension.
- Preterm delivery
- Polyhydramnios
- Macrosomic infants which may result in difficul- ties at delivery particularly shoulder dystocia.
- Sudden intrauterine death in the last 4 weeks of pregnancy. This appears to be confined to babies who are macrosomic.
- Perinatal mortality X2–3. This can be reduced to background levels with good diabetic control.
DIABETES
effects on the infant
- Macrosomia: birth weight for gestational age ex- ceeds the 90th centile.
- An increased risk of birth trauma, because of shoulder dystocia.
- An increased risk of asphyxia during delivery.
- An increased risk of respiratory distress syn- drome (RDS) compared with babies of similar gestation.
- Hypoglycaemia. The fetal pancreas secretes high levels of insulin during pregnancy to cope with the passage of glucose from the mother. After delivery, the glucose source is removed, but the pancreas continues to secrete extra insulin resulting in hypoglycaemia.
- Hypercalcaemia.
- Hypothermia. Infants with diabetic mothers have large surface areas and so lose heat rapidly. Al- though they have more fat than the normal baby,
EPILEPSY IN PREGNANCY
All anticonvulsant medications carry a small risk of teratogenicity. However, the risk of epileptic fits to the pregnancy outweighs the risk of teratogenicity, although some women may need a change in their medication in the first trimester to sodium valproate or phenytoin.
FOLIC ACID
describe its use in pregnancy
- Recommended before pregnancy and upto 12 weeks to reduce neural tube defects
- 400mcgs/day
- For women at higher risk (previous affected child, epilepsy, diabetes, obesity): dose of 5mg/day recommended
IRON
describe its use in pregnancy
- Only if medially indicated
- During pregnancy 3mg/day of iron is needed
CALCIUM
how should it be provided in pregnancy
- Ideally increase calcium in diet
IODINE
what issues can deficiency cause
- Deficiency can cause cretinism and neonatal hypothyroidism
ZINC
what are the issues with low levels
- Low levels associated with preterm labour and growth restriction
VITAMIN A
Intake >700mcgs/day may be teratogenic so avoid consumption of products such as liver and pate
alcohol in pregnancy
- Excessive alcohol shown to cause foetal malformations but the exact threshold is unknown
- Alcohol should be avoided
smoking in pregnancy
- Smoking has an adverse effect on the developing foetus (preterm labour, low birth weight), smoking cessation should be encouraged or reduction
drugs in pregnancy
- Recreation and illegal drugs can cause miscarriage, preterm birth, poor foetal development, intrauterine death
obesity in pregnancy and what should weight gain in pregnancy be
obesity associated with gestational diabetes and hypertension
- Confidential enquiry into maternal deaths found that obesity increased risk of maternal deaths
- Weight gain in pregnancy should be around 11-16kg and women should consume an extra 350kcal a day
food to avoid in pregnancy
- Food delicacies such as undercooked meats and eggs, pates, soft cheeses, shellfish and raw fish, and underpasteurized milk should be avoided as they are potential sources of Listeria and Salmonella that could lead to adverse perinatal outcome.
- Listeriosis in pregnancy is a known but rare cause of poor obstetric outcome and foetal death.
