antenatal care Flashcards
when should the first booking occur when they know they are pregnant
before 10 weeks
what happens during the booking
advise about health and lifestyle
vitamins - healthystart programme
folic acid - 400 mcg daily
Food hygiene, including how to reduce the risk of a food-acquired infection
smoking cessation, implications of recreational drug use & alcohol consumption in pregnancy
All antenatal screening- as well as risks and benefits of the screening tests
which food infection increase more in pregnant woman
mx for it
listeriosis gram +ve cocci
ampicillin
erythromycin
what foods can increase the infection of listeriosis
drinking only pasteurised or UHT milk
not eating ripened soft cheese such as Camembert, Brie and blue‑veined cheese (there is no risk with hard cheeses, such as Cheddar, or cottage cheese and processed cheese)
not eating pâté (of any sort, including vegetable)
not eating uncooked or undercooked ready‑prepared meals.
Pregnant women should be offered information on how to reduce the risk of salmonella infection by:
avoiding raw or partially cooked eggs or food that may contain them (such as mayonnaise), avoiding raw or partially cooked meat, especially poultry.
risks of drinking alcohol for the baby
low birth weight, preterm birth, and being small for gestational age may all be increased in mothers drinking above 1-2 units/day during pregnancy.
what clinical examination is carried out in a pregnant women at booking
measurement if weight and BMI
if no healthcare at UK before a complete general clinical examnato
what routine tests are offered to pregnant women
electrophoresis
- haemoglobinopathy
- – sickle cell and Beta thalassaemia
FBC
- anaemia
Blood group and rbc antibody screening
- rhesus status and risk of rhesus isoimmunisation
- non rhesus antibodies
Infection screening
- syphilis, hep B and HIV
- asymptomatic bacteriuria
Urinalysis
- glycosuria, proteinuria, haematuria
if smoker measure CO levels
what do we screening for infection
Asymptomatic bacteriuria- MSU
Serological screening for hep B virus should be offered & effective postnatal interventions offered to decrease the risk of MTCT
Pregnant women should be offered screening for HIV infection early in pregnancy as interventions can reduce MTCT
Syphilis
No evidence that routine screening for GBS, toxoplasmosis, CMV, chlamydia, Hep C, asymptomatic bacterial vaginosis is beneficial
when do we screen for gestational diabetes
based on risk assessment
between 24-28 weeks
BMI above 30
previous macrosomic baby weighing 4.5kg or above, previous gestational siabetes
FH of diabetes (first degree relative w diabetes)
family origin with a high prevalence of diabetes
- south aisan
- middle eastern
screening for pre eclampsia
BP & urinalysis check for protein at each antenatal visit to screen for pre-eclampsia.
risk for preeclampsia
Age 40 years or older
Nulliparity
Pregnancy interval of more than 10 years
Family history of pre-eclampsia
Previous history of pre-eclampsia
BMI 30 kg/m2 or above
Pre-existing vascular disease such as hypertension
Pre-existing renal disease
Multiple pregnancy
what symptoms should women at risk of pre eclampsia should be aware of
severe headache
problems with vision, such as blurring or flashing before the eyes
severe epigastric or right upper quadrant pain
vomiting
sudden swelling of the face, hands or feet.
At what DBP and SBP levels do you treat
DBP of above 100mmHg
two consecutive reading of 90mmHg more than 4 hours apart and/or significant proteinuria should prompt increased surveillance
SBP above 160mmHG
150-159 mmHg on two consecutive readings at least 4 hours apart consider treatment
keep SBP below 150mmHg
When is dating scan done
essential to all antenatal care timing, including fetal anomaly testing
first trimester (10-13+6 weeks)
CRL used unless less than 84mm, then HC used
also nuchal translucency scan plus biochem
when is screening for T13, T18, T21 done
first trimester by the end (13 weeks 6 days)
the combined test of bloods and US should be done (NT, BhCG, PAPP-).
what happen if women miss the window for scrrening of T13, T18, T21
15-20 weeks for late bookers
only serum screening quadruple test is available for these lot
hCG, aFP, uE3 and inhibin-A
if high suspicion of trisomy on screening test what do u do
explain the results and tell them when the confirmatory tests would occur
invasive tests
Purpose of the anomaly scan screening
identify fetal anomalies and allow
- reproductive choice - termination of pregnancy
- parents to prepare (for any treatment/disability/palliative care/ termination of pregnancy
- managed birth in a specialist centre
- intrauterine therpauy
what is used to assess rate of growth
head circumference
abdomen circumference
femur length
what fetal anomalies can we look for in scan
cleft palate
lip anomalies
nasal abridge
for uncomplicated nulliparous women how many appts are required
10
for uncomplicated parous women how many appts are requires
7
what happens at each visit
BP and urine check occurs
from 24 weeks: symphysis - fundal height should be measured and recorded
from 36 weeks check fetal presentation - USS if uncertain
routine auscultation is not normal unless requested
formal fetal movement counting not required
routine antenatal CTG in uncomplicated pregnancy NO BENEFIT
At 28 weeks what tests are done
FBC for anaemia
red cell alloantibodies
Glucose Transaminase T if infdicated
if mother is rhesus negative offer routine anti D prophylaxis
what happens at the third trimester 36 weeks visit
breastfeeding info, techniques and good management practises
birth plan, where they want to give birth, pain relief options
recognition of active labour
care of the new baby
vit K prophylaxis
newborn screening tests
postnatal self-care
awarness of baby blies and postnatal depression
risk assessment
what is documentation of care
structured maternity records should be used for antenatal care
women carry their own case notes
when is normal scanning done
20 weeks
in what circumstances are further scans done in pregnancy
low lying placenta at 20 weeks - rescan at 32 weeks
suspected small for dates in clinical examination/customised growth charts
suspected malpresentation (weird position) on clinical examination
from 42 weeks women who decline induction of labour should be offered US estimation of maximum amniotic pool depth
postnatally what occurs
physical and emotional health and well being
coping strategies adn support
commonhealth problems
encourage the woman and family members to report concerns
mental health problems
what test is done to screen for downs and how are the results are interpreted
The ‘combined test’ (nuchal translucency, beta-human chorionic gonadotrophin, pregnancy-associated plasma protein-A) should be offered to screen for Down’s syndrome between 11 weeks and 13 weeks 6 days. For women who book later in pregnancy the most clinically and cost-effective serum screening test (triple or quadruple test) should be offered between 15 weeks and 20 weeks.
The presence of an increased nuchal fold (6 millimetres or above) or two or more soft markers on the routine anomaly scan should prompt the offer of a referral to a fetal medicine specialist or an appropriate healthcare professional with a special interest in fetal medicine.
when is it not possible to measure nuchal transparency and what alternative test is done
owing to fetal position or raised BMI, women should be offered serum screening (triple or quadruple test) between 15 weeks and 20 weeks.
what is PROM
Premature rupture of membranes (PROM) is a rupture (breaking open) of the membranes (amniotic sac) before labor begins
if PROM occurs before 37 weeks of pregnancy then what is it called
preterm premature rupture of membranes (PPROM)
factors that contribute TO PROM
near the end of pregnancy (term) may be caused by a natural weakening of the membranes or from the force of contractions.
Low socioeconomic conditions (as women in lower socioeconomic conditions are less likely to receive proper prenatal care)
Sexually transmitted infections, such as chlamydia and gonorrhea
Previous preterm birth
Vaginal bleeding
Cigarette smoking during pregnancy
Unknown causes
Risks of PROM
fetal: prematurity, infection, pulmonary hypoplasia
maternal: chorioamnionitis
- placental infection (chorioamnioitis)
- placental abruption (early - detachment of the placenta from the uterus)
- compression of the umbilical cord
- cesarean birth
- postpartum (after delivery) infection.
- sepsis
- baby is more likely to be born within a few days
- (Early in pregnancy) may lead to oligohydramnios.
- Increased incidence of retained placenta and primary and secondary postpartum haemorrhage.
symptoms of PROM
Leaking or a gush of watery fluid from the vagina
Constant wetness in underwear
how is PROM diagnosed
Actually seeing amniotic fluid draining from the cervix and pooling in the vagina after the woman has been lying down for 30 minutes is the most accurate test[5]. Sterile speculum examination: check for liquor and for the umbilical cord.
Testing for insulin-like growth factor binding protein-1 or placental alpha-microglobulin-1 may aid diagnosis but results should not be considered in isolation.
The Vision Amniotic Leak Detector (ALD) is a non-invasive diagnostic liner that can be attached to underwear. I
Testing of the pH (acid or alkaline) of the fluid
Looking at the dried fluid under a microscope (may show a characteristic fern-like pattern)
Ultrasound - check for gestation and liquor volume
Ultrasound may also be useful to show oligohydramnios.
Temperature monitoring at least 12-hourly for ascending infection:
- — High vaginal swab.
- – If infection is suspected, check FBC (for WCC), CRP, MSU and blood cultures; start appropriate antibiotic treatment if tests, along with clinical signs, confirm intrauterine infection.
Fetal monitoring.
Mx of PROM
Hospitalization
P-PROM is suspected.
Ascending infection is suspected: maternal or fetal tachycardia, temperature, abdominal tenderness.
Expectant management (in very few cases of PPROM, the membranes may seal over and the fluid may stop leaking without treatment,
Monitoring for signs of infection, such as fever, pain, increased fetal heart rate, and/or laboratory tests.
Antibiotics (to prevent or treat infections)
- recommends the use of ORAL erythromycin 250 mg qds for 10 days (or until labour is established if this is sooner) following the diagnosis of P-PROM
antenatal steroids should be given if gestation is between 24+0and 34+6 weeks.
If Group B streptococcus is isolated from a swab or if erythromycin is contra-indicated then penicillin or clindamycin is usually recommended
Women with PPROM usually deliver at 34 weeks if stable. If there are signs of abruption, chorioamnionitis, or fetal compromise, then early delivery would be necessary.)
risk factors for P-PROM
Smoking
previous preterm delivery
vaginal bleeding at any time during the pregnancy
association between lower genital tract infection and P-PROM
earliest signs of ascending infection
fetal tachycardia
mild increase in maternal temperature
offensive vaginal discharge
which AB should not be used prophylatically in P-PROM
Co-amoxiclav
why are antenatal steroids given in PROM
Antenatal steroids are associated with a significant reduction in rates of neonatal death, respiratory distress syndrome and intraventricular haemorrhage and are safe for the mother
when should delivery be considered in P-PROM women
34 weeks
what risks are ass if pregnancy occurs above 36 weeks
increased risk of chorioamnionitis and a reduced risk of respiratory problems for the neonate.
what is intrapartum fetal monitoring
monitoring techniques that are used immediately preceding or during childbirth
what is symphysis fundal height
measured from the top of the pubic bone to the top of the uterus in centimetres
It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm
what is done if the symphysis fundal height is not within recommeded level
do US
what is folic acid
Folic acid is converted to tetrahydrofolate (THF). Green, leafy vegetables are a good source of folic acid.
functions of folic acid
THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA
causes of folic acid deficiency
phenytoin
methotrexate
pregnancy
alcohol excess
consequences of folic acid deficiency
macrocytic, megaloblastic anaemia
neural tube defects
how to prevent neural tube defects in all women and high risk women
400mcg of folic acid until the 12th week of pregnancy
women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
when are women considered high tisk for Neural tube defect
- either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
- the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
- the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
causes of increased AFP
- Neural tube defects (meningocele, myelomeningocele and anencephaly)
- Abdominal wall defects (omphalocele and gastroschisis)
- Multiple pregnancy
causes of decreased AFP
Down’s syndrome
Trisomy 18 - Edward’s
Maternal diabetes mellitus
anaemia ranges in pregnancy
1) first trimester Hb less than 110 g/l
2) second/third trimester Hb less than 105 g/l
3) postpartum Hb less than 100 g/l
Gestation Cut-off
Booking visit < 11 g/dl
28 weeks < 10.5 g/dl
increased NT
Down’s syndrome
congenital heart defects
abdominal wall defects
