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Reproductive System > Antenatal Care and Screening > Flashcards

Antenatal Care and Screening Flashcards

1
Q

What fraction of pregnancies are unplanned?

A

1/3

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2
Q

What is the incidence of maternal mortality?

A

9/100000

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3
Q

What are the most common causes of maternal death?

A
  1. Heart disease
  2. Blood clots
  3. Epilepsy and stroke
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4
Q

What is covered in pre-pregnancy counselling?

A
  • General health measures
    • Improve diet
    • Optimise BMI
    • Reduce alcohol consumption
    • Smoking cessation
  • Folic acid
  • Up to date cervical smear
  • Medical history
    • Optimise known medical problems
    • Stop/change unsuitable drugs
    • Occasionally advice against pregnancy
      • Significant cardiac disease
  • Previous pregnancy problems
    • Maternal
      • Pre-eclampsia – aspirin 150mg during pregnancy and regular BP monitoring
      • Gestational diabetes – HbA1C booking and OGTT at 28 weeks
      • Previous caesarean section – consider elective caesarean section
      • DVT or PE – consider antenatal thromboprophylaxis and 6 weeks postnatal treatment
    • Foetal
      • Intrauterine growth restriction – aspirin 150mg during pregnancy and serial USS
      • Preterm birth – transvaginal cervical length scans or cervical suture
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5
Q

What are some previous medical problems that need discussed at pre-pregnancy counselling?

A
  • Maternal
    • Pre-eclampsia – aspirin 150mg during pregnancy and regular BP monitoring
    • Gestational diabetes – HbA1C booking and OGTT at 28 weeks
    • Previous caesarean section – consider elective caesarean section
    • DVT or PE – consider antenatal thromboprophylaxis and 6 weeks postnatal treatment
  • Foetal
    • Intrauterine growth restriction – aspirin 150mg during pregnancy and serial USS
    • Preterm birth – transvaginal cervical length scans or cervical suture
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6
Q

What does antenatal examination involve?

A
  • Abdominal palpation
    • Assess symphyseal fundal height (SFH)
    • Estimate size of baby
    • Estimate liquor volume
    • Determine foetal presentation
  • Listen to foetal heart
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7
Q

What does abdominal palpating when pregnant allow?

A
  • Assess symphyseal fundal height (SFH)
  • Estimate size of baby
  • Estimate liquor volume
  • Determine foetal presentation
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8
Q

What does SFH stand for?

A

Symphyseal fundal height

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9
Q

What are examples of antenatal screening offered to woman?

A
  • Screening for infection (carried out in 1st trimester)
    • Hep B
    • Syphilis
    • HIV
      • Maternal treatment and planning reduces vertical transmission
    • MSSU
      • UTI
  • Anaemia and isoimmunisation (1st trimester and at 28 weeks)
    • Isoimmunisation is high levels of certain red cell antibodies that can cause anaemia in the foetus
  • Anomalies by USS
    • Ensure pregnancy is viable and identify abnormalities incompatible with life
    • First scan carried out between 11 and 14 weeks
    • Second scan in 2nd trimester
  • Chromosomal abnormalities
    • 1st trimester screening
      • Carried out at 10-14 weeks
      • Uses maternal factors, serum B-human chorionic gonadotrophin (B-hCG) and pregnancy associated plasma protein A (PAPP-A) and foetal nuchal translucency (NT) measurement
    • 2nd trimester screening
      • Sometimes NT measurement not possible due to foetal position or maternal BMI
    • Checks for down syndrome (trisomy 21), Edward’s syndrome (trisomy 18) and Patau’s syndrome (trisomy 13)
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10
Q

Screening for what infections is carried out?

A
  • Hep B
  • Syphilis
  • HIV
    • Maternal treatment and planning reduces vertical transmission
  • MSSU
    • UTI
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11
Q

Why are anomilies checked for with USS?

When do these scans occur?

A
  • Ensure pregnancy is viable and identify abnormalities incompatible with life
  • First scan carried out between 11 and 14 weeks
  • Second scan in 2nd trimester
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12
Q

What chromosomal abnormalities are checked for?

A
  • Checks for down syndrome (trisomy 21), Edward’s syndrome (trisomy 18) and Patau’s syndrome (trisomy 13)
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13
Q

How are chromosomal abnormalities checked for during screening?

A
  • Uses maternal factors, serum B-human chorionic gonadotrophin (B-hCG) and pregnancy associated plasma protein A (PAPP-A) and foetal nuchal translucency (NT) measurement
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14
Q

When would NT measurements not be possible?

A

Due to foetal position or maternal BMI

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15
Q

What does NT measurement stand up for?

A

Nuchal translucency measurement

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16
Q

When is 1st trimester screening for chromosomal abnormalities carried out?

A

Between 10-14 weeks

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17
Q

When do US anomaly scans take place?

A
  • First scan carried out between 11 and 14 weeks
  • Second scan in 2nd trimester
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18
Q

When does screening for anaemia and isoimmunisation take place?

A

1st trimester and at 28 weeks

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19
Q

If chromosomal screening reveals high risk, what can then be done?

What is considered to be high risk?

A

High risk is >1/150 chance

More testing is offered

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20
Q

What additional testing is offered if chromosomal screening reveals high risk?

A
  • CVS
    • Between 10-14 weeks
    • 1-2% of miscarriage
  • Amniocentesis
    • 15 weeks onwards
    • 1% risk of miscarriage
  • Non-invasive prenatal testing
    • Maternal blood taken to detect foetal cell free DNA and look for chromosomal trisomy
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21
Q

What can be a consequence of CVS or amniocentesis?

A

Miscarriage

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22
Q

When does CVS take place?

A

Between 10-14 weeks

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23
Q

When can amniocentesis take place?

A

Beyond 15 weeks

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24
Q

What does CVS stand for?

A

Chorionic villus sampling

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25
Q

Describe non-invasive prenatal testing as an additional form of testing after high risk chromosomal abnormality is identified?

A
  • Non-invasive prenatal testing
    • Maternal blood taken to detect foetal cell free DNA and look for chromosomal trisomy
    • Not offered on NHS
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26
Q

How does the risk of morbidity change with a twin pregnancy?

A

Increased risk

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27
Q

What is the incidence of twin pregnancy?

A

2-3% of all births, increasing due to assisted conception

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28
Q

Cardiac output (CO) increases by how much duing pregnancy?

A

30-50%

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29
Q

How much does the HR increase during pregnancy?

A

70-90 bpm

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30
Q

What is a common heart complaint during pregnancy?

A

Palpitations

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31
Q

How much must blood flow exceed at term?

A

1L/min

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32
Q

When does blood pressure drop during pregnancy?

Why?

A

In the second trimester

Expansion of the uteroplacental circulation

A fall in systemic vascular resistance

A reduction in blood viscosity

A reduction in sensitivity to angiotensin

BP usually returns to normal in the third trimester

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33
Q

What happens to the urine output during pregnancy?

A

Increased urine output

Renal plasma flow increases by 25-50%

Glomerular Filtration Rate increases by 50%

Serum urea and creatinine decrease

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34
Q

Why is there a risk of UTIs in pregnancy?

A

There is an increase in urinary stasis

Hydronephrosis is physiological in the third trimester and makes pyelonephritis more common

Can be associated with preterm labour so important to treat

Bladder capacity is reduced in the third trimester because of pressure in the pelvis from the expanding uterus

Decreased serum urea and creatinine partly due to increased GFR but partly due to dilutional effect of increased plasma volume

Easier path for ascending infection and increased pyelonephritis. Caution with UTI in pregnancy as increases the incidence of PTL therefore low threshold for MSSU and antibiotics if +ve

35
Q

Why can anaemia occur during pregnancy?

A

Plasma volume increases by about 50% and RBC mass by about 25%

This results in a drop in haemoglobin by dilution from 133-121g/L

Iron requirements are increased by 1g during pregnancy

WBC increase slightly to 9000-12000/mL

Platelet count falls by dilution

36
Q

What are the respiratory problems that can be caused in pregnancy?

A

•Progesterone acts centrally to reduce CO2

Increased ­Tidal volume

­Increased Respiratory rate

Increased­ Plasma pH

  • O2 consumption ­ by increased 20%
  • Plasma PO2 is unchanged
  • Hyperaemia of respiratory mucous membranes
37
Q

What are the gastrointestinal problems in antenatal women?

A
  • Oesophageal peristalsis is reduced
  • Gastric emptying slows
  • Cardiac sphincter relaxes
  • GI motility is reduced due to

­ Increase progesterone and decrease motilin

38
Q

Who is pre pregancny counselling good for?

A

Ideally for all women

In Scotland, a third of pregnancies are unplanned

39
Q

Who is pre pregnancy counselling done with?

What are some things that are looked at?

A

All women

This can be done in primary care

General health measures

Improve diet

Optimise BMI

Reduce alcohol consumption

Smoking cessation advice

Folic acid 400 mcg standard dose or 5mg high dose

Vitamin D 10mcg daily

40
Q

How does obesity affect pregnancy?

A

Obesity has a detrimental affect on pregnancy with a higher rate of poor outcomes including miscarriage and still birth. It also affects the function of the uterus in labour. Routine measurements of fundal height to monitor fetal growth and presentation may be impossible on abdominal palpation. Venous thromboembolic events are more common in obese patients.

41
Q

What is alcohol associated with?

A

Fetal abnormalities causing a fetal alcohol syndrome which produces a typical facial appearance and affects learning, the routine advice given to pregnant women is to avoid alcohol although there is no evidence of harm from minimal alcohol consumption during pregnancy

42
Q

How does age affect pregnancy?

A

Pregnancy outcomes are poorer at both ends of the fertile population. Teenagers may be socially deprived with lack of support, smoke more, and not receive the antenatal care they need, often booking late.

Older women, particularly the over 40s, are more prone to pre-existing medical conditions and develop complications of pregnancy such as gestational diabetes and hypertension.

Chromosomal disorders increase dramatically with advancing maternal age.

43
Q

How can parity affect pregnancy?

A

Pre-eclampsia is predominantly a condition of nulliparity, occurring in the first pregnancy. Grand multiparity (4 or more deliveries) predisposes women to postpartum haemorrhage.

44
Q

How can a patients occupation affect their pregnancy?

A

A patient’s occupation may expose them to situations that put either themselves or their fetus at risk. They may have a very busy job with inadequate rest periods or be exposed to substances such as chemicals which cause fetal anomalies.

45
Q

How does a substance misuse affect pregnancy?

A

Substance misuse such has effects both on the mother who may not seek antenatal care or attend intermittently and on the fetus. Heroin, methadone and benziodiazapines are addictive to the fetus and cause a withdrawal syndrome in the baby when it is cut off from its supply at birth.

Cocaine and crack are associated with abruption resulting in fetal death.

Women with substance misuse are seen in a specialist multidisciplinary clinic involving obstetricians, midwives, members of the substance misuse team (psychiatrists & CPNs), social workers and health visitors.

46
Q

How does folic acid affect pregnancy?

A

Higher dose if had issues like spina bifida in previous births

Vit D is now recommended for all women during pregnancy too

47
Q

What should you remember when looking at known medical problems during pregnancy?

A

Optimise maternal health

Psychiatric health is important

Stop/Change any unsuitable drugs

Advise regarding complications associated with maternal medical problems

Occasionally advise against pregnancy

48
Q

What is pheynlketonuria?

A

Inborn error of protein metabolism which causes an inability to metabolism essential amnio acid phenylalanine. This results in high levels which causes mental developmental impairment. It is screened for in newborn babies and amendable to treatment. However if a woman with PKU is pregnant she needs to restart her low phenylalanine diet to prevent high levels reaching the developing fetal brain.

49
Q

What is the most common thyroid disease in pregnancy?

A

Hypothyroidism

These women take thyroxine. The demand for thyroxine increases during pregnancy and therefore doses may need to be increased. Normal thyroxine levels are also required for fetal brain development.

50
Q

What should be done if a women is hyperthyroid entering pregnancy?

A

They need treatment to keep their thyroid hormone levels normal. Thyroid stimulating antibodies can cross the placenta to the fetus so the neonate will need to be checked as well.

51
Q

What is importnat in pregnancy with a women with pre-existing diabetes?

A

Require additional care in relation to pregnancy.

Ideally their glucose control is optimised prior to conception as high blood glucose levels are associated with congenital anomalies.

Women with type 2 diabetes who are on oral hypoglyceamic medications need to be switched to insulin.

Diabetic patients are more at risk of pregnancy complications such as pre-eclampsia, stillbirth and macrosomic infants. They should be cared for in a joint diabetic obstetric antenatal clinic.

52
Q

What are renal patients more likely to develop in pregnancy?

A

Renal patients are more likely to develop pre-eclampsia which may be difficult to diagnose if they already have proteinuria and pre-existing hypertension. Pregnancy is now possible for women who previously would not have been able to have children. Renal transplantation restores fertility as well as renal function

53
Q

What is the main concern for a women with epilepsy in pregnancy?

A

The main concern for women with epilepsy is the effect of their anti-epileptic medication on their developing fetus. Sodium valproate is an effective drug but is associated with a higher rate of spina bifida in the offspring of women taking it.

54
Q

What is important to think about with maternal past issues during future pregnancy?

A

Counsel regarding risk of recurrence

Caesarean Section

DVT

Pre-eclampsia

Actions to reduce risk of recurrence

Thromboprophylaxis

Low dose aspirin

55
Q

What is important to think about with fetal past issues during future pregnancy?

A

Counsel regarding risk of recurrence

Pre-term delivery

Intrauterine growth restriction

Fetal abnormality

Actions to reduce risk of recurrence

Treatment of infection

High dose folic acid

Low dose aspiri

56
Q

What is important if a patient has previously had a C-section?

A

If a patient previously had a caesarean section it is necessary to determine the safest mode of delivery on this occasion. Usually if she has only had one caesarean for a non-recurring cause such as breech presentation she will be fine to undertake a trial of labour. However after 2 previous caesareans it is customary to deliver by elective caesarean again.

57
Q

What is important in antenatal examination?

A

High quality antenatal care reduces fetal and maternal mortality

Aims to identify problems

Mother

Problems such as pre-exisiting or developing illness

‘minor’ problems of pregnancy such as anaemia

Fetus

Small for gestational age

Fetal abnormality

Social

Support

Domestic violence

Psychiatric Illness

58
Q

What is required to do in an antenatal examination?

A

Routine enquiry

Feeling well

Feeling fetal movements

(after 20 weeks)

Blood Pressure

Detect evolving hypertension

Urinalysis

Abdominal Palpation

Determine fetal presetnation

Listen to fetal heart

59
Q

What is important in abdominal palpation?

A

Assess symphyseal fundal

height (SFH)

Estimate size of baby

Estimate liquor volume

60
Q

What happens if fetal lie is abnormal?

A

Has implications for delivery

Some abnormal lies are secondary to problems such as placenta praevia which can have serious consequences around he time of delivery and are important to detect

Check the measurementrs are progressing normal. May not be possible maybe due to their BMI or other issues

61
Q

What does screening look at in pregnancy?

And is it compulsory?

A

Screening is the testing of a symptomless population in order to detect cases of a disease at an early stage and a variety of screening tests are offered to pregnant women

Women should be offered but not compulsory- Should get appropriate councelling but do not have to accept the screening

62
Q

What infections are screened for in pregnancy?

A

Hepatitis B- If infected can provide passive and active immunisation for baby

Syphilis- Easily treated with Penicillin

HIV- Maternal treatment and careful planning reduces vertical transmission

MSSU- Urinary tract infection

All pregnant women are screened for Rubella, Hepatitis B, Syphilis, and HIV as part of routine ANC

63
Q

When is the screening for anaemia and isoimmunisation done?

A

12 and 28 weeks gestation

64
Q

What is rhesus disease?

A

nRhesus disease is a condition where antibodies in a pregnant woman’s blood destroy her baby’s blood cells. It’s also known as haemolytic disease of the foetus and newborn (HDFN). Rhesus disease doesn’t harm the mother, but it can cause the baby to become anaemic and develop jaundice.

65
Q

How is iron deficiency anaemia screened?

A

Screen for it by routine full blood counts at booking and 28/40 gestation.

Additional iron is required to make extra maternal red blood cells as normal adaptation of pregnancy and needed by the developing fetus and placenta.

If her iron stores are low prior to pregnancy she may well become iron deficient during pregnancy.

Once detected this can be remedied by taking iron tablets.

66
Q

What is isoimmunisation?

A

Isoimmunisation refers to the development of antibodies against blood groups. The commonest isoimmunisation is Rhesus disease where anti-D antibodies occur. If a Rhesus negative women is carrying a rhesus positive baby she will develop anti D antibodies if the fetal red blood cells enter the maternal circulation.

This occurs with miscarriage beyond 12 weeks gestation, surgical or medical evacuation of the uterus either due to miscarriage or termination, ectopic pregnancy, antepartum haemorrhage and at delivery. Therefore the antibodies tend to develop following the first pregnancy.

In subsequent pregnancies with a Rhesus positive fetus the anti-D antibodies cross the placenta and lead to destruction of the fetal red blood cells causing fetal anaemia. Which can result in fetal death. Screening pregnant women allows us to identify women at risk ie Rhesus negative and provide them with passive immunisation to destroy fetal RBCs in the maternal circulation before the maternal immune system has the opportunity to be activated and produce its own antibodies.

It also identifies those women with pre-existing antibodies so that those pregnancies can be monitored more closely to detect the development of fetal anaemia and provide treatment.

Anti D IgG is offered to all Rh negative women both prophylactically and after potentially sensitising events.

67
Q

What is done in the first visit scan during pregnancy?

A

Ensure pregnancy viable

Multiple pregnancy

Identify abnormalities incompatible with life

Offer and carry out Down’s syndrome screening

68
Q

What is involved in the detailed anomaly scan?

A

nSystematic structural review of baby

nNot possible to identify all problems

nCan identify problems that need intrauterine or postnatal treatment

69
Q

What does a normal head look like?

A

A rugby ball

70
Q

What is shown in the right US

The left one is normal

A

Anacephaly

71
Q

What are the genes that are screened for? And what is important during this?

A

Trisomy 13, 18 and 21

Multiple screening tests are available

Women and their partners must be aware prior to any screening taking place that tests for fetal abnormality only provide a risk of their baby being affected.

Further testing will be offered to definitively tell if a baby is affected

Embarking on prenatal screening may sometimes result in parents having to make a difficult decision regarding termination of pregnancy

72
Q

When is the first trimester screening done? What does it look at?

A

Carried out at 10-14 weeks gestation

Uses maternal risk factors, serum b-human chorionic gonadotrophin (b-hCG) and pregnancy associated plasma protein A (PAPP-A) and fetal nuchal translucency (NT) measurement

Detection rate for Trisomy 21 of ~90%, invasive testing rate of 5%

73
Q

Where is nuchal translucency taken between?

A

NT measurements are taken between Crown Rump Length’s of 45-84mm

74
Q

What does nuchal transluency increase?

A

Increases with gestational age and the incidence of chromosomal and other abnormalities is related to the size, rather than the appearance of NT.

75
Q

What happens if there is a high risk result of downs syndrome in screening?

A

Further testing is offered if risk of Down’s syndrome is >1 in 150

Options:

  • CVS
  • Amniocentesis
  • Non-invasive Prenatal testing
76
Q

What is the non invasive prenatal testing?

A

nMaternal blood taken

nCan detect fetal cell free DNA released from the placenta

nNo risk of miscarriage

nNot diagnostic, so if gives a high risk result, parents are offered CVS/amniocentesis

77
Q

What is CVS?

A

Between 10-14 weeks

1-2% risk of miscarriage

78
Q

What is amniocentesis?

A

15 weeks onwards

~1% risk of miscarriage

79
Q

What is important about screening for neural tube defect?

A

Not routinely offered since introduction of first trimester screening

Personal or family history of NTD are at increased risk

Should be advised to take 5mg folic acid to reduce risk

First trimester ultrasound to detect anencephaly and sometimes spina bifida (variants of NTD)

Second trimester biochemical screening- Carried out if not able to get NT measurement. Maternal serum is tested for alpha fetoprotein. >2.0MoM is high risk and warrants investigation

Second trimester (20wk) ultrasound will detect >90% of NTD

80
Q

What is the second trimester US?

A

Performed with the purpose of detecting fetal abnormality

This is a good screening test for major structural abnormalities but a poor test for chromosomal abnormalities as

  • 50% of fetuses with T21 will have a normal detailed USS
  • 17% of fetuses with T18 will have a normal detailed USS
  • 9% of fetuses with T13 will have a normal detailed USS
81
Q

What does an early pregnancy scan look at?

A

Checks hearbeat, stage, confirms number of babies, gives nuchal transulency measurement

82
Q
A
83
Q

What is the lambda sign?

A

Projection of placental tissue into the interfetal membrane. In monochorionic pregnancies, there is no tissue seen and this is known as a T-sign

Reproductive System (88 decks)

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