antenatal care and screening Flashcards by Evie withington

physiological changes in the mother associated with normal pregnancy

pregnancy affects multiple systems of the body
can be difficult to determine which symptoms are physiological and which are pathological

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cardiac pregnancy blood problems (3)

HR increases from 70-90bpm
palpiations are common
blood pressure drops in the 2nd trimester - usually returns to normal in 3rd trimester

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what is blood flow to the uterus at term

must exceed 1L/min

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why does BP drop in the 2nd trimester

expansion of the uteroplacental circulation
fall in systemic vascular resistance
reduction in blood viscosity
reduction in sensitivity to angiotensin

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urinary pregnancy problems

increased urine output
UTI

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why is there increased urine output during pregnancy

renal plasma flow increases by 25-50%
GFR increases by 50%
serum urea and creatinine decrease

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why do UTIs occur during pregnancy

increase in urinary stasis
hydronephrosis is physiological in 3rd trimester - pyelonephritis is more common
can be associated with preterm labour so important to treat

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haematology pregnancy problems

anaemia

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why does anaemia occur during pregnancy

plasma volume increases by roughly 50% and RBC mass by 25%
this means a drop in Hb dilution from 133-121g/L
iron requirements are increased by 1g during pregnancy
WBC increase slightly to 9000-12000/µL
platelet count falls by dilution

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respiratory problems during pregnancy

nose bleeds
SOB
runny nose

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why do resp problems occur during pregnancy

progesterone acts centrally to reduce CO2 - increased tidal volume, increased resp rate, increased plasma pH
O2 consumption up by 20%
plasma PO2 is unchanged
hyperaemia of resp mucous membrances

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GI problems during pregnancy

heartburn
GORD
constipation

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why do GI problems occur during pregnancy

reduced oesophageal peristalsis
gastric emptying slows
cardiac sphincter relaxes
GI motility is reduced due to increased progesterone and reduced motilin

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pre-pregnancy counselling

ideally for all women
in scotland 1/3 of pregnancies are unplanned

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causes of maternal mortality - heart disease

heart disease - can occur for the first time during pregnancy
older, smokers, diabetes, FHx - greater risk of heart disease
signs - severe chest pain, SB when resting and lying flat

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causes of maternal mortality

heart disease - most common
blood clots
epilepsy and stroke
other physical conditions
sepsis
mental health conditions
bleeding
cancer
pre-eclampsia

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inequalities in maternal mortality

ethnicity - BAME groups at higher risk
age - older mothers more at risk
living in a more deprived area

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what does pre-pregnancy counselling involve

done in 1y care for all women
general health measures - improve diet, optimise BMI, reduce alcohol consumption
smoking cessation advice
folic acid - 400mcg standard or 5mg high dose, ideally start 3mths before pregnancy
vot D - 10mcg daily

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pre-pregnancy counselling - known medical problems

e.g. with diabetes/epilepsy
optimise maternal health
psychiatric health is important
stop/change any unsuitable drugs
advise regarding complications associated with maternal medical problems
occasionally advise against pregnancy

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pre-pregnancy counselling - previous pregnancy problems - maternal

counsel re. risk of recurrence - C section, DVT, pre-eclampsia
actions to reduce risk of recurrence - thromboprophylaxis, low dose aspirin

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pre-pregnancy counselling - previous pregnancy problems - fetal

counsel re. 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 aspirin

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why is antenatal examination important

high quality antenatal care reduces fetal and maternal mortality
aims to identify problems - mother, fetus, social

also mental health

what does antenatal examination involve

routine enquiry - feeling well, feeling fetal movements after 20wks - can be an indication something isn’t right with baby
BP - detect elevating hT
urinalysis

antenatal examination - abdominal palpitation

assess symphyseal fundal height - SFH - pubic symphysis to top of fundus, not always possible e.g. high BMI, fibroids on uterus etc
estimate size of baby
estimate liquor volume
determine fetal presentation - breech, vertex
listen to fetal heart

antenatal screening

women are offered screening but it isn't compulsory appropriate counselling prior to screening is important allows conditions to be detected early in a symptomless population to be treated for mother/baby

screening for infection

hep 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 - UTI

screening for anaemia and isoimmunisation at 12 and 28 wks

iron deficiency anaemia - can affect maternal health isoimmunisation - rhesus disease, anti C, anti Kell

first visit scan - screening for anomalies by US

ensure pregnancy viable multiple pregnancy and what type of multiple pregnancy identify abnormalities incompatible w/ life - counselling about options offer and carry out Down's syndrome screening - anencephaly

detailed anomaly scan - screening for anomalies by US

systematic structural review of baby not possible to identify all problems can only identify structural issues can identify problems that need intrauterine or postnatal treatment

screening for trisomy 13, 18 and 21

multiple screening tests 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

first trimester screening

carried out at 10-14 weeks gestation uses maternal risk factors, serum beta human chorionic gonadotropin (beta-HCG) and pregnancy associated plasma protein A (PAPP-A) and fetal nuchal translucency (NT) measurement

detection rate of trisomy 21 in first trimester screening

~90% invasive testing rate of 5%

Nuchal translucency measurememnts

area of fluid behind the baby's neck that can be measured very difficult to measure therefore must only be done if you can properly get an accurate measurement taken between crown rump lengths of 45-84mm

how does nuchal translucency change

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

what happens with a high risk result in first trimester screening

further testing is offered if risk of Down's syndrome is \>1/150

options for further testing

CVS amniocentesis non-invasive prenatal testing

what is non-invasive prenatal testing

maternal blood taken can detect fetal cell free DNA released from the placenta no risk of miscarriage not diagnostic, if a high risk result is received, parents are offered CVS/amniocentesis

when is CVS carried out what is the risk of miscarriage

between 10-14 wks 1-2% risk of miscarriage

when is amniocentesis carried out and what is the risk of miscarriage

15wks onwards ~1% risk of miscarriage, closer to 0.5% now

is screening for neural tube defects routinely offered?

not since the introduction of 1st trimester screening

who is at risk of neural tube defect (NTD) what preventative measures can be taken

personal or family hx at increased risk advised to take 5mg of folic acid to reduce the risk

screening for NTD

1st trimester US to detect anencephaly and sometimes spina bifida - variants of NTD 2nd trimester biochemical screening 2nd trimester US - 20wks, will detect \>90% of NTD

2nd trimester biochemical screening for NTD

carried out if not able to get NT measurement maternal serum is tested for alpha fetoprotein \>2.0MoM is high risk and warrants investigation

2nd trimester US

purpose - detect fetal abnormality good screening test for major structural abnormalities

disadvantages of 2nd trimester US

poor test for chromosomal abnormalities - some babies with with major defects can have completely normal scans 50% w/ T21 will have normal detailed USS 17% w/ T18 9% w/ T13

what is being measured here

nuchal translucency

what test is this

CVS - chorionic villous sampling sample of placenta taken

what test is this

aminocentesis

what is shown in these US scans

US markers for NTD 1. lemon sign, lemon shaped skull, typical spine of spina bifida 2. banana sign, cerebellum is slightly tapered 3. spina bifida, often no seen as clearly

what abnormality is shown

hypoplastic L heart - failure of LV to grow, major abnormality, babies will need multiple surgeries after birth normal heart also

what abnormality is shown here

exomphalos - protrusion of bowel coming out with the umbilical cord, can be in a sac or can be loops without a sac, 30% association w/ underlying abnormalities normal also - umbilical cord going into the tummy

what abnormality is shown

cleft lip from L to R - bottom lip, top lip, nose easily treatable following birth with surgery

what condition is shown here

anencephaly