Antenatal Care and Screening

Question 1

What physiological changes in the mother are associated with normal pregnancy ?

Answer 1

• Pregnancy affects multiple systems of the body
• Women develop symptoms and it can be difficult to determine which are physiological and which are pathological

Understanding what happens to the body when pregnant allows us to understand what can be normal

Question 2

Why do we do Pre-pregnancy Counselling ?

Answer 2

• Ideally we want to do it for all women (In Scotland 1/3rd of pregnancies are unplanned)
• In 2015-2017 209 women/9.2 women per 100,000 died during or up to 6 weeks after pregnancy/childbirth

Question 3

What changes can be made doing Pre-pregnancy Counselling in a Primary Care setting?

Answer 3

General Health measures;
- improve diet
- Optimise BMI
- Reduce alcohol consumption

Smoking cessation advice

Folic acid - 400mg standard dose or 5mg high dose

Vitamin D - 10mcg daily

Question 4

Why is it important to discuss known past medical problems?

Answer 4

This allows us to
- Optimise maternal health
- Psychiatric health is important
- Stop/change any unsuitable drugs
- Advise regarding complications associated with maternal medical problems
- Occasionally advise against pregnancy

Good examples are diabetes and epilepsy - want stable before to reduce complications

Question 5

What medications do you not want patients taking when pregnant?

Answer 5

Sodium valproate and ACE inhibitors

Question 6

What women are advised against pregnancy?

Answer 6

Not many are advised against but main ones are congenital cardiac conditions and women with multiple c-sections or complications from a surgical view

Question 7

What is important to cover when discussing Previous Pregnancy Problems?

Answer 7

Mother;
- Pre-eclampsia (Recommend Aspirin)
- DVT/PE (Give Dalteparn)
- Previous Delivery - LSCS (lower segment c-section) or perineal tear? (Risk tear again)

Baby;
- Foetal abnormality
- Intrauterine growth restriction
- Preterm birth

Question 8

What sections should you cover in Pre Pregnancy counselling?

Answer 8

• General Health (Diet, BM, Alcohol)
• Smoking
• Vitamins - Folic acid + Vitamin D
• PMH - Known medical conditions
• POMH - Previous Pregnancies ?
• Antenatal screening

Question 9

What are the features of discussing Antenatal Screening?

Answer 9

• Women are offered screening but
  this is not compulsory
• Appropriate counselling prior to
  screening is important
• Allows conditions to be detected
  early in a symptomless population to
  be treated for mother/baby

Question 10

What scans do we offer and what for?

Answer 10

First visit scan;
- Ensure pregnancy viable
- Multiple pregnancy
- Identify abnormalities incompatible with life
- Offer and carry out Down’s syndrome screening

Detailed anomaly scan;
- Systematic structural review of baby
- Not possible to identify all problems
- Can identify problems that need intrauterine or postnatal treatment (like spina bifida or congenital cardiac issues - can affect birth location, neonatal cardiac team in Glasgow).

Every family is offered these 2 scans

Even although incompatible with lives families may carry on with this. Some do it for baby organs to be donated but we don’t have the facilities to do here.

Also offer edwards and patau’s (life expectancy is significantly effected in these two)

We don’t count number fingers etc, check head, heart, angle foot okay. Also don’t know function, might look okay but cant say if will have autism

Question 11

What Trisomy’s do we screen for and what is important to remember with these?

Answer 11

We screening for Trisomy 13 (Patau’s), 18 (Edwards) and 21 (Down Syndrome)

Multiple screening tests are available

Women and their partners must be aware prior to any screening taking place that tests for foetal 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

Question 12

What is the Nuchal Translucency test?

Answer 12

Nuchal Translucency (NT) measurements are taken between Crown Rump Length’s of 45-84mm

1st visit scan, all baby’s have fluid behind head nuchal translucency (very hard, points of mm)

Screening test involves;
- NT measurement
- CRL (Crown-Rump Length)
- Blood test for PAPP-A (pregnancy associated plasma protein-A), hCG (human chorionic gonadotrophin)
- Maternal age

These all go into a calculator and a figure is calculated giving the risk of a Trisomy, if risk is >1 in 150 further testing options are offered

Question 13

If you cannot get a Nuchal Translucency measurement at the first scan what can be done?

Answer 13

• If not able to get NT measurement or pregnancy is over this gestation, a second trimester screening test can be
  done between 14+2 and 20+0
• Also looking at Alpha-fetoprotein, Oestriol, hCG and inhibin-A

Question 14

If a Nuchal Translucency test comes back with a high risk result what is then offered?

Answer 14

If risk is >1 in 150 further testing options are offered;

• CVS (Chorionic Villus Sampling) - Involves removing and testing a small sample of cells from the placenta, the organ linking the mother’s blood supply with the unborn baby’s.
• Amniocentesis - Needles placed in abdominal guided by US and takes sample of amniotic fluid
• Non-invasive Prenatal Testing - It involves a maternal blood test. Most of the DNA comes from the mother but a small amount comes from the baby’s placenta. It is important to know that NIPT does not give a yes/no answer about chromosomal conditions but less invasive!

Question 15

What does the first trimester ultrasound look for?

Answer 15

• Anencephaly
• Neural tube defect like Spina Bifida (‘Banana Sign’ shows spina bifida from base of skull to spine)

Question 16

What does the second trimester ultrasound look for?

Answer 16

Checks;
- Heart formed property (Hypoplastc heart - some families can terminate, need to go to a hospital that can do the surgery, also check fr underlying genetic problems)
- Exomphalos associated with 30% chromosomal abnormality
- Gastroschisis
- Cleft lip (Biggest worry is visual abnormality in these patients)

Question 17

What screening s done throughout the pregnancy ?

Answer 17

• Depending on risk profile of mother, care can be midwife led or shared care between midwife and obstetric team
• Examination
• Symphysial fundal height (estimate of gestation and if baby is over or underweight)
• Serial ultrasound scans (try and calculate size of baby)

Question 18

What its involved in an Antenatal examination ?

Answer 18

Routine enquiry;
- Feeling well
- Feeling fetal movements (after 20 weeks) (Days preceding stillbirth women report change in movements)

Blood Pressure;
- Detect evolving hypertension (Pre-eclampsia worry)

Urinalysis (Proteinuria for pre-eclampsia)

Abdominal Palpation;
- Assess symphyseal fundal height (SFH) (Pubic symphysis to fungus of uterus)
- Estimate size of baby
- Estimate liquor volume (baby harder to feel? = more fluid)
- Lie of baby (breech c-section?)
- Listen to foetal heart - 110-160bpm for baby (higher for younger then 110-140bpm at later stages)