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Obstetrics > Antenatal Care/ Congen Abnorm/ Infections > Flashcards

Antenatal Care/ Congen Abnorm/ Infections Flashcards

1
Q

Why is preferred to have a health check done before conception?

A
  1. Pick up any abnormal smear
  2. Rubella immunization
  3. If diabetic
  4. Regular medications can be changed to ones that are safe for pregancy
  5. Start 0.4mg/day folic acid
  6. Advice with regards to drinking and smoking
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2
Q

What is preconceptual 0.4mg/day folic acid useful for?

A

Reducing the chance of neural tube defects

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3
Q

When during pregnancy is the booking visit?

A

before 10 weeks

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4
Q

During a booking visit, why is past obstetric history important?

A

Many disorders have a small but significant recurrent rate

pre-term labour
SGA
IUGR
still-birth
ante & post partum haemorrhage
pre-eclampsia
gestational diabetes
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5
Q

What are the sections of an antenatal examination?

A

General Health and Nutritional status

  • BMI
  • BP

Abdominal Exam (not much use before third trimester)

  • Once uterus is palpable around 12 weeks, FHR can be auscultated

Routine vagina examination and clinical assessment of pelvic capacity

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6
Q

When during pregnancy is an USS scan done? What is it for?

A

between 11 & 13+6 weeks

  1. dating using crown-rump length if less than 14 weeks unless IVF
  2. detects multiple pregnancies
  3. screening for chromosomal abnormalities
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7
Q

What are the routine booking investigations?

A

Urine culture

FBC - pre-existing anaemia

Antibody Screen - anti-d

Serological tests for syphilis

Rubella immunoglobulin G

USS

Screening for chromosomal abnormalities

Haemoglobin electrophoresis - sickle-cell, thalasaemia

HIV and Hep B OFFERED

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8
Q

Why is it impt to do a Urine MC&S?

A

Asymptomatic bateruria in pregnancy can lead to pyelonephritis

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9
Q

How long should Folic acid be taken for? what dose?

A

till 12 weeks

0.4mg/day

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10
Q

What groups of recommended to take Vit D and what dose?

A

BMI > 30
South Asian
Afro-carribean
Low-sunlight

10 micrograms/day

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11
Q

When would sex be contra-indicated in pregnancy?

A

1, placenta praevia

  1. membranes have ruptured
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12
Q

How can listeriosis be avoided?

A

Only drink pasteurized or UHT milk
avoid soft and blue cheese
avoid pate
uncooked or partially cooked food

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13
Q

What exercise is recommended for pregnant women?

A

swimming

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14
Q

What is the recommended sleeping position in pregnancy?

A

left lateral position

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15
Q

What are the components of the follow up antenatal appointments?

A

History Reviewed

Assess physical and mental health

BP

Urinanalysis (looking for protein, glucose, leucocytes and nitries)

Abdo examined - but presentation is variable and unimportant until 36 weeks

FHR

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16
Q

During the 16 week antenatal visit, what is assessed?

A

Chromosomal Abnormality and booking blood tests are reviewed

IF chromosomal abnorm test is missed a TRIPLE TEST is offered

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17
Q

During the 18-21 weeks antenatal visit, what is assessed?

A

Anomaly scan performed

Repeat
aranged of 32 weeks if the placenta is low

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18
Q

What is the use of the 25 week antenatal visit for?

A

For nulliparous women, to exclude early onset pre-eclampsia

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19
Q

During the 28 week antenatal visit, what is assessed?

A

Fundal height is measured

FBC and antibodies

glucose tolerance test

anti-D is given to rhesus-negative women

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20
Q

During the 36, 38 and 40 week antenatal visit, what is assessed?

A

Fundal height
Fetal Lie
Presentation

IF presentation is breech, a referral for external cephalic version

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21
Q

During the 41 week antenatal visit, what is assessed?

A

Fundal height is measured

Fetal Lie

Presentation

Membrane sweeping is offered

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22
Q

If someone who is pregnant presents with itching, what should be looked out for? What tests can be ordered?

A

Liver Pathology

sclerae for jaundice, LFTs, bile acids

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23
Q

While most likely benign, what are some conditions that can be looked out for in pregnancy when patient presents with Abdominal Pain?

A

Appendicitis

Pancreatitis

UTIs

Fibroids

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24
Q

While most likely to be heartburn, what can epigastric pain also be a presentation of?

A

Pre-eclampsia

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25
Q

What supplement can exarcerbate constipation?

A

Oral Iron

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26
Q

What is a treatment option for vaginitis?

A

Imidazole vaginal pessaries

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27
Q

What is the difference between a screening test and a diagnostic test?

A

screening test - For all women, a measurement of risk of a fetus being affected by a certain disorder

diagnostic test - test on high risk women to confirm/refute the diagnosis

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28
Q

What are methods of testing samples from CVS/Amnio?

A

FISH

Karyotyping

Micro-array CGH

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29
Q

What blood tests can be used to diagnose congenital abnormalities?

A

Alpha Fetoprotein - neural tube defects

Beta -HCG

Pregnancy - associated plasma protein A (PAPP-A)

Oestriol

Inhibin A

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30
Q

When is a USS used to identify congenital abnorm? What is measured?

A

1st during 11-14 weeks to measure nuchal translucency
with the combined blood test
(larger the gap the higher the risk of abnormalities)

2nd scan 18-20 weeks for structural abnormalities

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31
Q

What can amniocentesis used for? When can it be done? What risk is associated?

A

Can pick up chromosomal abnorm, CMV, toxoplasmosis, sickle-cell, thallassaemia and CF

> 15 weeks

1% risk of misscarriage

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32
Q

What is CVS? when is it done? What is the disadvantage compared to amniocentesis?

A

Chorionic Villus Sampling, biopsy of trophoblast through abdo wall/cervix

> 11 weeks, which is within the abortion period

higher miscarriage rate than amniocentesis

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33
Q

What are the differences between exomphalos vs gastroschisis?

A

exomphalos - hole in belly button
- intestines covered by protective sac

gastrochisis - hole next to belly button
- intestines not covered by protective sac

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34
Q

What is the detection rate?

A

proportion of affected individuals who will be indentified by the screening test

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35
Q

What is a false positive?

A

proportion of unaffected individuals that show up as higher risk/screen +ve

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36
Q

What is a flase -ve?

A

proportion of affected individuals that show up as low risk/screen -ve

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37
Q

What are the similarities between Edward’s and Patau’s? which chromosomes are affected in each?

A

incidence of both increase with maternal age
most will die antenatally, still born or shortly after birth

Edward’s - trisomy 18

Patau’s - trisomy 13

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38
Q

What is the screening test for T21, T18, T13?

A

The combined test - nuchal transparency and serum testing (PAPP-A & beta- hCG)

nuchal transparency offered if crown-rump length 45 - 84mm (11-14 wks)

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39
Q

What is the risk that qualifies you for a diagnostic test after undergoing combined trisomy test?

A

1 in 150, any less likely than this = low risk

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40
Q

What is offered if the combined test is not possible? (late booker, nuchal transparency not obtained)

A

Quadruple test

head circ. 101mm - 173mm (14-20 wks)

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41
Q

What does the quadruple test contain?

A

AFP

beta-hCG

Oestriol

inhibin A

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42
Q

What other information is taken into account for the quadruple test?

A

scan movements

mother’s D.o.b.

ethnicity

smoking

diabetes

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43
Q

If the combined or quadruple test comes up as positive, what are the diagnostic tests possible?

A

CVS or amniocentesis

non-invasive prenatal testing in private

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44
Q

What is the use of an early USS?

A
  1. gestational age
  2. mult pregnancies
  3. anencephaly
  4. exomphalus
  5. increased nuchal transparency
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45
Q

What is the use of an mid USS?

A
  1. major abnormality
  2. conditions that may benefit from antenatal treatment
  3. optimise postnatal treatment
  4. termination
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46
Q

What are the main infectious diseases being scanned for in pregnancy?

A

HIV

Hep B

Syphilis

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47
Q

When would you screen for haemoglobinopathies? What would you be screening for?

A

recommended at 8-10 weeks

sickle cell
thalassaemias

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48
Q

From an USS, what would present as risk factors for Down’s?

A

Thickened nuchal translucency

Some structural abnormalities

absent or shortened nasal bone

tricuspid regurg

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49
Q

From a blood test, what would present as risk factors for Down’s?

A

1st trimester - LOW PAPP-A

1st/2nd trimester - HIGH beta hCG
LOW AFP

2nd trimester - LOW oestriol
HIGH inhibin

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50
Q

What are the components being screened in the NEWBORN HEEL PRICK TEST?

A

Sickle Cell
Cystic Fibrosis
Congenital Hypothyroidism

Phenylketonuria
MCADD
Maple Syrup disease
Isovaleric Acidaemia
Glutaric Aciduria
Homocystinuria
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51
Q

What are the components of the Newborn & Infant Physical Exam (NIPE)

A 
Gen. Physical Exam
Eye Problems
Congenital Heart Defects
Dysphasia of the Hips
Undescended testes
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52
Q

What are the fetal consequences of a CMV infection?

A

Symptomatic -IUGR, Pneumonia and Thrombocytopenia

Asymptomatic - risk of deafness

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53
Q

How is a CMV infection diagnosed and managed?

A

CMV IgM remains positive long time after infections, there AMNIOCENTESIS will confirm/refute vertical transmission

there is no prenatal treatment or vaccine
termination is offered

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54
Q

How would you diagnose and manage a Herpes Simplex infection?

A

Clinically clear in other

referall to GU clinic, caesarean recommended

mother given daily acyclovir in late pregnancy

if infant exposed, given acyclovir as well

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55
Q

What are the fetal consequences of a rubella infection? how can it be managed?

A

deafness, cardiac disease, eye problems and retardation?

termination offered if mother is infected before 16 weeks

vaccine is live and therefore contraindicated

56
Q

What is the organism responsible for toxoplasmosis?

A

Toxoplasma Gondii

57
Q

How is toxoplasmosis diagnosed and managed?

A

USS - hydrocephalus sometimes, IgM —- amniocentesis to confirm

Spiramycin as soon as mother is diagnosed

58
Q

What are the risks involved with Herpes Zoster infection in pregnancy?

A

Chicken Pox has severe maternal consequences in pregnancy

Teratogenicity

59
Q

What is management of a Herpes Zoster Infection?

A

Immunoglobulin for prevention esp in women who aren’t immunised

Aciclovir for treatment

If neonate is delivered 5 days after/ 2 days before maternal infection - prophylactic immunoglobulin and then acyclovir if infected

60
Q

How does Parvovirus present?

A

‘slapped cheek’ + arthralgia but can be asymptomatic

in neonates - anaemia, thrombocytopenia, fetal death 10%

61
Q

How would you diagnose Parvovirus?

A

+ve maternal IgM

Anaemia and oedema detectable on USS

62
Q

How does group B strep present in mother’s?

A

aymptomatically

63
Q

What situations are risk factors for vertical transmission of group b strep? What can be done to prvent this?

A

Infected normally during labour after membranes ruptured

Pre-term labours
Prolonged labours
Maternal fevers

IV penicillin

64
Q

Which individuals are at risk for group b strep infection?

A

previous infected neonate

+ve urine culture

preterm labour

rupture of the membranes >18hrs

Maternal fever during labour

65
Q

How to prevent vertical transmission of group b strep?

A

anal and vaginal cultures at 35-37 wks
Urine culture
Infant previously affected

if any of the above are positive IV high dose penicillin given

66
Q

What is group A strep responsible for?

A

Puerperal sepsis

most common cause of maternal death

67
Q

how doe group A strep present?

A

most common symptom is sore throat

chorioamnionitis with abdo pain, diarrhoea and severe sepsis

infected fetus usually dies and labour will ensue

68
Q

how to manage group A strep?

A

Early recognition

Culture

High dose Abx

69
Q

Whats the percentage of infants that become chronic carriers of Hepatitis B?

A

90%

70
Q

How would you reduce the risk of HIV vertical transmission? Would this be the same in poorer countries?

A

Maternal antiretroviral
Caesarean Section
No breastfeeding
Neonatal Antiretroviral

In poorer countries, nevirapine in labour and to neonate, as it will be vaginal delivery

breast feeding still advised for 6 months with antiviral

71
Q

How can antiretrovirals affect pregnancy?

A

Not teratogenic but are folic acid antagonists

72
Q

What are risk factors for pre-eclampsia?

A 
young female
blacks
multifetal pregnancies
hypertension
rena disease
collagen vasc. disease
73
Q

What are the 4 forms of hypertension in pregnancy?

A

gestational

pre-eclampsia -eclampsia

chronic hypertension

pre-eclampsia superimposed upon chronic htn/renal disease

74
Q

How would you define chronic HTN?

A

Diagnosed before pregnancy

Present during pregnancy and not resolved postpartum

75
Q

How would you define gestational HTN?

A

Starts after 20 wks gestation
>140/90
no or little proteinuria

76
Q

How would you define pre-eclampsia?

How would you class mild, moderate and severe?

A

after 20th week

Increased BP (>140/90) + proteinuria (0.3g/24hr/>2 on urine dipstick)

mild - proteinuria and mild to mod htn (140/90 -149/99) (150/100 - 159/109)

mod - proteinuria and severe htn (160/110+) with no maternal complications

severe - proteinuria & any hypertension <34 weeks/ with maternal complications

77
Q

What is Eclampsia?

A

Pre-eclampsia + generalised tonic-clonic

78
Q

What is pathophysiology behind pre-eclampsia?

A

Incomplete trophoblastic invasion of spiral arterioles. results in decreased uteroplacental blood flow

this causes an ischaemic placenta via exaggerated maternal inflammation response —– widespread endothelial damage

causing

  1. vasocontriction
  2. increased vascular permeability
  3. clotting dysfunction
79
Q

How would you pre-eclampsia present?

A

headache, drowsiness, visual disturbances, nausea/vomiting or epigastric pain

80
Q

What are the complications of pre-eclampsia?

A

Eclampsia

Cerebrovascular Hemorrhage

Liver and Coagulation problems - HELLP (hemolysis, elevated liver enzymes and low platelet count)

DIC

Liver Failure

Liver Rupture

Renal Failure

Pulmonary Oedema

81
Q

What is the most common fetal associated problem with pre-eclampsia?

A

IUGR

82
Q

What can be given to reduce the risk of pre-eclampsia?when?

A

low-dose aspirin before 16 weeks

83
Q

On admission with pre-eclampsia? What medications can be given?

A

labetalol

magnesium sulphate (increases cerebral perfusion)

Steroids (for fetal development)

84
Q

Why is the presence of proteinuria impt?

A

One or more fetal or maternal complications are likely to occur within 2 weeks of proteinuria onset

85
Q

When should delivery be if mother has

I) gestational htn?

ii) mild pre eclampsia
iii) moderate - severe pre eclampsia?
iv) severe with complications?

A

i) without fetal compromise - induction by 40 weeks?
ii) 37 weeks

iii) 34-36 weeks
if less than 34 weeks - conservative specialist unit, weigh up the maternal vs fetal risks - give steroids, CTG and fluid balance

iv) requires delivery - less than 34 weeks (C-section)
- more than 34 weeks (labour induced with prostaglandins)

86
Q

Why is oxytocin preferred to ergometrine in the 3rd stage of pregnancy?

A

ergometrine caused increased BP

87
Q

What should be monitored post natally for 24hrs? why?

A

Delivery cures pre-eclampsia but only after 24 hrs

monitor LFTs. platelets and renal function

fluid balance

blood pressure - maintain around 140/90mmHg with beta -blocker

88
Q

How would you confirm diagnosis of pre-eclampsia?

A

MSU and urine protein measurement (PCR or 24-h collection)

89
Q

What are the consequences of diabetes on the fetus? How do these changes occur?

A

Macrosomia

raised fetal blood glucose levels leads to fetal hyperinsulinaemia

This leads to fat deposition and excessive growth

90
Q

What are the differences between the NICE definition for gestational diabetes and the Internal Consensus?

A

NICE : Fasting glucose > 7.0mmol/L
after 2 hrs, 75g glucose load >7.8 mmol/L

International Consensus : fasting > 5.1mmol
1 hr after 75g glucose load > 10.0mmol

2 hrs after…. : >8.5 mmol/L

91
Q

What are some fetal complications of gestational diabetes?

A

Congenital Abnormalities

Preterm labour

Decreased fetal lung maturity

Increased body weight due to increased urine output
and polyhydramnios

Dystocia and birth trauma more common

Fetal compromise, distress and sudden death

92
Q

What are some maternal complications of diabetes?

A

Hypoglycaemia

UTIs

wound or endometrial infection after delivery

pre-eclampsia more common

IHD worsens

Diabetic retinopathy often deteriorates

93
Q

How would monitoring differ in a woman with diabetes?

A

Visits fortnightly up to 34 weeks

then weekly thereafter

glucose levels checked by patient before and after food - levels ideally should be below 6mmol/L

In addition to usual scans - fetal echo, USS for fetal growth and liquor volume, renal function, retinae screen

94
Q

How would management differ in a woman with diabetes?

A

In type 2 - may need addition of insulin on top of usual medication

careful diet + one night-time-long/intermediate acting + 3 preprandial short-acting insulin injections

doses of regular medication may increase with pregnancy

glucagon prescribed in case of hypoglycaemia

75mg Aspirin daily from 12 weeks to reduce risk of pre-eclampsia

95
Q

When should delivery be for women with diabetes? when is a C-section indicated? how is medication managed during labour?

A

by 39 weeks

C-section indicated where estimated fetal weight is >4kg

during labour glucose levels maintained with ‘sliding scale’ or insulin and dextrose infusion

96
Q

What complications can arise with a neonate from a diabetic mother?

A

hypoglycaemia
respiratory distress syndrome occasionally occurs even if older than 38 weeks

breast feeding is advised

97
Q

What pre-existing risk factors can be used to screen for gestational diabetes?

A

previous largebaby
explained still birth

first degree relative w/ diabetes

BMI > 30

south asia, black, middle eastern

PCOS

*all of above would indicate 28 week GTT

98
Q

What pregnancy risk factors can be used to screen for gestational diabetes?

A

polyhydramnios

persistent glycosuria

99
Q

What would management for gestational diabetes be?

A

diet advice + glucose monitoring @ home

metformin (will be under control for 60%)
insulin

100
Q

What changes on the cardiovascular system happens during pregnancy?

A

40% increase in cardiac output
40% increase in blood volume
50% decrease in systemic vascular resistance

101
Q

What kind of murmur is present in 90% in pregnant women? Why?

A

Ejection Systemic Murmur caused by increased blood flow

102
Q

What are some cardio specific medications contra-indicated during pregnancy?

A

Warfarin

ACE-I

103
Q

Should thromboprophylaxis be continues during pregnancy? what should be used?

A

LMWH

104
Q

During labour, what steps should be taken for a mother who has cardiac pathology?

A

Fluid balance checked

Elective epidural analgesia reduced afterload

Elective Forceps (reduced stress of pushing)

Abx recommended against endocarditis

105
Q

Out of PDA, VSD, ASD and Pulm. Hypertension, which is contra-indicated for pregnancy?

A

Pulmonary Hypertension

106
Q

What is peripartum cardiomyopathy? What are the consequences ? how is it treated?

A

Cause of HF in pregnancy

Occurs in either last month of pregnancy or first 6 months AFTER

causes 15% mortality , mostly due to left ventricular dysfunction

Treated with diuretics and ACE-I

107
Q

What changes does pregnancy have on the respiratory system?

A

40% increase in tidal volume, while no change in resp rate

Asthma common in pregnancy

108
Q

Why do women on long-term steroids require an increase dose during pregnancy?

A

Adrenal cortex is chronically supressed

109
Q

What are some major issues pertaining to mothers that have epilepsy and are pregnant?

A

Seizure control can decrease in pregnancy

Epilepsy is a major causes maternal death, therefore anti-epileptics are continued

However, anti-epileptics cause a risk of congenital abnormalities which is dose-dependent

110
Q

What is management plan for pregnant women with epilepsy? What drugs are safe?

A

To achieve seizure control with the least amount of drugs at the lowest dosage

Folic Acid

Ideally avoid Sodium Valproate

Carbamazepine and Lamotrignine are safest

111
Q

What risks are associated with sodium valproate during pregnancy?

A

Congenital Malformation

Reduced IQ

Autism risk

112
Q

What is the biggest risk of untreated hypothyroid and hyperthyroid during pregnancy?

A

High Perinatal Mortality

113
Q

What is the treatment for hypothyroid during pregnancy?

A

Thyroxine + TSH monitoring every 6 weeks

114
Q

What is the treatment for hyperyroid during pregnancy? What fetal risk is associated with this treated?

A

PROPHYLTHIOURACIL (PTU) - can cross placenta and cause fetal hypothyroid

115
Q

What is characteristic of Intrahepatic Cholestatis of pregnancy? What causes it?

A

Itching without skin rash but abnormal LFTs

Caused by abnormal sensitivity to cholestatic effects of oestrogens

116
Q

What risks are associated with intrahepatic cholestatis of pregnancy?

A

Increase risk of stillbirth and preterm

117
Q

What is treatment of intrahepatic cholestatis of pregnancy?

A

Vit K 10mg/day for 36 weeks
Ursodeoxycholic Acid relieves itching

Induction of labour around 38 weeks is advised

118
Q

What is characteristic of Antiphospholipid syndrome?

A

Lupus anti-coagulant and/or anti-cardiolipin antibodies in association with adverse pregnancy complications

119
Q

What presentations are common in antiphospholipid syndrome?

A

reccurent miscarriage + IUGR + early pre-eclampsia

caused by placental thrombosis

120
Q

How would you treat antiphospholipid syndrome?

A

Aspirin + LMWH
USS and elective induction by term

Postnatal anticoagulation recommended to prevent VTE

121
Q

What is the clinical criteria of antiphospholipid syndrome?

A

vascular thrombosis

1+ fetus death >10 weeks

Pre-eclampsia or IUGR requiring delivery <34 wks

3+ fetal losses <10 weeks otherwise unexplained

122
Q

What changes does pregnancy have on the renal system?

A

glomerular filtration rate increases by 40% this causes a decrease in urea and creatinine levels

123
Q

What complications can renal disease cause during pregnancy?

A

pre-eclampsia
IUGR
polyhydramnios
pre-term

124
Q

What are risk factors make pregnant women prone to thromboses?

A

inherited prothrombotic conditions
family hx
personal hx

125
Q

How would VTE be treated during pregnancy?

A

subcut LMWH - if poss treatment stopped shortly before labour
but restarted after

126
Q

What would factors would qualify a women as HIGH VTE risk?

A

previous VTE - 6 weeks of LMWH

127
Q

What would factors would qualify a women as INTERMEDIATE VTE risk?

A

thrombophilia, c-sect, BMI > 40, prolonged hosp stay, IV drug abuser

1 week LMWH if 1+

128
Q

What would factors would qualify a women as MOD VTE risk?

A 
BMI > 30
> 35 y/o or parity >/3
smoker
varicose veins
pre-eclampsia
immobility
PPH
labour > 24 hrs

1 week LMWH if 2+

129
Q

Maternal risks of obesity during pregnancy

A

VTE

pre-eclampsia

diabetes

wound infections

PPH

Maternal death

130
Q

Management of obese preg ladies?

A

high dose preconceptual folic acid

vit D

weight MAINTAINED

screen gest diabetes

131
Q

What is red blood cell isoimmunisation?

A

When mother mounts an immune response against antigens on fetal red cells that enter her circulation

The resulting antibodies then cross the placenta and cause fetal red blood cell destruction

132
Q

In terms of D rhesus when would red blood cell isoimmuniation occur?

A

if small of amount of fetal blood from a baby that is D rhesus +ve, enters a mother who’s D rhesus -ve blood, there will be an immune response, producing anti-D antibodies

133
Q

What are some potential sensitizing events?

A

termination

evacuation of retained products of contraception

ectopic pregnancy

vaginal bleeding

invasive procedure (amniocentesis or CVS)

intrauterine death

delivery

134
Q

When is anti-D given and at what dose?

A

1500IU anti-D given to all women who are rhesus -ve @ 28 wks

also to same women within 72 hrs of sensitising event

135
Q

What is the Kleihauer test?

A

Postnatal test to assess the number of fetal cells in the maternal circulation.

performed 2 h after birth to detect occasional larger fetomaternal haemorrhage that require larger doses of anti-D to ‘mop-up’

136
Q

What complications can arise from red blood cell isoimmunisation?

A

mild - neonatal jaundice or neonatal anaemia

moderate - in utero anaemia (cardiac failure, ascites, oedema and fetal death)

137
Q

How would you assess fetal anaemia and subsequently treat it?

A

Assessed using USS fortnightly

transfuse if fetus anemic and deliver is more than 36 weeks

all neonates born to rhesus-negative women - FBC, blood film and bilirubin

Obstetrics (5 decks)

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