Antenatal care for uncomplicated pregnancies, including screening+diagnosis Flashcards
What do NICE recommend in relation to Vit D for pregnant mothers?
all women at booking appointment should be told of importance of maintaining adequate vit D stores during pregnancy for themselves and baby, which can be achieved with 10 micrograms per day as found in the Healthy Start multivitamin supplement.
ensure those at greatest risk are taking this supplement e.g. women of south asian, african, caribbean or middle eastern family origin, those with limited exposure to sunlight, those with diet low in meat, eggs, oily fish so low vit D intake from diet, and those with BMI more than 30 pre-pregnancy.
when should the booking appointment take place?
by 10 weeks of pregnancy, usually happens between 8 and 12 weeks, important to be this early in order to arrange screening tests-those for sickle cell and thalassaemia should be before 10 weeks.
what is mean by the ‘combined test’ for Downs screening, and when should this be done?
nuchal translucency, beta-hCG and PAPPA-pregnancy assoc. plasma protein A
to be performed between 11+0 and 13+6 weeks of gestation.
which women should be offered testing for gestational diabetes after their booking appointment?
those with any 1 of the following RFs:
BMI more than 30
gestational diabetes in previous pregnancy
previous macrosomic baby 4.5kg or greater
FH of DM (1st degree relative)
family origin with high prevalence of diabetes-south asian, black caribbean, middle eastern.
what is recommended pre-conceptually for those women planning a pregnancy?
folic acid 400 micrograms daily to reduce risk of neural tube defects (plus throughout 1st 12 weeks)
advice regarding what care will be offered during a pregnancy-all antenatal screening including risks, benefits and limitations-information should be given as soon as possible when pt 1st presents to healthcare professional
food hygience and lifestyle advice
diabetic eye screening for those with DM-offer when 1st present for care.
what antenatal care tests and checks should be offered at the booking appointment (ideally by 10wks)?
- offer blood tests-sickle cell and thalassaemia to be done before 10 weeks. offer to check blood for Hb, group, rhesus and antibodies as early as possilbe. blood for syphilis, HIV, Hep B and rubella susceptibility as early as possible, or at any stage of the pregnancy.
- height, weight BMI
- BP and urine for proteinuria
- identify those that may need additional care and plan accordingly
- offer screening for asymptomatic bacteriuria
- determine RFs for gestational diabetes and pre-eclampsia
- advise those under 25yrs about high prevalence of chlamydia in this age group and give details of their local National Chlamydia Screening Programme.
- identify women who have had genital mutilation
- ask about mental illness or psych tment
- ask about mood
- ask about occupation
- offer Downs screening
- offer early US scan for gestational age assessment and screening for structural anomalies.
role of the early pregnancy ultrasound scan/dating scan (between 10 weeks and 13+6)?
confirm the pregnancy
gestational age-crown rump length, do head circumference if crown rump length more than 84mm.
EDD
number of gestation
viability of the pregnancy (is baby growing in the right place), and structural anomalies e.g. neural tube defects like spina bifida.
can also screen for Downs during this scan by looking at nuchal translucency IF has already been agreed for screening to take place and dating scan is occurring between 11 and 13+6 wks gestation.
when is an US scan for Downs screening to look at nuchal translucency able to be performed?
when the crown rump length is between 45 and 84mm
nuchal translucency is only visible between 11 and 13+6 weeks of gestation.
what is nuchal translucency?
refers to a collection of fluid at the back of the neck of the fetus, the size of this fluid collection denotes risk of chromosomal and other abnormalities.
when is the fetal anomaly scan performed?
between 18 and 20+6 weeks gestation
if mother’s placenta extends across internal os then offer another US at 32wks.
what happens in terms of downs screening if dating scan is performed after 14 weeks gestation?
unable to test nuchal translucency and so can’t do combination test
instead another blood test offered between 15 and 20 wks=quadruple test=beta-hCG, inhibin A, alpha fetoprotein and unconjugated oestriol.
what problems are being looked for specifically when performing the fetal anomaly scan?
anencephaly (98% chance of being seen)-die soon after birth open spina bifida (90% chance of being seen) cleft lip (75% chance of being seen) diaphragmatic hernia (60% chance of being seen) gastroschisis (98% chance of being seen)-hole in wall of baby's tummy to 1 side of umbilical cord so some of their bowel can escape through this hole onto the outside of the body and develop here. exomphalos (omphalocele) (80% chance of being seen)-tummy fails to close around the base of the umbilical cord so some organs develop on outside of baby's tummy. serious cardiac abnormalities (50% chance of being seen) bilateral renal agenesis (84% chance of being seen)-die soon after birth lethal skeletal dysplasia-baby won't survive as chest and lungs do not fully develop (60% chance of being seen) edward's syndrome (trisomy 18) (95% chance of being seen) patau's syndrome (trisomy 13) (95% chance of being seen)
things to explain in terms of what is likes to have a fetal anomaly scan?
usually takes around 30min, may take longer if difficult to see baby as in an awkward position or moving around a lot
recommend you bring someone with you who should accompany you to and from the hospital
doctor or midwife before appointment will let you know if full bladder required
room will be dimly lit to get best view of baby, will have to lie down on couch and lift up top and lower trousers/skirt, gel will be applied so that there is good contact between machine and your skin, probe used which emits ultrasound, may be slight pressure
considerations to explain to parents before a fetal anomaly scan with regards to the detection of abnormalities
in most cases, baby is healthy and will develop normally
some problems are obvious from the scan and we can tell you what these are, others are more difficult to detect, therefore baby may be born with an abnormality we didn’t see on the scan
if an abnormality is found a 2nd opinion may be needed, may require further tests to confirm a problem, if there is a definite problem this may just mean further scans to monitor the pregnancy as may get better on its own or may not be serious. if serious, 1 option may be terminate the pregnancy, support and advice on this will be readily available. finding a problem can help to plan treatment after birth e.g. surgery, by ensuring baby born in a hospital where there is ready access to this.
when is blood test for Hb and antibodies repeated?
at 28 weeks gestation
checks and info to be given at 16 weeks?
discuss results of screening tests
check BP and urine for proteinuria
investigate a Hb below 11 and consider iron supplements
give info on fetal anomaly scan
what antenatal appointment is required next after fetal anomaly scan in women who are nulliparous?
check at 25 weeks:
BP and urine for proteinuria
measure and plot symphysis-fundal height
antenatal care offered at 28weeks?
BP and urine for proteinuria
bloods for Hb and antibodies
investigate a Hb less than 10.5 and consider iron supplementation
offer anti-D prophylaxis (500IU) for women who are rhesus-D negative
measure and plot symphysis-fundal height
OGTT if pt at risk
antenatal care at 31 weeks for nulliparous women?
discuss screening results from 28 weeks
BP and urine for proteinuria
measure and plot symphysis-fundal height
antenatal care at 34 weeks?
discuss screening results from 28 weeks
offer 2nd dose of anti-D prophylaxis (500IU) to those who are rhesus-D negative
BP and urine for proteinuria
measure and plot symphysis-fundal height
give advice on labour and birth including pain control, birth plan and recognising active labour
