Antenatal Care & Maternal Medicine Flashcards
When is the “dating scan”?
8-14 weeks
ideally 10-14 weeks to T21 screening can be offered
When is the usual window for the booking appointment?
8-12 weeks
When is the best time for pregnant people to have the whooping cough vaccine?
after the anomaly scan and before 32 weeks gestation
When is the “anomaly scan”?
18-20 weeks
often called the 20 week scan
People who are pregnant for the first time will be offered extra midwife appointments, when are these?
25 weeks
31 weeks
40 weeks
When is the first anti-D treatment offered for Rhesus negative pregnant people?
28 weeks
At what weeks will people usually have routine antenatal check ups with a midwife or doctor?
8-12 weeks - booking 16 weeks 28 weeks 34 weeks 36 weeks 38 weeks 41 weeks 42 weeks
Which three infectious diseases are recommended to be screened for in pregnancy?
HepB
HIV
Syphilis
What does the “20 week scan” look for?
looks in detail at baby’s bones, heart, brain, spinal cord, face, kidneys and abdomen to assess for 11 rare conditions:
- anencephaly
- open spina bifida
- cleft lip
- diaphragmatic hernia
- gastroschisis
- exomphalos
- serious cardiac abnormalities
- bilateral renal agenesis
- lethal skeletal dysplasia
- Edwards (T18)
- Patau (T13)
What is the combined screening test in pregnancy?
- screening for T13, 18, 21
- a combination of blood test and USS to determine nuchal translucency
- can happen between 10 weeks and 14 weeks
- not diagnostic, just estimates risk: results are lower chance or higher chance
If someone gets a “higher chance” result from the combined screening test, what are their options for further testing?
diagnostic tests:
- amniocentesis (15+ weeks)
- chorionic villus sampling (11-14 weeks)
further risk assessment:
- non-invasive prenatal testing (NIPT) blood test to determine risk more accurately
When should screening for sickle cell and thalassaemia take place in pregnancy?
- ideally before 10 weeks
If screening shows there is a chance a pregnancy could have sickle cell or thalassaemia, what are the options for further tests?
diagnostic tests:
- amniocentesis (15+ weeks)
- chorionic villus sampling (11-14 weeks)
What is the purpose of the dating scan?
- check how many weeks pregnant the individual is and work out the EDD
- determine if this is a multiple pregnancy
- check the pregnancy is in the uterus
- check the pregnancy’s development
What are the recommendations about using supplements in pregnancy?
- anyone who is pregnant or thinks there’s a chance they could be pregnant should take 400micrograms of folic acid every day from before conception to 12 weeks gestation to reduce the chance of neural tube defects
- pregnant people should also take a daily vitamin D supplement
- they should avoid supplements containing cod liver oil or vitamin A (retinol)
Who should take higher-dose folic acid?
Anyone who’s pregnancy has a higher chance of being affected by neural tube defects, e.g.
- mum or dad have a neural tube defect
- mum or dad have a family history of neural tube defects
- mum had a previous pregnancy affected by a neural tube defect
- mum has diabetes
- mum takes anti-epilepsy medicine
- mum takes anti-retroviral medicine for HIV
What are the two doses of folic acid recommended in pregnancy?
- 400micrograms if low risk for neural tube defects
- 5mg if higher risk
What is the Healthy Start scheme?
If you’re pregnant or have children under the age of 4 you can get free vouchers or payments every 4 weeks to spend on:
- cow’s milk
- fresh, frozen or tinned fruit and vegetables
- infant formula milk
- fresh, dried, and tinned pulses
You can also get free Healthy Start vitamins
When do foetal movements start?
around 20 weeks and continue until birth
What lifestyle advice should be given to pregnant people?
Avoid:
- alcohol (risk of miscarriage, small for dates, preterm delivery, foetal alcohol syndrome)
- smoking (many risks)
- unpasteurised dairy (risk of listeriosis)
- undercooked or raw poultry (risk of salmonella)
- contact sports
- live vaccines
Safe:
- sex
- moderate exercise
Be aware:
- flying increases risk of VTE, most airlines need note from a medical professional after 28 weeks
- seatbelts should go above or below bump, not across
What are the risks associated with smoking in pregnancy?
- FGR
- miscarriage
- stillbirth
- preterm labour and delivery
- placental abruption
- pre-eclampsia
- cleft lip or palate
- SIDS
What are the features of foetal alcohol syndrome?
- microcephaly
- thin upper lip
- smooth flat philtrum
- short palpebral fissure
- learning disability
- behavioural difficulties
- hearing and vision problems
- cerebral palsy
What risks are associated with underrated hypothyroidism in pregnancy?
- miscarriage
- anaemia
- small for gestational age
- pre-eclampsia
How should hypothyroidism be treated in pregnancy?
- titrate levothyroxine to achieve a low-normal TSH
- dose usually needs to be increased 25-50mcg compared to pre-pregnancy requirement
- levothyroxine does cross the placenta
How should existing hypertension be managed in pregnancy?
- stop teratogenics: ACEi, ARB, thiazides
- use labetalol, calcium channel blockers, alpha blockers instead
How should epilepsy be managed in pregnancy?
- ideally achieve symptom control using a pregnancy-safe single therapy before conception (levetiracetam, lamotrigine, carbamazepine)
- advise that seizure control may worsen during pregnancy but that seizures in themselves are not harmful to baby
- avoid sodium valproate (neural tube defects and developmental delay) and phenytoin (cleft lip and palate)
How should rheumatoid arthritis be managed in pregnancy?
- ideally achieve good symptom control for three months before conception
- avoid methotrexate (miscarriage and congenital abnormality)
- hydroxychloroquine is safe and first-line in pregnancy, sulfasalazine is also considered safe
- steroids can be used during flare ups
- advise that sx are likely to improve during pregnancy and flare after delivery
Prescribing in pregnancy: NSAIDs
Ok to use?
- generally avoid unless absolutely necessary
- use in third trimester can cause premature closure of the ductus arteriosis
- they’re use can also delay labour
Prescribing in pregnancy: beta blockers
Ok to use?
- labetalol is most commonly used in pregnancy
- can cause foetal growth restriction, hypoglycaemia and bradycardia in the neonate
- risks of pre-eclampsia outweigh risks of medication
Prescribing in pregnancy: ACEi and ARBs
Ok to use?
- avoid
- risks of oligohydramnios, neonatal renal failure and miscarriage/foetal death
Prescribing in pregnancy: opiates
Ok to use?
- can be used
- can result in withdrawal sx in the neonate: neonatal abstinence syndrome (NAS)
- NAS presents 3-72 hours after birth with irritability, tachypnoea, fever and poor feeding
Prescribing in pregnancy: warfarin
Ok to use?
- avoid
- teratogenic: risk of foetal loss, congenital malformations, bleeding during pregnancy
Prescribing in pregnancy: sodium valproate
Ok to use?
- avoid
- teratogenic: neural tube defects and developmental delay
Prescribing in pregnancy: lithium
Ok to use?
- can be used as a last resort in the second or third trimester
- first trimester use is associated with congenital cardiac abnormalities including Ebsteins anomaly
- need levels monitored regularly
- cannot be used in breastfeeding as it is toxic to the infant
Prescribing in pregnancy: SSRIs
Ok to use?
- the most commonly used antidepressants in pregnancy
- risk/benefit assessment should be made
- risks:
- – first trimester: congenital heart defects (especially paroxetine)
- – third trimester: persistent pulmonary hypertension in the neonate, neonates can experience withdrawal symptoms
Prescribing in pregnancy: isotretinoin
Ok to use?
- avoid
- highly teratogenic: miscarriage and congenital defects
Prescribing in pregnancy: chlorphenamine
Ok to use?
- safe but limit use, especially in third trimester
Prescribing in pregnancy: paracetamol
Ok to use?
safe
Prescribing in pregnancy: laxatives
Ok to use?
- mainly ok
- advise increasing water and fibre in the first instance
- if needing medication favour lactulose, Senna or bulk forming laxatives
Prescribing in pregnancy: antacids
Ok to use?
safe expect sodium bicarbonate
Prescribing in pregnancy: PPIs
Ok to use?
safe
What is pre-eclampsia?
triad of: - proteinuria - hypertension - oedema after 20 weeks gestation
What causes pre-eclampsia?
abnormal spiral arteries of the placenta causing high vascular resistance
What is chronic hypertension in pregnancy?
- high BP
- that pre-exists pregnancy
What is pregnancy-induced hypertension or gestational hypertension?
- new, high BP
- after 20 weeks gestation
- without proteinuria
What is eclampsia?
seizures resulting from pre-eclampsia
What are the risk factors for pre-eclampsia?
High:
- pre-existing HTN
- previous HTN in pregnancy
- AI conditions
- diabetes
- CKD
Moderate:
- age >40
- BMI >35
- more then 10 years since previous pregnancy
- multiple pregnancy
- first pregnancy
- FH of pre-eclampsia
What are the risk factors for pre-eclampsia used to determine?
- whether a pregnant person should be offered prophylactic aspirin from 12 weeks gestation until birth to prevent pre-eclampsia
- it should be offered if 1 high risk factor or multiple moderate risk factors
What are the symptoms of pre-eclampsia?
- headache
- visual disturbance
- nausea and vomiting
- epigastric pain
- oedema
- reduced UO
- brisk reflexes
What is the management for eclampsia seizures?
IV magnesium sulphate
What is HELLP syndrome?
- a combination of features that occur as a complication of pre-eclampsia and eclampsia
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
What are the complications of gestational diabetes?
- large for dates foetus
- macrosomic baby (risk of shoulder dystocia)
- long term higher risk of T2DM for mum
What are the risk factors for GDM?
- previous GDM
- previous macrocosmic baby (>4.5kg BW)
- BMI >30
- not Caucasian
- FH of diabetes in a first-degree relative
Who should be screened for GDM?
anyone with risk factors
How does one screen for GDM?
- OGTT at 24-38 weeks
- fasting glucose >5.6 or glucose at +2 hours >7.8 is diagnostic for GDM
What is the management of GDM?
Fasting glucose:
<7 - diet/exercise, then metformin, then insulin
>7 - insulin +/- metformin
>6 with complications - insulin +/- metformin
How is existing T2DM managed in pregnancy?
- metformin and insulin
- stop all other OHA and injectables
- aim for same sugars as GDM
