Antenatal Care - Normal Pregnancy

Question 1

Which vitamin supplementations are recommended for pregnancy women?

Answer 1

Folic acid 400mg - before conception, until 12 weeks gestation
Vitamin D - during pregnancy and continued when breastfeeding

Question 2

Which groups of women should carry on taking folic acid after 12 weeks? How much should they take?

Answer 2

Diabetes
Anti-epileptic medications
BMI > 30
Previous neural tube defect in pregnancy
--> take 5mg daily from 12 weeks

Question 3

What are the risks of smoking in pregnancy?

Answer 3

Increased risk of:

• miscarriage
• pre term labour
• IUGR
• still birth
• SIDS (sudden infant death syndrome)

Question 4

What are the risks of drinking alcohol during pregnancy?

Answer 4

Foetal alcohol syndrome (FAS)
IUGR + postnatal restricted growth
Learning difficulties
Risk of miscarriage
Withdrawal
Wernicke's encephalopathy + Korsakoff's syndrome 
Microcephaly

Question 5

What are the features of FAS?

Answer 5

Learning + behavioural problems
Poor growth
Facial abnormalities:
- smooth philtrum
- thin vermillion
- small palpebral fissures

Question 6

When is the booking visit and who is it with?

Answer 6

At 10-12 weeks gestation (ideally - can be done up to 14 weeks)
With community midwife
(referred to obstetrician if any risk factors identified)

Question 7

What is done at the booking visit?

Answer 7

Detailed history
- medical
- drug
- social
- family 
- ethnicity (haemoglobinopathies)
- LMP
Obstetric history
Measure BP
Blood tests:
- blood group (Rh status)
- Hb levels
- haemoglobinopathies
- infections: HIV/AIDs, syphilis, hep B + C
- immunity against chicken pox, rubella etc
Dating scan

Question 8

What is the normal schedule for antenatal care in Scotland?

Answer 8

10 - 13+6 weeks (booking)
16 weeks
18-20 weeks
24 weeks
28 weeks
31-32 weeks (primiparous women)
34-36 weeks
38 weeks
40 weeks
41 weeks
42 weeks

Question 9

What happens at the 16 weeks appointment?

Answer 9

Discuss results from screening tests
BP + urine to check for protein
Information about anomaly scan

Question 10

What happens are the 18-20 weeks appointment?

Answer 10

Anomaly scan

offered to all - can decline

Question 11

What happens at the 24 weeks appointment?

Answer 11

Advice on antenatal classes
Discuss foetal movements
BP + urine check
Check symphyseal fundal height (SFH)
Foetal heart auscultation

Question 12

What happens at the 28 weeks appointment?

Answer 12

Discuss whooping cough vaccine (offered between 28-32 weeks)
Random glucose - gestational DM
Anti-D if rhesus negative

Question 13

What happens at the 34-36 weeks appointment?

Answer 13

Discuss labour + birth plan
BP, urine, SFH, foetal heart
Position + lie of baby

Question 14

What happens at the 40 weeks appointment?

Answer 14

Information on what will happen if pregnancy lasts more than 41 weeks –> induction

Question 15

How many antenatal appointments will uncomplicated nulliparous + multiparous women have?

Answer 15

Nulliparous –> 10
Multiparous –> 7

(with midwife)

Question 16

What additional monitoring is given to women with pre-existing or gestational DM?

Answer 16

Additional scans at money intervals between 28 + 36 weeks gestation
- monitor foetal growth + amniotic fluid volume as increased risk of stillbirth, congenital malformation + polyhydramnios

Question 17

Which conditions are screened for during the anomaly scan at 18-20 weeks?

Answer 17

Anencephaly
Open spina bifida
Cleft lip
Diaphragmatic hernia
Gastroschisis
Exomphalos
Cardiac anomalies e.g. TGA, ASD, VSD, TOP, HLHS
Bilateral renal agenesis
Lethal skeletal dysplasia
Edward's (trisomy 18)
Patau's (trisomy 13)

Question 18

How is Down syndrome screened for?

Answer 18

Combined test –> blood test + USS

Done at 11+0 and 13+6 weeks gestation

Question 19

What is the USS looking for in Down’s screening?

Answer 19

Nuchal thickness

Question 20

What is the blood test looking for in Down’s screening?

Answer 20

Triple test:

• PAPP-A
• alpha fetoprotein (aFP)
• beta-hCG

If foetus has Down syndrome –> PAPP-A + aFP is low, beta-hCG + nuchal thickness increased

Question 21

Why does exposure to rhesus antigen in an rhesus -ve mother cause problems for future pregnancies, rather than the current pregnancy?

Answer 21

When first exposed to rhesus antigen, mother forms IgM which is too big to cross the placenta
In future pregnancies, when exposure to same antigen on foetal RBCs, mother forms IgG (smaller and can cross placenta)
–> haemolytic disease of newborn

Question 22

What can be done in cases of suspected rhesus isoimmunisation and how does it work?

Answer 22

Anti-D can be given to Rhesus negative mothers who have been exposed
- removes rhesus positive RBCs from mother’s circulation before antibodies are formed

Question 23

When does anti-D have to given for maximal effect?

Answer 23

Within 72 hours of sensitising event or after birth

Question 24

Which situations would require anti-D?

Answer 24

Placental abruption
Abdominal trauma
Amniocentesis or chorionic villus sampling
External cephalic version
Intra-uterine surgery/transfusion
Foetal death
Vaginal bleeding from 12 weeks
Surgical management of miscarriage at < 12 weeks
Evacuation of retained products
Termination of pregnancy
Ectopic pregnancy
Delivery (if baby is rhesus positive)

Question 25

How is the anti-D dose calculated?

Answer 25

Kleinbauer test –> quantifies foetal RBCs in mother’s blood

Question 26

When is prophylactic anti-D given even if there has been no sensitising event?

Answer 26

at 28 weeks gestation in rhesus negative mothers