Antenatal Care: Pregnancy Timeline, Chronic Conditions in Pregnancy, Rhesus Flashcards
Define gestational age
The duration of the pregnancy starting from the date of the last menstrual period
Define gravida (G)
The TOTAL number of pregnancies a woman has had
Define primigravida
the patient is pregnant for the 1st time
Define multigravida
patient that is pregnant for at least the 2nd time
Define parity (P)
number of times the woman has given birth after 24 weeks gestation, regardless of whether the foetus was alive or stillborn
Define nulliparous
a patient that has never given birth after 24 weeks gestation
Define primiparous
a patient that has given birth after 24 weeks gestation once before
Define multiparous
a patient that has given birth after 24 weeks gestation two or more times
Multiparous vs multigravida
Multiparous refers only to pregnancies PAST 24 weeks
Give the G and P for a pregnant woman with three previous deliveries at term
G4 P3
Give the G and P for a non-pregnant woman with a previous birth of healthy twins
G1 P1
Give the G and P for a non-pregnant woman with a previous miscarriage
G1 P0 + 1
Give the G and P for a non-pregnant woman with a previous stillbirth (after 24 weeks gestation)
G1 P1
What is the 1st trimester?
From start of pregnancy to 12 weeks gestation
What is the 2nd trimester
From 13 weeks until 26 weeks
What is the 3rd trimester?
27 weeks - birth
When do foetal movements begin?
Around 20 weeks gestation
What are the 5 key appointments during pregnancy? When do they occur?
1) Booking clinic: 8 - 12 weeks but preferably before 10 weeks
2) Dating scan: between 10 and 13+6 weeks
3) Down’s syndrome screening: between 11 and 13+6 weeks
4) Antenatal appointment: 16 weeks
5) Anomaly scan: between 18 and 20+6
6) Antenatal appointments for routine care: 25, 28, 31, 34, 36, 38, 40, 41 and 42 weeks
When does the booking visit occur?
8-12 weeks (ideally <10 weeks)
What happens at the booking visit?
Offer baseline assessment and plan pregnancy:
1) General info e.g. diet, smoking, alcohol, folic acid, vit D, antenatal classes, vaccinations
2) Vitals; BP, urine dipstick, check BMI
3) Booking bloods/urine
a) FBC, rhesus status, red cell alloantibiodies, haemoglobinopathies
b) hep B, syphilis
c) HIV test offered
d) urine culture to detect asymptomatic bacteriuria
4) Risk assessment:
a) rhesus negative –> book anti-D prophylaxis
b) VTE –> provide prophylactic LMWH if high risk
c) pre-eclampsia –> provide aspirin if high risk
d) gestational diabetes –> book OGTT
e) foetal growth restriction –> book additional growth scans
5) Ensure woman has access to a midwife/care at the begninning and throughout 40 weeks and post-partum
When does the dating scan occur?
Between 10 and 13 + 6
Purpose of the dating scan?
1) Accurate gestational age calculated from crown rump length (CRL)
2) Multiple pregnancies are identified
When is the Down’s syndrome screening appointment?
Between 11 - 13+6 weeks
Purpose of Down’s syndrome screening appointment?
The purpose is to decide which women should receive more invasive tests to establish a definitive diagnosis - it is the choice of the woman whether to go ahead with the screening
Purpose of the antenatal appointment at 16 weeks?
To discuss results (anomaly and blood results) and plan future appointments
When is the anomaly scan?
Between 18 and 20+6 weeks
Purpose of anomaly scan?
An ultrasound to identify any anomalies e.g. heart conditions
Purpose of antenatal appointments at weeks 25, 28, 31, 34, 36, 38, 40, 41, 42?
Monitor the pregnancy and discuss future plans
Information e.g. breastfeeding, vitamin K, ‘baby blues’, labour plans, possibility of induction
1st line screening test for Down’s syndrome?
Combined test: combining results from US and maternal blood tests
What does the US measure in Down’s syndrome screening?
Measures nuchal translucency (thickness of the back of the neck of the foetus)
What is nuchal translucency?
Thickness of back of neck of foetus
Nuchal thickness in Down’s syndrome?
Down’s syndrome is one cause of a nuchal thickness > 6mm
What maternal blood tests are done in Down’s syndrome screening?
1) beta-hCG
2) pregnancy-associated plasma protein-A (PAPPA)
What maternal blood test results indicates a greater risk of Down’s syndrome?
1) Higher beta-hCG
2) Lower PAPPA
What hCG indicates a higher risk of Down’s?
Higher
What PAPPA indicates a higher risk of Down’s?
Lower
What are the 3 options for screening in Down’s syndrome?
1) combined test
2) triple test
3) quadruple test
When does a triple test screening for Down’s syndrome occur?
performed between 14 and 20 weeks gestation
What does a triple test screening for Down’s syndrome involve?
What results indicate a greater risk for it?
Only involves maternal blood tests:
1) beta-hCG - higher
2) Alpha-fetoprotein (AFP) - lower
3) Serum oestriol uE3 (female sex hormone) - lower
What AFP indicates a lower risk for Down’s?
Higher
What is involved in a quadruple test Down’s syndrome?
identical to triple test BUT also includes maternal blood testing for inhibin-A (higher result indicates greater risk)
The screening tests for Down’s syndrome provide a risk score for the foetus having Down’s syndrome.
What risk leads to a woman being offered further investigations?
1 in 150 (occurs in 5% of tested women)
What are the next investigations for Down’s syndrome?
What do these tests involve?
Amniocentesis or chorionic villus sampling
These tests involve taking a sample of the foetal cells to perform karyotyping for a definitive answer about Down’s
When should you take folic acid in pregnancy? Purpose? How much?
When: from before pregnancy to 12 weeks
Why: Reduces neural tube defects
How much: 400mcg
General lifestyle advice in pregnancy?
1) Take folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects)
2) Take vitamin D supplement (10 mcg or 400 IU daily)
3) Avoid vitamin A supplements and eating liver or pate (vitamin A is teratogenic at high doses)
4) Don’t drink alcohol when pregnant (risk of fetal alcohol syndrome)
5) Don’t smoke (smoking has a long list of complications, see below)
6) Avoid unpasteurised dairy or blue cheese (risk of listeriosis)
7) Avoid undercooked or raw poultry (risk of salmonella)
8) Continue moderate exercise but avoid contact sports
9) Sex is safe
10) Flying increases the risk of venous thromboembolism (VTE)
11) Place car seatbelts above and below the bump (not across it)
What does chorionic villus sampling involve?
US guided biopsy of placental tissue (used when testing is done earlier in pregnancy i.e. before 15 weeks)
What does amniocentesis involve?
US guided aspiration of amniotic fluid using needle and syringe (used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample)
Supplements to take in pregnancy?
1) folic acid
2) vitamin D
3) vitamin A
What can alcohol in early pregnancy lead to?
1) Miscarriage
2) Small for dates
3) Preterm delivery
4) Fetal alcohol syndrome
Why should you not drink alcohol whilst pregnant?
Risk of foetal alcohol syndrome
What is foetal alcohol syndrome?
Fetal alcohol syndrome refers to certain characteristics that can occur in children of mothers that consumed alcohol during pregnancy.
Why should pregnant women avoid unpasteurised dairy or blue cheese?
risk of listeriosis (a serious infection usually caused by eating food contaminated with the bacterium Listeria monocytogenes)
When are the effects of alcohol greatest in pregnancy?
first 3 months
What features can be seen in foetal alcohol syndrome?
1) microcephaly (small head)
2) thin upper lip
3) smooth flat philtrum (groove between the nose and upper lip)
4) short palpebral fissure (short horizontal distance from one side of the eye to the other)
5) learning disability
6) behavioural difficulties
7) Hearing and vision problems
8) Cerebral palsy
What can smoking in pregnancy increase the risk of?
1) Fetal growth restriction (FGR)
2) Miscarriage
3) Stillbirth
4) Preterm labour and delivery
5) Placental abruption
6) Pre-eclampsia
7) Cleft lip or palate
8) Sudden infant death syndrome (SIDS)
Can you fly in pregnancy? Up to what dates in:
a) a single pregnancy
b) in a twin pregnancy
The RCOG advises flying is generally ok in uncomplicated healthy pregnancies up to:
a) 37 weeks in a single pregnancy
b) 32 weeks in a twin pregnancy
After 28 weeks gestation, most airlines need a note from a midwife, GP or obstetrician to state the pregnancy is going well and there are no additional risks.
What pregnancy-related topics are covered during the booking clinic?
1) What to expect at different stages of pregnancy
2) Lifestyle advice in pregnancy (e.g. not smoking)
3) Supplements (e.g. folic acid and vitamin D)
4) Plans for birth
5) Screening tests (e.g. Downs screening)
6) Antenatal classes
7) Breastfeeding classes
8) Discuss mental health
9) Can Discuss female genital mutilation
10) Can discuss domestic violence
A set of booking bloods are taken at the booking clinic. What bloods are taken?
1) Blood group, antibodies and rhesus D status
2) Full blood count for anaemia
3) Screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
Patients are also offered screening for infectious diseases, by testing antibodies for:
1) HIV
2) Hepatitis B
3) Syphilis
Other investigations at booking clinic?
1) Weight, height and BMI
2) Urine for protein and bacteria
3) Blood pressure
Women are assessed for risk factors for other conditions, and plans are put in place with additional appointments booked.
These conditions include:
1) Rhesus negative (book anti-D prophylaxis)
2) Gestational diabetes (book oral glucose tolerance test)
3) Fetal growth restriction (book additional growth scans)
4) Venous thromboembolism (provide prophylactic LMWH if high risk)
5) Pre-eclampsia (provide aspirin if high risk)
What is offered to women at high risk of pre-eclampsia at booking clinic?
Aspirin
What is offered to women at high risk of VTE at booking clinic?
prophylactic LMWH
What is the purpose of the initial Down’s syndrome screening test?
To decide which women should receive more invasive tests to establish a definitive diagnosis.
Give 5 examples of chronic conditions that must be monitored during pregnancy
1) Hypothyroidism
2) Hypertension
3) Epilepsy
4) Rheumatoid arthritis
5) Diabetes