Antenatal Care pt 1

Question 1

What are the physiological changes in pregnancy on the Cardiovascular and respiratory systems?

Answer 1

CV - Increased heart rate, increased stroke volume and cardiac output, increased plasma volume and reduces blood pressure.

Respiratory - Increased respiratory rate, increased oxygen consumption.

Question 2

What are the normal haematological changes seen in pregnancy?

Answer 2

Increased plasma volume - this can cause dilutional anaemia.

Pregnancy increases demand for iron so serum iron falls.

Leukocytosis (<16 is normal)

Procoagulant due to increased clotting factors.

Question 3

What are the normal urinary tract changes in pregnancy?

Answer 3

Increased eGFR due to increased blood volume and cardiac output. This causes increased excretion and reduced blood levels of urea, creatinine and bicarb.
Urea > 4.2 is high.
Creat > 73 is high
Mild glycosuria and/or proteinuria.
Reduced plasma osmolality due to water retention.
Bladder muscle relaxes which increases capacity and risk of UTI.

Question 4

What are the normal GI tract changes in pregnancy?

Answer 4

Decreased LOS pressure,
Decreases gastric peristalsis,
Delayed gastric emptying,
Increased small and large bowel transit times.
This can result in GORD, N+V and constipation.

Question 5

What are the normal skin changes in seen in pregnancy?

Answer 5

Hyperpigmentation of umbilicus, nipples, linea nigra (abdominal midline) and face (melasma)
Hyperdynamic circulation and high levels of oestrogen can cause spider naevia and palmer erythema.
Stretch markes (Striae gravidarum)

Question 6

What are the normal MSK changes in pregnancy?

Answer 6

Increases ligamental laxity due to increased levels of relaxin and progesterone - back pain and pubic symphysis dysfunction.

Exaggerated lumbar lordosis.

Question 7

What are some risk factors in pregnancy?

Answer 7

Age > 40 or age < 18.
Para 6+ or 0,
Extremes of BMI,
Low socio-economic status,
Drugs and alcohol misuse,
Previous obstetric complications,
Vulnerable groups eg, asylum seekers,
Pre-existing medical problems

Question 8

What are the RFs for GDM?

Answer 8

BMI > 30,
Previous big baby >4.5kg,
Previous GDM,
Family history of diabetes,
Ethnicity with high prevalence of diabetes
Offer GTT at 24-28 weeks unless previously had GDM in which case offer an extra GTT at 14-16 weeks.

Question 9

WHat are the RFs for PET?

Answer 9

High risk (give LDA if have 1+) - HTN in previous pregnancy, CKD, autoimmune diseases eg, SLE or antiphospholipid syndrome. Type 1/2 diabetes, chronic hypertension.

Moderate risk (Give LDA if 2+) - Nulliparity, age 40+, pregnancy interval of 10+ years, BMI > 35, family history of PET, multi-fetal pregnancy

Question 10

How can you reduce risk of VTE in pregnancy?

Answer 10

If score is 2 then LMWH postnatally.

If score > 3 - LMWH at 28 weeks.

If Score >4 - LMWH from booking.

Question 11

What are the risk factors for VTE?

Answer 11

Previous VTE,
ALPS(autoimmune lymphoproliferative syndrome),
Nephrotic syndrome,
Significant autoimmune disease,
> 35 years old,
Smoker,
BMI > 30
IVF pregnancy
Multiple pregnancy,
Para 3+,
Family history

Question 12

Risk factors for SGA/FGR birth?

Answer 12

Previous FGR, PET or stillbirth,
Low/high BMI,
IVF
Age 40+,
Multiple pregnancy,
Fibroids,
Uterine anomalies,
Smoking/drug use,
HTN, Diabetes, inflammatory conditions, ALPS, SLE, Low papp-a (pregnancy associated plasma protein A), renal disease, cardiac disease,
Anti-epileptics and beta blockers

Question 13

What bloods should be done as screening at booking appointment?

Answer 13

FBC,
Ferritin - replace even if Hb is normal.
Blood group (rhesus group, may need anti-D),
Sickle cell and thalassaemia,
Hep B/ syphilis/ HIV

Question 14

What is the antenatal care timetable?

Answer 14

<10 weeks - Booking visit, bloods and urine dip/culture.
10-13 weeks - Early scan to confirm dates
11-13 weeks - Downs syndrome screening.
16 weeks - BP and urine dip. Information on anomaly.
18-20 weeks - Anomaly scan.
25 weeks (prims only) - routine care: BP, urine dip, symphysis-fundal height.
28 weeks - second screen for anaemia and atypical red cell antibodies. First dose of anti-D prophylaxis to rhesus negative women.
31 weeks (prims only) - routine care.
34 weeks - Routine care, second dose of anti-D.
36 weeks - Routine care and check presentation (offer cephalic version)
38 weeks - routine
40 weeks - routine care

Question 15

What is polyhydramnios and its presentation?

Answer 15

Excess amniotic fluid with amniotic fluid index >90th centile or DVP >8cm. This may present with large for dates, tense abdomen and unable to feel fetal parts.

Question 16

What is polyhydramnios associated with?

Answer 16

Placental abruption,
Malpresentation,
Cord prolapse,
Large for gestational age infant (diabetes),
PPH,
C section delivery,
Premature birth

Question 17

What is oligohydramnios and how does it present?

Answer 17

Reduced amniotic fluid. May present with small SFH. Diagnosed when AFI < 5th percentile or single DVP (deepest vertical pool) <2cm

Question 18

What are the causes of oligohydramnios?

Answer 18

Premature rupture of membranes,
Potter sequence (bilateral renal agensis and pulmonary hypoplasia),
Intrauterine growth restriction,
Post-term gestation,
Pre-eclampsia

Question 19

What is the definition of pre-eclampsia?

Answer 19

New onset BP >140/90 after 20 weeks of pregnancy and 1+ of following: Proteinuria or other organ involvement eg, renal insufficiency, liver, neuro or haem involvement.

Question 20

What are the potential consequences of pre-eclampsia?

Answer 20

Eclampsia,
Fetal complications - IUGR, prematurity,
Liver involvement (elevated transaminases,
Haemorrhage (placental abruption),
Cardiac failure

Question 21

What are the features of severe pre-eclampsia?

Answer 21

HTN > 160/110 and proteinuria
Proteinuria ++/+++
Headache,
Visual disturbences,
Papilloedema,
RUQ/epigastric pain,
Hyperreflexia,
Platelets < 100 or HELLP syndrome.

Question 22

What is the management of pre-eclampsia?

Answer 22

Initial - Arrange emergency secondary care assessment for any woman where pre-eclampsia is suspected. If BP >160/110 then likely to be admitted.
Further management: Oral labetalol or nifedipine if asthmatic. Delivery of baby is definitive management. Give steroids to woman having premature birth to mature foetal lungs. After delivery of baby switch to enalapril.

Question 23

What fetal screening is offered and when?

Answer 23

CUBS (combined US biochemical screening) is offered at 11-14 weeks. Looks at nuchal translucency, serum B-HCG and pregnancy associated plasma protein A.
If comes back positive then can offer Non-invasive prenatal screening test (NIPT). Either chorionic villus sampling or amniocentesis.

Question 24

What CUBS test indicated a risk of Down’s syndrome?

Answer 24

Increase HCG,
Reduced PAPP-A
Thickened nuchal translucency

Question 25

What is the definition of small for gestation age and its causes?

Answer 25

Fetus which measures below 10th centile for gestation age.
Causes are either: constitutionally small (matching mother and growing appropriately on growth chart) or Fetal Growth Restriction (FGR) (fetus not growing as expected)

Question 26

What are the causes of fetal growth restriction?

Answer 26

Placenta mediated growth restriction: Idiopathic, pre-eclampsia, maternal smoking, maternal alcohol, anaemia, malnutrition, infection, maternal health conditions.

Non-placenta mediated growth restriction: Genetic abnormalities, structural abnormalities, fetal infection, errors of metabolism.

Question 27

What signs indicated FGR other than fetus being SGA?

Answer 27

Reduced amniotic fluid volume,
Abnormal doppler studies,
Reduced fetal movements,
Abnormal CTGs

Question 28

What are the complications of fetal growth reducetion?

Answer 28

Death or stillbirth,
Birth asphyxia,
Neonatal hypothermia,
Neonatal hypoglycaemia,
Long term risk of CV disease, T2DM, obesity and mood/behavioral problems

Question 29

How do you monitor women with a SGA fetus?

Answer 29

Low risk women - Monitor symphysis fundal height.
High risk - serial growth scans with umbilical artery doppler.
With confirmed SGA - Serial US monitoring estimated fetal weight and abdo circumference, UA-PI and amniotic fluid volume.

Question 30

What is the management of SGA?

Answer 30

Aspirin 150mg at night if risk of pre-eclampsia,
Treat modifiable risk factors (stop smoking),
Serial growth scans,
Early delivery where growth is static or other concerns,
Investigate underlying cause.

Question 31

What are the causes and potential risks of a big baby (Macrosmia)

Answer 31

Causes: Constitutional, maternal diabetes, previous macrosomia, maternal obesity, overdue or male baby.
risks - Shoulder dystocia, failure to progress, perineal tears, instrumental delivery, PPH, uterine rupture.
Risks to baby - Birth injury, neonatal hypoglycaemia, obesity in childhood or later life, T2DM.

Question 32

What is pregnancy induced hypertension?

Answer 32

Hypertension occurring after 20 weeks gestation without proteinuria.
Eclampsia is when seizures occur in pre-eclampsia

Question 33

What is HELLP syndrome?

Answer 33

Features that occur as complication of pre-eclampsia and eclampsia. Presents with:
Haemolysis
Elevated Liver enzymes
Low Platelets

Question 34

What is the management of eclampsia?

Answer 34

IV Magnesium sulphate is used to manage seizures.