Antenatal care pt1 Flashcards
What are the 3 trimesters?
T1 = <12 wks T2 = 12-26 wks T3 = 26-37 wks
What antenatal urine tests are done?
MSU MC&S
Urinalysis
Which UTI medication can you not give in pregnancy?
Trimethoprim can’t be given in first 2 Trimesters
Nitro can’t be given in 3rd
Co-amoxiclav is chosen for 3rd trimester
Why should we monitor blood pressure in pregnancy?
Falls a little in T1 but returns to normal in T2
T1 measurement can identify undiagnosed hypertension which requires treatment (antiHTN and aspirin)
What are the booking tests in pregnancy?
FBC MSU Blood group and antibody screen Haemoglobinopathy screen Infection Screen (Current not past) Dating scan and first trimester screen
What vaccines do you give at 27-36 weeks?
DtaP and influenza
When is DTaP and influenza Vx given?
27-36wks
What is anaemia in pregnancy in T1, T2 and T3?
T1 - <110
T2 - <105
T3 - <100
What are you looking for in platelets?
· Gestational thrombocytopaenia rarely presents in first trimester (more common >28 weeks)
· So, a low platelet count in the first trimester warrants further investigation
· A baseline platelet count is also useful later in pregnancy if the patient is suspected of having developed pre-eclampsia or HELLP syndrome
What are the causes of Microcytic anaemia in pregnancy?
T - Thalassaemia A - ACD I - IDA L - Lead poisoning S - Sideroblastic anaemia
What are the causes of Normocytic anaemia in pregnancy?
M-Marrow Failure
R- Renal Failure
I- early IDA
C- aCd
A - Aplastic anaemia, acute loss
L- Leukaemia
M - Myelofibrosis
What are the causes of Macrocytic anaemia in pregnancy?
A- Alcohol M- Myeloid neoplasms H- Hypothyroid/ Haemolytic anaemia L- Liver failure F- Folate/ B12 deficiency
What do you look for in blood group analysis?
§ Identify Rhesus D -ve women
§ Anti-D (250 IU) administered <72 hours of sensitising events (e.g. CVS, amniocentesis, trauma)
When do you give Anti D in early pregnancy?
§ In pregnancy <12 weeks, anti-D prophylaxis indicated if:
Ectopic pregnancy
Molar pregnancy
Therapeutic TOP
Uterine bleeding (repeated, heavy or with abdominal pain)
When do you normally give anti D?
§ Otherwise, give anti-D at 28 weeks (single large dose 1,500 IU or two at 28 and 34 weeks)
What do you do if you find glycosuria on dipstick?
2 hour 75g OGTT (immediate + HbA1c testing for pre existing diabetes mellitus)
What do you do if a woman has had previous gestational diabetes or any risk factors?
§ Previous GDM -> 2-hour 75g OGTT (immediate -> if normal, again at 24-28 weeks)
§ Any RF on clerking (not prior GDM) -> 2-hour 75g OGTT (at 24-28 weeks)
How do you diagnose gestational diabetes?
· Fasting plasma glucose >5.6 mmol/L
· 2-hour OGTT >7.8 mmol/L
What do you do after a diagnosis of GDM?
If diagnosed, offer a review at a joint diabetes and antenatal clinic within 1 week
How do you diagnose thalassaemia?
§ Autosomal recessive
§ Family Origins Questionnaire ± Hb electrophoresis
Who get’s sickle cell?
§ Carrier rate of Sickle Cell Trait (HbAS) in Afro-Caribbean is 1 in 10
§ Carrier rate of HbAC trait is around 1 in 30
What is the most serious sickle cell genotype?
HbSS
What does HbSS cause?
Chronic haemolytic anaemia and acute sickle cell crises
How is HbSC different from HbSS?
Milder features but still can have crisis
What investigations do you do for sickle cell?
· Bloods – FBC (low Hb, reticulocytes [HIGH = haemolytic crisis, LOW = aplastic crisis]), U&Es
· Blood film – Sickle cells, anisocytosis, [target cells, Howell-Jolly bodies = hyposplenism]
· Sickle solubility test – increased turbidity on dithionate addition to blood
· Hb electrophoresis – determines presence of HbS and trait/homozygous
What is the management of SSD crisis?
· Hydration
Oxygen
· Analgesia
Screen for infection (urinary, respiratory)
· Blood transfusion
Exchange transfusion
· Prophylactic antibiotics
Prophylaxis against thrombosis (heparin)
What can you not give pregnant women with SSD?
Hydroxyurea- stop 3 months before pregnancy
What do you give to SSD women?
Low dose aspirin for 12 wks
Serial growth scans every 4 weeks from 24 weeks
Delivery IOL at 38 weeks
What postnatal care do you do for SSD women?
LMWH (hospital and 7 days post discharge, 6 weeks after C section)
Contraception (POP, Depo provera or LNG IUS)
What is in the first trimester infection screen?
Syphilis
Hep B
HIV
(Hep C if High risk)
If a baby is born to a woman with active hepatitis B, what do you give the child?
Hep B vaccine within 12 hours, 1 month and 6 months
One dose of HBV IVIG within 12 hours
What should you do if a mother is HIV positive?
o Initiation of ART by 24 weeks if naive
o Planned elective C-section if viral load > 50 copies/mL at 36 weeks
o Exclusive formula feeding from birth
Women who decline initial screening should be offered screening again at 28 week
What does the USS do in T1?
Dating
Multiple pregnancy
Trisomy screen
Gross abnormalities of the foetus
What do you measure at 12 wks (11+3 to 13+6)?
Crown rump length (45-84 mm)
Head circumference after 14 weeks
What tests can you do after 10 weeks?
NIPT for Trisomy 21, 18 and 13 (>98% sensitivity)
What do you do 11-14 weeks?
Combined- NT, bHCG and PAPP-A
What do you find out in the combined test?
Tests for Trisomy 21, 18 and 13
What is in the combined test?
§ Nuchal translucency (NT)
§ Maternal b-hCG Combined test is only these 3
§ PAPP-A (pregnancy-associated plasma protein
· Trisomy 21 -> High b-hCG, Low PAPP-A
A) Maternal age used in calculation
What is done 14-20 weeks?
Quadruple test (for Down’s)
What is in the Quadruple test?
AFP
Oestriol
bHCG
Inhibin A (not in the triple test)
What happens if you miss the combined test?
Mid pregnancy scan for Patau’s (13) and Edwards (18)
If a positive result is found what should be done?
§ Chorionic villous sampling -> 11-14 weeks (99% accurate)
§ Amniocentesis -> 15-20 weeks (99% accurate)
What would be fond in antenatal screening in Down’s?
Low AFP Low oestriol Low PAPP A High bHCG thickened NT
What causes increased AFP?
Neural tube defects
Abdominal wall defects
Multiple pregnancy
What causes decreased AFP?
Trisomy 21
Trisomy 18
Maternal DM
How do you manage a woman with pre eclampsia risk?
§ 75mg aspirin OD from 12 weeks to delivery (if high risk)
§ Screened at every antenatal visit with BP and urinalysis
How do you identify a woman with pre term birth risk?
Previous pre term birth
Previous late miscarriage
Multiple pregnancy
Cervical surgery
How do you manage a woman with IUGR risk?
§ SFH at all antenatal appointments from 24 weeks
§ USS to check for IUGR if suspected
How do you manage a woman with Vit D Deficiency risk?
§ Not routinely screened
§ All pregnancy women should take 10ug of vitamin D OD
What do you screen for in T2?
Anomaly scan (18-21 wks) Gestational DM
What does the anomaly scan check for?
Spina bifida
Diaphragmatic hernia
Major congenital anomalies
Renal Agenesis
What are the RFs for GDM?
Previous GDM Raised BMI Asian, black Caaribbean or middle eastern Previous macrosomia 1st degree relative with diabetes
What is the USS schedule?
o 10-14 weeks -> booking scan (gestational age, multiple pregnancy, NT test)
o 18-21 weeks -> anomaly scan (structural abnormalities, TOP options if required)
What are sensitising events in RhD negative women?
o 0-12 weeks -> 250 IU if needed:
§ Foetal blood volume small so sensitisation is unlikely
§ Anti-D is only indicated following: ectopic pregnancy, molar pregnancy, therapeutic TOP and in cases of uterine bleeding which is heavy/repeated or accompanied by abdominal pain
o 12-20 weeks -> 250 IU (<72 hours) -> Kleihauer test
o 20+ weeks -> 500 IU (<72 hours) ->Kleihauer test
Summarise sensitising events
§ Delivery of RhD+ infant
Any TOP
§ Miscarriage if > 12 weeks
Ectopic pregnancy (if managed surgically)
§ External cephalic version
Antepartum haemorrhage
§ Amniocentesis, CVS, foetal blood sampling
Abdominal trauma
What supplementation do women need?
Folic acid (400 mcg or 5mg)
Vit D (10mcg)
Who needs high dose folic acid?
Women whove had a previous child with NTD DM HIV on co trimoxazole Epileptics SCD IBD Obese Thalassaemia
When should first movements be?
Primigravida 20 wks
Multiparous 16-18wks
latest 24 wks
How do the nips change?
Nipples darken and breasts enlarge around 12w (highest oestrogen and human placental lactogen / hPL)
What is hPL?
homologue to GH and prolactin (unsure of role); made from placenta
What does hPL do?
o Decrease insulin sensitivity (-> i.e. multiple pregnancy, more placenta, more hPL, more chance of GDM)
o Increase lipolysis -> FFA release for ketogenesis for mother’s energy use -> more glucose available for baby
o Decrease glucose utilisation
What is bHCG?
Homologue to TSH
What does bHCG do?
Thyroid enlargement
T4 production
What visits do only primigravida patients get?
25wks: routine care: BP, urine dip, symphysis fundal height
31 wks: routine care: BP, urine dip, symphysis fundal height
40 wks: routine care: BP, urine dip, symphysis fundal height, Discussion about prolonged pregnancy
When is the booking visit?
8 - 12 weeks
Ideally <10w
What happens during the booking visit?
Booking visit
• General information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
• BP, urine dipstick, check BMI
Booking bloods/urine
• FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
• Hepatitis B, syphilis, HIV
• Urine culture to detect asymptomatic bacteriuria
When is the early scan? what does it tell us?
10 - 13+6 weeks
Early scan to confirm dates, exclude multiple pregnancy
When do you screen for Down’s?
11 - 13+6 wks
What happens at 16 weeks?
Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick
When is the anomaly scan?
18-20+6 wks
What happens at 28 weeks?
Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb <10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
In which week is routine care, second anti D dose and information on labour and birth plan?
34 weeks
What happens at 36 weeks?
Routine care: BP, urine dipstick, SFH
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, ‘baby-blues’
What happens at 38 weeks?
Routine care: BP, urine dipstick, SFH
What happens at 41 weeks?
Routine care: BP, urine dipstick, SFH
Discuss labour plans and possibility of induction
