Antenatal Care Timetable: Key dates, Folate, VitD, Reduce pre-eclampsia/DVT/Rh Disease risk, VTE, Pre-eclampsia

Question 1

How many antenatal visits should one expect if uncomplicated?

Answer 1

10 - 1st pregnancy
7 - subsequent pregnancies
Will not be seen by consultant unless complicated

Question 2

8-12wks

Answer 2

Booking visit
-diet, alcohol, smoking
-folate - 400mcg daily before conception to wk12
-VitD - 10mcg
-antenatal classes
-BP, BMI
-DVT risk assessment

Booking bloods/urine
-ABO, Rh status
-HepB, HIV, syphilis, sickle cell, thalassemia
-Fe deficiency anemia
-urinedip, culture

Blood ideally to be done before 10wks

Question 3

12wks
-results interpretation

Answer 3

Combined test for Downs, Edwards, Patau
-nuchal translucency, BHCG, PAPPA

Downs
-High HCG, nuchal translucency
-Low PAPPA

Edwards and Patau
-High nuchal translucency
-Low HCG, PAPPA

Lower chance - 1 in 150 chance or more
Higher chance - 1 in 150 chance or less
=> offered NIPT or amniocentesis or CVS

NIPT - analysis of fragments of fetal DNA in mother’s blood
-high sensiticity and specificity for Downs and chromosomal abnormalities

Question 4

20wks

Answer 4

Anomaly scan

Question 5

28wks

Answer 5

2nd screen for anemia and atypical red cell alloantibodies

1st dose of anti-D to Rh-ve mothers

Question 6

34wks

Answer 6

2nd dose of anti D to Rh-ve mothers

Question 7

36wks

Answer 7

Check presentation - offer external cephalic version if needed

Question 8

Use of folate in antenatal period

Answer 8

Before conception to wk12
Minimum 400mcg

High risk of NTD if
-Hx of NTD in partner, past pregnancy, FHx
-antiepileptic drugs, coeliac, DM, thalassemia trait
-obese
=> 5mg

Question 9

Use of Fe in antenatal period

Answer 9

Anemia screening - booking and 28wks

1st - U110
2nd/3rd - U105
4th - U100

PO ferrous sulfate/ferrous fumarate
-continue for 3months after correction to replenish iron stores

Question 10

Use of VitD in antenatal period

Answer 10

10mcg daily

Question 11

Lifestyle choices in the antenatal period

Answer 11

Don’t drink

If smoking, consider risks - low birthweight, premature birth
-NRT can be used if they have stopped smoking
-don’t use varenicline or bupropion

Medication
-adjust prescribed meds with HCP, risk benefit discussion needed
-avoid OTCs where possible

Question 12

VTE risk in antenatal period

Answer 12

35+
Obese BMI - 30+
Parity 3+
Smoker
Varicose veins visible
Pre-eclampsia
Immobile
FHx unprovoked VTE
Low risk thrombophilia
Multiparous
IVF pregnancy

3 risk factors => LMWH 28wks => 6wks postnatal
4+ risk factors => LMWH NOW => 6wks postnatal

Avoid DOAC and warfarin in pregnancy

Question 13

Identifying risk of pre-eclampsia in pregnancy
-moderate risk factors
-high risk factors
-management

Answer 13

High - 1
-HTN - past pregnancy/chronic
-CKD
-AI - SLE, APS
-T1,2DM

Moderate - 2
-1st pregnancy
-40y/o+ or 10year gap between pregnancy
-BMI 35+ at 1st visit
-FHx preeclampsia
-multiple pregnancy

75-150mg aspirin daily 12wks => birth

Question 14

Rhesus negative pregnancy
-pathophysiology
-prevention

Answer 14

Rh-ve mother and Rh+ve child’s blood mixes
=> antiD IgG AB form in mother
In later pregnancies, can cross placenta => hemolysis in fetus

Booking - D AB test in Rh-ve mothers
Anti D given at 28 and 34wks

Question 15

VTE
-risk factors assessed at booking
-management of VTE prophylaxis

Answer 15

Age 35+, BMI 30+, Parity 3+
Multiplets, IVF pregnancy
Smoker
Gross varicose veins
Current pre-eclampsia
Immobility
FHx unprovoked VTE
Low risk thrombophilia

4+ - immediate treatment with enox
3+ - enox 28wk-6wks post-natal

AVOID DOACS AND WARFARIN IN PREGNANCY

Question 16

Gestational diabetes
-risk factors
-screening and diagnostic thresholds
-management

Answer 16

BMI 30+
PHx macrosomic baby (4.5kg+)
PHx GD
1st degree relative with DM
South Asian, Afro-Caribbean, Middle Eastern

OGTT
PHx GD
-ASAP after booking
-24-28wks if 1st test normal

Other risk factors
-24-28wks

Fasting glucose - 5.6+
2hour glucose - 7.8+

Newly diagnosed => joint diabetes + antenatal clinic within 1wk
-self-monitoring BMs
-low glycemic diet, exercise

FPG U7 => diet + exercise
-target not met U2wks => add metformin
-target not met => add short acting insulin

FPG 7+ => insulin
FPG 6-6.9 AND evidence of macrosomia, hydramnios => insulin