Antenatal check Flashcards
Signs of fetal compromised
Fetal movement reduced
Abnormal fetal FR eg reduced variability
Deepest amniotic fluid pocket - AFI 5cm or less, DVP 2cm or less, Oligohydramnios ass with adverse perinatal outcomes
USS of fetal growth - usually asymmetrical IUFG
Umbilical artery flow doppler - increase resistance, absent or reversed end diastolic flow.
Ductus venous doppler - absent or reversed a wave
Counselling a women on prenatal care
Hx Q - PmHX (Epilepsy, DM), Ob Hx (year, sex, wt, GA, Mode of delivery, length of labour, Cx), FmHx chromosomal, neural tube defects or genetic. Contraception (nature, not, wanted or not), SoHx (folate, Eoth, Smoking, drugs), Medication (stop ACE I, Tetracycline, retinoids, DES, isoprostol. AE - Phenytoin,valproate, carbamazepine, lithium, warfarin, Erythromycin, Sulpha, Chloramphenicol, trimethoprim.
Vaccination - MMR, Varicella, Diphtheria, tetanus and pertussis
Ex - BP, Wt, auscultation, breast examination and Pap smear if needed.
Mx - Stablisation of medical condition, med changes, vaccines, healthy diet, wt loss if obese, Folic acid 0.4mg/day (5mg/day) for 1 month prior and 3 months after. Cease smoking, Eoth, illegal drug. Healthy environment.
Education on antenatal care
High risk for neural tube defects - anticonvulsant meds, DM, Obese, PmHx, FmHx.
First contact Antenatal Care
Same as prenatal counselling
Calculation EDD - LMP +1yr 7d - 3months if 28 day cycle. + 1 day for every day over.
Symptoms of pregnancy - Antenatal bleeding, N and V, amenorrhea, breast tenderness, urinary frequency, fatigue
Ex - Wt, Ht, BMI, complete examination to determine base line. Pelvic exam with Pap smear if needed.
Urine
Bloods
Imaging
Visit every 4-6 wks until 28 wk then 2 wks until 36 then weekly until delivery.
Rh neg and pregnancy
If father is positive then antibodies at prophylaxis needed at 28wk, 34 wks, and 72 Hr after birth.
Ix by indirect combs test at first visit
Cx Erythroblastosis fatalis, Hydrous fatalis assess by MCA doppler and amniocentesis for bilirubin if needed
Tx intrauterine transfusion
A 28 year old in first pregnancy. Which is likely to be correct?
(a) The risk of Down Syndrome is low and screening is not indicated
(b) The most sensitive screening test to detect Down Syndrome is NIPT
(c) Down Syndrome is likely to be detectable with features on 20 week morphology scan
(d) The most sensitive screening test to detect Down Syndrome is second trimester biochemistry
b
The risk of fetal loss following a CVS or amniocentesis is (a) 1:10000 (b) 1:1000 (c) 1:100 (d) 1:10
c
Congenital anomalies may be prevented using: A. Asprin B. Heparin C. Progesterone D. Folate E. All of the above
d
Risk of aneuploidy increases with maternal age, except for A. Trisomy 13 B. Trisomy 18 C. Trisomy 21 D. Triploidy
c
27 year old at 9 weeks gestation requests a test to exclude Down Syndrome. You recommend A. Nothing as she is low risk B. CVS at 11 C. First trimester CFTS D. Second trimester biochemistry E. Amniocentesis at 16 weeks F. 18 - 20 week morphology scan G. NIPT
c
With respect to prepregnancy
Diabetes
(a) Type 1 is more associated with more fetal anomalies than Type 2
(b) Maternal hyperglycaemia is teratogenic to the fetus
(c) Oral hyperglycaemic agents contraindicated in pregnancy as they cross the placenta
(d) Maternal administered insulin will cross the placenta
?
NIPT
a) Has replaced other screening tests for Down Syndrome
b) Has high sensitivity and high specificity for Down syndrome
c) Has poor specificity for Down Syndrome
d) Is a diagnostic test for 22q11.1 deletion syndromes
B
20 year old in first pregnancy has high risk NIPT for Down Syndrome; Chance of affected pregnancy
1. 99.9% 2. 99.8% 3. 99.0% 4. 90% 5. 50%
1/240
?
What is the commonest type of major fetal anomaly A. Congenital Heart Disease B. Neural Tube Defect C. Urogenital anomalies D. Down Syndrome E. Developmental delay
Neural tube defects
What are the common fetal anomalies
Hypospadias Trisomy 21 - Down Other chromosomal defects (trisomy 21, trisomy 18, 13, ) Neural tube defects Cardio defect
Maternal age risk for Down syndrome
20yr 1 in 1500 30 yr 1/900 35 yr 1/360 40 yr 1/100 Also a increase of other defects
First trimester screen involves
1st trimester biochemistry and markers and biochemistry - BHCG and PAPPA
Detection rate 91%, False positive rate 5%, False positive rate 0.5%
Done 11wk and 1d to 13 wk and 6days.
Only a screening test - false positive rate 5%
Other test, in NIPT but only self funded or to women that have a high risk result on 1st trimester screen to reduce the number of invasive testing
Needs a diagnostic test afterward
Amniocentesis at 16 wks (1% risk of loss, have to induce labour if TOP)
Chorionic villus sampling at 11-13wk (quicker and ability to do suction curette if aneuploidy but may have different CPM 1-2%)
Calculating risk done by maternal age, previous hx of affected baby. Nuchal translucency and gestational age (decreases with age). Biochemistry levels for PAPPA and free HBCG.
Scans to be organised in pregnancy
Dating scan - 8-12 wk
Nuchal translucency 11-13 wks - Needs free Beta hCG and PappA blood 3-5 days prior
Fist trimester screen 11 +-13+6wk — NT + Beta hCG and PappA
Maternal Serum screen 15-20wk— MSAFP, Beta hCG, µE3
Integrated Prenatal screen - NT + FTS + MSS + inhibit A
Pt with Positive screen offer amniocentesis refer below
Diagnostic morphology 18-20wks
Which high risk populations need further screening and what are they screened for
Thalassemia - Mediterranean, SE Asian, W Pacific, African, Middle Eastern, Caribbean, S American. FBC (MCV and MCH) and HB electrophoresis.
Sickle cell - African, caribbean, mediterranean, Middle eastern, Indian, S American.
Cystic Fibrosis - Mediterranean, Finnish, Caucasian or FmHx - CFTR gene DNA analysis
Tay Sachs Disease- Ashkenazi Jewish, French Canadians, Cajun - Enzyme HEXA or DNA analysis for HEXA gene.
Fragile X syndrome - FmHx confirmed or suspect - DNA analysis FMR-1 gene
Conditions in pregnancy or birth that indicate an Ob consultant referral
insulin dependent GD VBAC HTN Multiple gestation Malpresentation Active APH PTL/PPROM Failure to progress/descend Induction/augmentation if high risk Tears: 3rd or 4th degree retained placenta
When are the antenatal visits in uncomplicated pregnancy and what is checked
every 4-6 wk until 28 wk
every 2 wk from 28 to 36
weekly from 36 until delivery
Assess at every visit
Record GA
Hx of present pregnancy - fetal movement, uterine bleeding, leaking, cramping
O/E - BP, wt gain, SFH (12wk = pubic symphysis, 20wk = at umbilicus, 37 wk = sternum), Leopold’s manoeuvres (T3) for lie, position, presentation of fetes, FHR
Ix - Urinalysis for glucosuria, ketones, proteinuria,
Vaccination recommend in pregnancy
Influenza
dtpa at 28 - 32 wks
Normal symptoms of pregnancy
Morning sickness - Hormonal, Diet/antiemetics
Constipation - progesterone, diet/laxatives
Heart burn - enlarged uterus, Semi-recumbent/antacids
Pelvic pain - lax ligaments, physiotherapy, belts
Varicose Veins/Haemorrhoids - Venous obstruction, rectum, support tights
Carpal tunnel syndrome - Median nerve compression, physiotherapy, surgery in rare cases.
Vaginal discharge - increased vascularity of the vagina/cervix, swabs, reassurance
Consult someone about Amniocentesis
Indications - ID genetic anomalies or assess fetal lung maturity
Advantages - 96% accurate for NTD, Women >35 the risk of chromosomal anomaly (1/180) is greater than the risk of miscarriage from procedures. More accurate than CVS and lower risk of spontaneous abortion.
Disadvantage - 1/400-1/500 risk of spontaneous abortion, Result take 14-28 days. FISH can be cone on chromosomes X,Y, 21, 13, 28 to give preliminary results in 48 hrs
Counsel someone about Chorionic villus sampling
Chorionic villus Sampling - biopsy of fetal derived chorion using a transabdominal needle or trans-cervical catheter at 10-12 wk
Advantages - Enable pre termination earlier than with amniocentesis. Rapid karyotyping and biochemical assay within 48 hr including FISH analysis. High sensitivity and specificity.
Disadvantages - 1-2% risk of spontaneous abortion. Does not screen for NTD, 1-2 % incidence of genetic mosicism “false negative” results.
Blood tests in pregnancy
Booking -
bloods - FBC, Rh, serology for Rubella, HBV, HCV, HIV, Syphilis,
Urine - urine bacteamia
24-26 wk
GTT, FBC, G+H and syphillis
34 wk - FBC, G+H
If Anti D in Rh+ baby - 28wk and 34 wk and again
How to calculate EDD
LMP
applies if regular periods, 28day cycle (29 just add +1), not IVF, not on contraceptions, etc..
LMP -3month +7days +1yr.
USS
Bloods during pregnancy
Urinanalysis - proteinuria, B hCG
Bloods - FBC, Blood group, Antiscreen for Rubella, Syphilis(TPHA,TPPT, FTA), HIV, Hep B, Hep C, Varicella, B hCG,
Repeated at 24-26 wks GTT, FBC, G and H and syphillis, 34 wks FBC and G and H.
Imaging in pregnancy
Dating scan 8-12 wk USS, First trimester screen 11-13+6wk NT with blood for B hCG and PappA 3-5 days prior. Morphology scan 18-20 wk
Iron and folate requirements in pregnancy
Iron 30mg - prevention, tx is 30-120mg
Folate 0.4-1mg or 5mg in high risk
High risk is NTD, DM, anti epileptic meds.
Cx of iron deficiency anaemia
Maternal: Angina, CHF, infection, slower recuperation, preterm labour
Fetal: decreased O2 carrying capacity leading to fetal distress, IUGR, and low birth wt.
Cx of folate deficiency anaemia
Maternal: decrease BV, N/V, anorexia
Fetal: neural tube defects in T1, Low BW, prematurity
