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Antenatal Obstetrics 1 Flashcards

1
Q

Aims of antenatal care?

A
  1. Identify mothers who need medical attention
  2. Detect + manage pre-existing maternal disorders, comps of pregnancy, foetal comps, and others that may affect pregnancy outcome
  3. Detect congenital foetal probs if requested
  4. Plan with the mother the circumstances of delivery
  5. Provide education and advice about lifestyle & minor symptoms of pregnancy
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2
Q

Antenatal appointments of multiparous woman?

A
  • 7 antenatal appointments for multiparous

o Booking (ideally by 10wks) then seen at 16, 28, 34, 36, 38 & 41 weeks

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3
Q

Antenatal appointments of nulliparous woman?

A
  • 10 antenatal appointments for nulliparous

o Booking (ideally by 10wks) then seen at 16, 25, 28, 31, 34, 36, 38, 40 & 41 weeks

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4
Q

Who is in charge of antenatal care?

A

Seen by midwives which manage care, call in obstetricians if risks or specific needs are identified

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5
Q

What does a booking visit consist of?

A
  • Full obstetric history
  • Examination
  • Tests
  • Screening
  • Determining Risk
  • Advice
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6
Q

Information needed from full obstetric history at booking visit?

A

o Planned pattern of care

o EDD - LMP + 7/7 + 9/12 = EDD (e.g LMP: 21.8.11 EDD: 28.05.12) then dating USS (10-13wks +6days)

o Particularly FH of diabetes, hypertension, foetal abnormalities, inherited disease or twins

o Concurrent illness, risk assess for VTE and if high risk – refer to obstetrics

o Is GDM a risk?

 Screen at 28 weeks if BMI>30, previous baby >4.5kg, 1st degree relative diabetic, family origin from area at high risk of diabetes

 If previous GDM, screen at 16 and 28 weeks

o Past mental illness – assessment with prenatal mental health team

o Women born outside UK

o Unsupported women - Ask about domestic violence, substance abuse, healthy start vitamins (folic acid, vitamins C & D are free to some on healthy start scheme)

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7
Q

Examinations performed at booking visit?

A

o Check heart, lungs, BP, weight (BMI), abdomen

o Is smear needed? Varicose veins?

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8
Q

Routine screening tests performed at booking visit? When is chlamydia screened for? When is a CXR or Mantoux needed?

A

o Blood glucose

o Blood (opt out tests) - FBC (Hb), Blood group/antibody screen, Haemoglobinopathies (sickle cell or thalassaemia), Syphilis, HepB, HIV

o Urinalysis & culture for asymptomatic bacteruria

o Women <25 – encourage screening for chlamydia

o CXR and Mantoux – if from area endemic with TB or TB contact

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9
Q

Screening performed at booking visit?

A

o Screening for chromosomal and structural abnormalities offered at booking visit

 Dating scan also confirms EDD

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10
Q

Risk assessment done at booking visit?

A

o High risk need to directed to relevant clinics (miscarriage clinic, joint endocrine clinic, child protection concerns, teenage pregnancy, Leeds addiction unit

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11
Q

General advice at booking visit?

A

 All meds avoided in 1st trimester.

 Diet well balanced- at least 2500calories

 Folic acid supplementation (0.4mg folic acid daily) while trying to conceive + for at least 12 weeks during preg

 Vit D- (Asian) women- less sunlight exposure

 Dental check-up and exercise.

 VTE risk decreased by good hydration, low dose of aspirin or heparin if high risk of VTE

 Maternity pay is for up to 26wks

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12
Q

Alcohol advice at booking visit?

A

 max of 1 drink/day. <15units/week

 incd alcohol: decd birthweight, decd child intelligence, fetal alcohol syndrome (growth restriction and neuro abn)

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13
Q

Smoking advice at booking visit?

A

 Reduces fertility, Incd risk of miscarriage, placecntal abruption, preterm labour, IUGR and perinatal mortality

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14
Q

Drug use advice at booking visit?

A

 Preterm labour and incd perinatal mortality and drug dependence in the neonate

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15
Q

Planning pregnancy care advice at booking visit?

A

 Consultant led care - for high risk women. Led in hospital. GP + midwife + obstritician

 Clinics (renal, hypertension, CV, mental health, haematology, bariatric, neurology, endocrine, young women clinics)

 Community care: midwives and GP

 Advice on MAC, EPAU services

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16
Q

Other advice at booking visit?

A

o Correct use of seat belts (above or below bump, not over)

o Antenatal classes, information on maternity benefits, including free dental care

o Usual exercise and travel OK up to 36 weeks – check with airline

 Many require fit to fly letter beyond 32 weeks

o Intercourse OK if no vaginal bleeding

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17
Q

Details of the 11-13+6 week scans?

A
  • Dating Scan +/- combined screening test for Down’s
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18
Q

How is dating scan performed?

A

o Crown-Rump length measured

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19
Q

When are women offered Down’s syndrome testing? What tests and when? What if thats not possible?

A

o All pregnant women offered (opt in) screening for Down’s syndrome (by end of 1st trimester 13+6)

o Combined test (11+0 – 13+6) should be offered.

 Nuchal translucency

 Beta-human chorionic gonadotrophin (BhCG)

 Pregnancy associated plasma protein A (PAPPA)

o When not possible to measure NT (due to fetal position or  BMI) offer women serum screening (triple or quadruple test) between 15+0 and 20+0

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20
Q

Details of 16 week scan?

A
  • Review results of all screening/blood tests o Investigate iron <11g/100ml and consider iron supplementation
  • BP
  • Urinalysis – test for protein
  • Information on routine anomaly scans and information supported by antenatal classes
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21
Q

Details of scans at 18+0-20+6 weeks?

A
  • Anomaly scan
  • USS to detect structural abnormalities

o Reproductive choice (termination of pregnancy)

o Parents to prepare for any treatment/disability/palliative care/terminaton.

o Managed birth in a specialist centre - anomaly found, refer to obstetrician/foetal medicine

o Intrauterine therapy

  • If placenta extends across internal cervical os, another scan at 32 weeks
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22
Q

Details of 25 week visit? When is this offered?

A

25 Weeks (Nulliparous)

  • Measure and plot symphysis-fundal height (SFH)
  • BP - Urinalysis – test for protein
  • MATB1 Form

o Enabling a pregnant woman to claim Statutory Maternity Pay (SMP) from her employer or Maternity Allowance (MA) from Job Centre

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23
Q

Details of 28 week visit?

A

28 Weeks

  • Second screening for anaemia and atypical red-cell alloantibodies

o Investigate iron <10.5g/100ml and consider iron supplementation

  • Offer anti-D prophylaxis (to Rh -ve women)
  • BP, urinalysis, SFH
  • MATB1 (multip)
  • Ensure Breastfeeding checklist is completed
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24
Q

Details of 31 week visit and when is this offered?

A

31 weeks (Nulliparous)

  • BP, SFH, urinalysis
  • Discuss results of screening tests taken at 28 weeks, reassess planned pattern of care for pregnancy
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25
Details of 34 week visit?
- Offer 2nd dose of Anti-D to rhesus-negative women - BP, urinalysis, SFH - Discuss results of screening tests taken at 28 weeks, reassess planned pattern of care for pregnancy - Discuss bed sharing
26
Details of 36 week visit?
- BP, SFH, urinalysis - Check position of baby - For babies in breech position – offer external cephalic version (ECV)
27
What information should be discussed at 36 week visit?
o Discuss labour, birth and coping strategies (Birth Plan) o Recognition of active labour o Care of the new baby o Breastfeeding information (including technique and good management practices that help women succeed) o Vit K prophylaxis o Newborn screening test o Post-natal self care o Awareness of ‘baby blues’ and postnatal depression. o ECV should be offered if breech presentation
28
Details of 38 week visit?
- BP, SFH, urinalysis - Information o Arrange post dates appointment o Options for management of prolonged pregnancy. o Discuss IOL Discuss membrane sweep (Multip)
29
Details of 40 week visit? When is this offered?
40 Weeks (nulliparous) - BP, urinalysis, SFH - Information o Arrange post dates appointment o Discuss IOL o Discuss membrane sweep (Primip)
30
Details of 41 week visit?
41 Weeks (if woman hasn’t given birth) - Membrane sweep - Induction of labour offered and booked - BP, SFH, urinalysis
31
Define gravidity?
- Total number of pregnancies, regardless of outcome
32
Define parity?
- Total number of pregnancies delivered over threshold of viability (24+0 weeks in UK) - Twins count as 1
33
Tests used to screen for chromosomal abnormalities?
Screening Tests  Widely available, non-invasive, safe  Good detection rate  Provides a measure of risk of being affected by certain condition (e.g. 1 in 100)  If high risk, must have diagnostic tests Diagnostics Tests  Often invasive  Definitively confirms or rejects diagnosis  Implications of disorder must be serious enough to warrant invasive test
34
When should Downs syndrome screening test be offered? Success?
- Pregnant women should be offered screening for the condition regardless of their age - Opt in test - Screening techniques must have a detection rate 85% and a false positive rate of \<3%
35
When is Down's syndrome combined test offered?
o Scan and blood test at 11 to 13+6 weeks.
36
How is Down's syndrome combined test performed?
o Nuchal Translucency  USS of the subcutaneous tissue between the skin and the soft tissue overlying the cervical spine with the foetus in the neutral position.  Determines viability, dates, diagnoses multiple pregnancies o A blood test measuring:  Pregnancy associated plasma protein A (PAPP-A)  Β-human chorionic gonadotrophin (hCG)
37
Risk of Down's syndrome in combined test expressed?
o Calculated by multiplying the background maternal age and gestation-related risk by a likelihood ratio derived from the NT measurement and the two blood tests. o Risk of 1:150 or less is high risk (2% of women)  Offered pre-natal diagnosis
38
Advantages of Down's syndrome combined test offered?
o Performance ~90% detection for 5% FPR o May detect other abnormalities such as anenecephaly. o An increased NT is also a marker for structural defects (e.g. cardiac malformations). o Acceptable detection of all trisomies.
39
Disadvantages of Down's syndrome combined test offered?
o Expensive and difficult to perform nuchal scan
40
When and how is quadruple test in Down's syndrome screening performed?
o Dating scan o Uses oestriol, hCG, AFP and inhibin A between 15+0-20 weeks (useful if woman presents in 2nd trimester) o 80% detection rate for 5% false positive rate
41
Risk of quadruple test in Down's syndrome screening expressed?
o Calculated by multiplying the background maternal age and gestation related risk by a likelihood ratio derived from the two stages of blood tests.
42
Advantages of quadruple test in Down's syndrome screening performed?
o Good detection rate o By not relying on a nuchal scan, may be cheaper and easier to perform.
43
disadvantages quadruple test in Down's syndrome screening performed?
o Little experience in practice. o Two stage screen so result only available after 15 weeks. o Not useful for multiple pregnancies
44
What invasive diagnostic tests are used in Down's syndrome?
o Chorionic villus sampling (10-13+6 weeks) – 1% miscarriage risk o Amniocentesis (\>15 weeks) – 1% miscarriage risk
45
How is CVS performed in Down's syndrome diagnosis?
o Chorionic villus sampling (10-13+6 weeks) – 1% miscarriage risk * CVS involves a needle through the transabdominal/transcervical to take a sample of the placental cells through ultrasound guidance (trophoblast cells) * Karyotyping, FISH, PCR, rapid analysis done
46
Indications for CVS performed in Down's syndrome diagnosis?
* For karyotyping if 1st trimester screening test suggests high risk for aneuploidy. * For DNA analysis if parents are carriers of an identifiable gene mutation such as CF or thalassaemia
47
Benefits of CVS performed in Down's syndrome diagnosis?
• Allows 1st trimester TOP if an abnormality is detected (surgical/medical and before the pregnancy has become physically apparent).
48
Risks of CVS performed in Down's syndrome diagnosis?
* Miscarriage as a result of CVS is estimated at ~1%. * Increased risk of vertical transmission of blood borne viruses such as HIV and hep B. * False negative results (rare) from contamination with maternal cells. * Placental mosaicism producing misleading results - estimated at \<1%.
49
How is amniocenetesis performed in Down's syndrome diagnosis?
o Amniocentesis (\>15 weeks) – 1% miscarriage risk • It involves aspiration of amniotic fluid which contains fetal cells shed from the skin and gut using a fine gauge needle under ultrasound guidance transabdominally
50
Indications of amniocenetesis performed in Down's syndrome diagnosis?
* For karyotyping if screening tests suggest aneuploidy. * For DNA analysis if parents are carriers of an identifiable gene mutation such as CF or thalassaemia. * For enzyme assays looking for inborn errors of metabolism. * For diagnosis of fetal infections such as CMV and toxoplasmosis
51
Benefits of amniocenetesis performed in Down's syndrome diagnosis?
* Lower procedure attributed miscarriage rate than CVS ~1%. * Less risk of maternal contamination or placental mosaicism.
52
Risks of amniocenetesis performed in Down's syndrome diagnosis?
* Miscarriage as a result of amniocentesis is estimated at 1%. * Failure to culture cells = ~0.5% * Full karyotyping may take 3 weeks.
53
How long do diagnostic tests take to come back for Down's syndrome?
o Tests give definitive answer of genetic conditions – results take 1-2 weeks o Termination can be done at any time if there is genetic abnormality
54
What is the anomaly scan?
- Anomaly Scan (20 weeks) o Detailed USS o Takes around 30 minutes to complete o Aim to identify structural abnormalities
55
What does the anomaly scan identify?
 Head shape and internal structures: • Cavum pellucidum , cerebellum, ventricular size at atrium \<10 mm, nuchal fold  Spine  Longitudinal and transverse views.  Thorax at the level of the cardiac ‘four chamber’ view, outflow tracts  Abdominal shape and content at the level of - stomach, kidneys, umbilicus, bladder  Renal pelvis (\<5mm AP measurement)  Abdominal and thoracic appearance in the longitudinal axis: diaphragm, bladder  Limbs - Arms (three bones and hand), legs (three bones and foot)
56
What abnormalities are identified on anomaly scan?
 Neural tube defects Anencephaly Spina bifida Renal agenesis Posterior urethral valve syndrome Hydronephorisis Lung hypoplasia  Diaphragmatic hernia Congenital cystic adenomatoid malformation (CCAM) Exomphalos (omphalocele) Gastroschisis Gastrointestinal obstruction  May be associated with trisomy 21, 18 or other congenital abnormalities.  Ventricular septal defects are most common
57
Describe what foetal growth scans entails?
o Head circumference and abdominal circumference used to calculate foetal weight o Liquor volume used to assess pattern of growth o Scans should be \>2 weeks apart o Used: growth restriction, pre-eclampsia, small for dates
58
What is antenatal day unit/MAU?
- Emergency and follow-up antenatal care for women over 18 weeks gestation with specific pregnancy-related problems - Midwife-led with support from obstetrician - Open 24 hours a day - Referrals are accepted from General Practitioners and Community Midwives. You can also refer yourself if you are concerned about your baby's movements or think your waters have broken
59
Describe Rhesus haemolytic disorder?
o RhD negative mother delivers RhD positive baby – leak of foetal red cells into her circulation may stimulate anti-D IgG antibodies (isoimmunisation) o Subsequent pregnancies, these can cross placenta and cause worsening RHD o IgG binds to foetal red cells and are destroyed o The ensuing anaemia, if severe precipitates fetal hydrops which is often referred to as immune hydrops
60
When are first pregnancies affected by Rhesus haemolytic disease?
 Threatened miscarriage  APH  Mild trauma  Amniocentesis, CVS  External cephalic version
61
Give examples of sensitising events for Rhesus disease?
 Termination of pregnancy or evacuation of retain products of conception (ERPC) after miscarriage.  Ectopic pregnancy  Vaginal bleeding \>12 weeks or earlier if heavy.  External cephalic version (ECV).  Blunt abdominal trauma.  Invasive uterine procedure (e.g. amniocentesis or CVS)  Intrauterine death  Delivery
62
How many women are Rhesus negative?
o 15% of Caucasian women are Rhesus negative
63
Symptoms and signs of rhesus haemolytic disease?
o Haemolysis then anaemia (haemolytic anaemia) o Mild – Neonatal jaundice, anaemia, bleeding o Severe – Cardiac Failure, hepatosplenomegaly, hypoalbuminemia, hydrops fetalis (oedema of entire body), kernicterus and death
64
Management of rhesus haemolytic disease?
o Identification – antibody titres (\>10U/ml) assessment needed o Assess severity – Doppler of foetal middle cerebral artery, foetal blood sample o Rhesus prophylaxis o Transfusion (if foetal haematocrit \<30) – red packed cells into umbilical vein at cord insertion
65
Postnatal management of rhesus haemolytic disease?
 Check FBC, bilirubin, Rhesus group, Coomb’s test  Transfusion if Hb\<7g/dL  Phototherapy  Extra water  Avoid heat loss, protect eyes, keep baby naked
66
Prevention of rhesus haemolytic disease? Indications? Drug? Dose?
 All women checked for Rh antibodies at booking, 28 and 34 weeks  Indications * Given to Rhesus negative women * Within 72 hours of any potentially sensitising event  Drug • Anti-D immunoglobulin  Dose * 500U at 28 and 34 weeks, still give post-natally if Rhesus positive * IM in deltoid, can go IV/SC if bleeding disorder * After delivery if the neonate is found to be rhesus +ve
67
Epidemiology of constipation in pregnancy?
• Common, tends to decrease as the pregnancy advances
68
Causes of constipation in pregnancy?
* Exacerbated by oral iron, which is given to treat anaemia in pregnancy. * The pressure of the uterus on the rectum during pregnancy. * Progesterone slows the gut motility
69
Symptoms and signs of constipation in pregnancy?
* Lower abdominal pain * Bloating * Difficult stool passage
70
Management of constipation in pregnancy?
* Increase fruit and fibre in diet. * Drink plenty of water. * Regular exercise. * Regular laxatives/stool softeners as necessary but avoid bowel stimulants
71
Epidemiology of reflux in pregnancy?
• Estimated to occur in 70% all pregnancies.
72
Pathology of reflux in pregnancy?
* Relaxation of the oesophageal spinchter (due to progesterone) occurs in pregnancy * Pressure of the gravid uterus on the distal end of the oesophagus, results in an increased incidence of reflux oesophagitis. * Gastric ulceration is less common due to decreased gastric acid secretion
73
Aetiology of reflux in pregnancy?
- Polyhydramnios (excess amniotic fluid in the uterus). - Multiple pregnancy
74
Symptoms/Signs of reflux in pregnancy?
* Epigastric.retroternal burning pain exacerbated by lying flat. * Discomfort * Nausea and vomiting * Bloating • Feeling full quickly after eating • Waterbrash (excessive salivation)
75
Investigations of reflux in pregnancy?
• Exclude pre-eclampsia.
76
DDx of reflux in pregnancy?
Pre-eclampsia can present with epigastric pain.
77
Treatment of reflux in pregnancy?
* Sitting up rather than lying down just after eating, sleeping in a propped-up position on a couple of pillows, and changing the way the woman eats i.e. small frequent meals, and to cut down on high fat foods and caffeine. * Foods that make symptoms worse in some people: spicy meals, peppermint, tomato, chocolate, fatty food, fruit juices, hot drinks, coffee, alcohol. * Alginate preparations like gaviscon reduce reflux symptoms. * Ranitidine (H2 blocker) can be used in severe cases.
78
Epidemiology of headache, palpitations, fainting?
• Commoner in pregnancy
79
Pathology of headache, palpitations, fainting?
• Dilated peripheral circulation
80
Symptoms of headache, palpitations, fainting?
• Increased sweating and feeling hot
81
Treatment of headache, palpitations, fainting?
* Increase fluid intake * Stand slowly if postural
82
Epidemiology of increased urinary frequency?
• More problematic later in pregnancy
83
Pathology of increased urinary frequency?
* Due to pressure of foetal head on bladder in later pregnancy * GFR also increases, increasing urine output
84
Treatment of increased urinary frequency?
* Exclude UTI * Reassure that normal
85
Epidemiology of symphysis pubis dysfunction?
• Common – 10%
86
Patholoy of symphysis pubis dysfunction?
• Due to pelvic ligament and muscle relaxation
87
Symptoms/Signs of symphysis pubis dysfunction?
* Pelvic pain * Discomfort in pubic and sacroiliac joints
88
Treatment of symphysis pubis dysfunction?
* Simple analgesia * Physiotherapy * May need crutches
89
Pathology of carpal tunnel syndrome?
* Compression of median nerve as it passes under flexor retinaculum * Due to fluid retention
90
Symptoms/Signs of carpal tunnel syndrome?
* Night hand pain & tingling felt in thumb, index and middle fingers * Wasted thenar eminence and decreased sensation over lateral 3 ½ digits
91
Investigations of carpal tunnel syndrome?
* Phalen’s Test * Tinnel’s Test
92
Treatment of carpal tunnel syndrome?
* Simple analgesia * Wrist splints until delivery
93
What are the dates of the 1st trimester?
0-12 weeks
94
What are the dates of the 2nd trimester?
13-28 weeks
95
What are the dates of 3rd trimester?
29-40 weeks

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