Antenatal Problems

Question 1

What are minor disorders of pregnancy?

Answer 1

Itching
Symphisis Pubis Dysfunction
Abdo pain
Heartburn
Ankle oedema - sudden change warrants investigation
Leg cramps
Carpal tunnel syndrome
Vaginitis
Tiredness
Backache
Constipation

Question 2

Peak onset of hyperemesis gravidarum?

Answer 2

6-11 weeks

Question 3

Signs of hyperemesis gravidarum?

Answer 3

Dehydration with large amounts of ketones in the urine and liver tenderness

Question 4

Management of hyperemesis gravidarum if not tolerating oral food/fluids?

Answer 4

Admission

IV rehydratio and antiemetics (cyclizine or promethazine) 
Vitamin supplementations (B1) if prolonged
Last resort = high dose corticosteroids

Question 5

Foetal consequences of hyperemesis gravidarum?

Answer 5

Growth restriction - serial growth scans needed later in prego

Question 6

When should you be aware of foetal movements?

Answer 6

20 weeks (sometimes 18)
Plateau at 32 weeks but shouldn't reduce in frequency

Question 7

Risk factors for reduced foetal movements?

Answer 7

Sedating drugs that cross placenta (alcohol, opiates)
Anterior lying placenta (up to 28 weeks)
Corticosteroids
Position of baby

Question 8

What should you advise the woman does in reduced foetal movements?

Answer 8

Contact maternity unit and be seen the same day

Question 9

Management of reduced foetal movements? (>28 weeks)

Answer 9

If auscultation shows heartbeat, and no risk factors for RFM or stillbirth –> reassure

Otherwise:

1. Viability (auscultation)
2. CTG (then if normal…)
3. USS (abdo circumfrence/weight to see if small for GA)

If all normal - reassure and contact if happens again

Question 10

Management of reduced foetal movements? (<28 weeks)

Answer 10

Auscultate foetal heart rate

If present, assess foetus for neuromuscular conditions

Question 11

Definition of small for dates and IUGR?

Answer 11

SFD = weight or estimated weight below 10th/5th/3rd centile
IUGR = implies compromise - growth has slowed or is less than expected taking into account constitutional factors.

Question 12

Constitutional determinants and pathological determinants of small for dates?

Answer 12

Constitutional = low maternal weight/height, nulliparity, asian, female foetal gender

Pathological = maternal disease (renal/AI), maternal complications (pre-eclampsia), multiple pregnancy, smoking, drug use, infection, extreme malnutrition, congenital abnormalities

Question 13

Complications of IUGR?

Answer 13

Preterm delivery and cerebral palsy more common

Question 14

Examination and investigations of small for dates?

Answer 14

Serial measurement of symphisis-fundal height
BP/urinalysis - screen for pre-eclampsia

Serial USS and umbilical artery doppler - oligohydramnios, head sparing
CTG

Question 15

Management of SFD/IUGR?

Answer 15

SFD only - growth scans at fortnightly intervals. Consistent growth and normal doppler –> no intervention

IUGR
Term - deliver
34-37 weeks - regular doppler, daily CTG, consider delivery
<34 weeks - steroids, regular doppler, daily CTG, consider delivery if CTG abnormal

Question 16

Risk factors for large foetus?

Answer 16

Male infant sex, multiparity, maternal age 30-40, white race, diabetes, gestational age >41 weeks

Question 17

Complications of large foetus?

Answer 17

Increased likelihood of C section
Shoulder dystocia
Chorioamnionitis
Fourth degree perineal laceration
PPH

Question 18

Definition of large for dates? What to do next?

Answer 18

> 90th percentile on customised growth chart (abdominal circumfrence)

OGTT for mum - if abnormal, refer to diabetes

Question 19

Monitoring of large for dates foetus?

Answer 19

Plot growth on customised growth chart, confirm size on scan at 36 weeks

Question 20

Management of large for dates foetus?

Answer 20

Macrosomia alone is not good enough reason for elective C section.

At 41 weeks:
BMI <30, favorable cervix - induction of labour at 41+4
BMI >30, unfavorable cervix - induction of labour or LSCS

Question 21

Definition of prolonged pregnancy? What is the risk?

Answer 21

> 42 weeks completed gestation

Risk of perinatal morbidity/mortality increases between 41 and 42 weeks (absolute risk of problem is still small)

Question 22

Management of prolonged pregnancy?

Answer 22

Check gestation carefully.
Induction before 41 weeks inappropriate unless complications present.

At 41 weeks - examine patient vaginally and induce unless cervix unfavorable or patient prefers to wait
If no induction - stretch and sweep, daily CTG
If CTG abnormal - delivery whatever the conditon of cervix (possibly LSCS)

Question 23

What is PPROM?

Answer 23

Rupture of membranes before labour at <37 weeks. Occurs before 1/3 of preterm deliveries

Question 24

Complications of PPROM?

Answer 24

Preterm delivery (within 48h in 50%)
Chorioamnionitis
Prolapse of umbilical cord
Absence of liquor (before 24 weeks)

Question 25

History of in PPROM?

Answer 25

Gush of clear fluid, followed by further leaking

Question 26

Examination in PPROM?

Answer 26

Check lie and presentation
Pooling of blood in posterior fornix on sterile speculum
DO NOT PERFORM UNNECESSARY DIGITAL VAGINAL EXAMINATION

Question 27

Investigations in PPROM?

Answer 27

USS - may show reduced liquor
Infection - HVS, FBC, CRP, maternal obs
CTG - foetal wellbeing

Question 28

Management of PPROM?

Answer 28

1. Admit for 24-48 hours
2. Steroids - betamethasone 12mg IM x2 doses 24 hours apart
3. Abx - erythromycin 250mg QDS x 10 days

If >34 weeks –> induction
If not - send home with monitoring (ANDU twice a week) until 34 weeks.