Antenatal screening Flashcards
When is booking appointment done
By 10 weeks
If later presentation then must within 2 weeks
What do in antenatal booking appointment
History
- obs history
- PMH
- medications
- social- job, smoking, alcohol, illicit drugs
Examination
- BP and BMI
Investigations
- urine dip for asymptomatic bacteriuria, protein ad glycosuria
- bloods- FBC, rhesus D, blood group, screen for auto-antibodies, haemoglobinopathies, Hep-B, syphyllis and HIV
Assess risk of VTE, GDM and pre-eclampsia
Advice
- antenatal classes
- diet
- vitamin D
- screening for infections, blood disorders, anomaly scans
What is vitamin D advice for pregnant women
Should take 10mcg/day
Who should have an OGTT based on identification at booking
People with family history of DM
Previous baby over 4.5kg
BMI over 30
Ethnicity with high DM prevalence
Previous GDM (has OGTT straight away)
Management if has any of risk factors for GDM noticed at booking
If history of GDM have an OGTT ASAP
If 1 of other rfx then have it at 24-28 weeks
If have had previous GDM and initial OGTT is negative what do
Repeat at 24-28 weeks but can also offer self monitoring
When would glycosuria prompt consideration of GDM
Glycosuria 2+
Glycosuria 1+ On 2 occasions
Immediate management if diagnosis of GDM made
Referral to joint DM and antenatal clinic within 1 week
What is management of GDM
Advise about exercise and low glycaemic index foods
If fasting glucose under 7
- lifesyle and exercise first line
- if not met within 2 weeks metformin then second line insulin
- consider treating straightaway with insulin if evidence of macrosomia, polyhydramnios or
If fasting glucose over 7
- use insulin straight away
What type of insulin is used in GDM/ chronic DM
Short acting
When consider treating GDM with insulin if fasting glucose under 7
Macrosomia
Polyhydramnios
What defines GDM
Fasting glucose above 5.6
2 hour glucose is over 7.8
REMEMBER AS COUNTING 5 6 7 8
Management of pre-existing DM
Ensure low BMI
Good exercise and diet
Folic acid until end of first trimester
Stop all hypoglycaemics except insulin and metformin
Screen for renal and retinal damage within first 3 months
Targets for self monitoring glucose in GDM
Fasting- 5.3
1 hour after eating- 7.8
2 hours after eating- 6.4
Management if history of VTE
Antenatal LMWH and until 6 weeks after
If provoked by a major surgery then do from 28 weeks
Assessing VTE risk factors
Look at table of rfx
If 2 then LMWH for 10 days post partum
If 3 then LMWH from 28 weeks but make postnatal assessment
If 4 or more then LMWH through whole pregnancy but make postnatal assessment
When do you advise folic acid to all women
400mcg up until 13 weeks
What is monitored in antenatal urine dips
Asymptomatic bacteriuria
Glycosuria
Protein
Management if develop heartburn during pregnancy
Advise about diet changes
If does not work then can trial antacids or alginate
Management of recurrent pelvic girdle pain
Refer to physio and consider non-rigid lumbopelvic belt
Management of abnormal vaginal discharge in pregnancy
Reassure that it is normal
If symptomatic at all then consider high vaginal swab
Treating vaginal candidiasis in pregnancy
Vaginal clotrimazole
Treating bacterial vaginosis in pregnancy
Can treat with twice daily metronidazole or intravaginal metronidazole gel
If recurrent change the treatment method
Management if unexplained bleeding post 13 weeks in pregnancy
Refer to secondary care
If rhesus negative give anti-D
Ideal preparation for dating scan
Come with a full bladder
What happens at dating scan
Estimated date of delivery
Check if more than 1 pregnancy
That it is growing in the correct place
Detect any gross anomalies
Nuchal translucency if opted in
If opt in for congenital syndrome screening what are options
If book early then offered between 11 and 13+6 weeks the COMBINED test
Between 14+2 and 20+0 offered QUADRUPLE test
What does combined test include
B-HcG and PAPP-A from mothers blood
Nuchal translucency
What does quadruple test include
B-HcG
Inhibin A
Unconjugated oestriol
AFP
What indicates down syndrome on combined test
Thickened nuchal translucency
High bHCG
Low PAPPA-A
What indicates edwards or pataus in combined test
Thickened nuchal translucency
Low PAPP-A
Raised bHCG too but no where near as high as in down’s
How does combined and quadruple test categorise people
Into either high or low chance
Low- more than 1 in 150 chance
High- less than 1 in 150 chance
What qualifies someone for extra testing after combined or quadruple tests
If chance is lower than 1 in 150 then can be offered second screening test the NIPT or invasive diagnostic testing for the syndromes
How does non-invasive prenatal testing work
Is a blood test which involves analysing cell free fetal DNA (cffDNA) which is DNA from placental cells which have broken off from placenta which are identical to DNA of foetus
What invasive diagnostic tests are offered for screening of chromosomal disorders
Amniocentesis
Chorionic villous sampling
What is screened for in booking visit bloods
HIV
Hep B
Syphillis
Red cell autoantibodies
Haemoglobinopathies
Anaemia
What are quadruple test results for downs, edwards, pataus or neural tube defects
Downs- HIgh, bHcg, InhIbIn
Edwards- HEs down, low Hcg and Estradiol
Pataus- think P, high AFP
Neural tube defect- high AFP
What is sensitivity and specificity of NIPT
99%
What is done at anomaly scan
Check location of placenta
Babies growth
Sex of baby if want
Checking for 11 conditions and offering options surrounding
- termination
- management if necessary
How is a babies growth assessed at anomaly scan
Crown rump length
Femur length
Abdominal circumfrence
Biparietal diameter
What do at 16 week visit
Discuss results of blood tests
- infections
- autoantibodies
- rhesus D
- Hb and folate etc
Treat Hb
Offer vaccinations
- pertussis
- influenza ideally in Oct-jan
Discuss mid-pregnnacy scan
What are the dates of 7 normal antenatal visits if uncomplicated and not nullioarous
Booking
16 weeks
28 weeks
34 weeks
36 weeks
38 weeks
41 weeks
What are dates of 10 antenatal visits if uncomplicated and nulliparous
Booking
16 weeks
25 weeks
28 weeks
31 weeks
34 weeks
36 weeks
38 weeks
40 weeks
41 weeks
What is done at extra primip meetings
25 and 31
- measure SFH
- BP and urine dip
40
- measure SFH
- BP and urine dip
- offer membrane sweep
What is done at 28 week visit
BP and urine dip
Measure SFH
Bloods for second screening of
- antibodies
- Hb
- folate and B12
Offer first anti rhesus D
When is anti-D antibodies given
28 weeks
34 weeks
Can give just at 28 weeks depends on site
What is done at 34 week visit
BP and urine dip
Measure SFH
Discuss birth plan and give information on them
What is done at 36 week visit
BP and urine dip
Measure SFH
Check presentation and offer ECV
Discuss neonatal management and breastfeeding
What is done at 38 week visit
BP and urine dip
SFH
Information about prolonged pregnancy
What is done at 41 week visit
Measure BP and urine dip
Offer induction of labour
When are bloods taken in pregnancy
Booking and 28 weeks
How long are pregnnacy VTEs treated for
3 months after
Management if VTE provoked by major surgery
Antenatal LMWH from 28 weeks and 6 weeks postnatally
What can cause folic acid deficiency
Methotrexate
Phenytoin
Pregnancy
Alcohol
IBD
In which women do you advise taking 5mg folic acid while trying to conceive
BMI over 30
Either partner has a neural tube defect
History of thalassaemia, coeliac, diabetes
Taking an anti-epileptic drug