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Antenatal screening Flashcards

1
Q

When is booking appointment done

A

By 10 weeks
If later presentation then must within 2 weeks

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2
Q

What do in antenatal booking appointment

A

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

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3
Q

What is vitamin D advice for pregnant women

A

Should take 10mcg/day

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4
Q

Who should have an OGTT based on identification at booking

A

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)

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5
Q

Management if has any of risk factors for GDM noticed at booking

A

If history of GDM have an OGTT ASAP
If 1 of other rfx then have it at 24-28 weeks

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6
Q

If have had previous GDM and initial OGTT is negative what do

A

Repeat at 24-28 weeks but can also offer self monitoring

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7
Q

When would glycosuria prompt consideration of GDM

A

Glycosuria 2+
Glycosuria 1+ On 2 occasions

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8
Q

Immediate management if diagnosis of GDM made

A

Referral to joint DM and antenatal clinic within 1 week

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9
Q

What is management of GDM

A

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

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10
Q

What type of insulin is used in GDM/ chronic DM

A

Short acting

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11
Q

When consider treating GDM with insulin if fasting glucose under 7

A

Macrosomia
Polyhydramnios

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12
Q

What defines GDM

A

Fasting glucose above 5.6
2 hour glucose is over 7.8
REMEMBER AS COUNTING 5 6 7 8

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13
Q

Management of pre-existing DM

A

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

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14
Q

Targets for self monitoring glucose in GDM

A

Fasting- 5.3
1 hour after eating- 7.8
2 hours after eating- 6.4

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15
Q

Management if history of VTE

A

Antenatal LMWH and until 6 weeks after
If provoked by a major surgery then do from 28 weeks

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16
Q

Assessing VTE risk factors

A

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

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17
Q

When do you advise folic acid to all women

A

400mcg up until 13 weeks

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18
Q

What is monitored in antenatal urine dips

A

Asymptomatic bacteriuria
Glycosuria
Protein

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19
Q

Management if develop heartburn during pregnancy

A

Advise about diet changes
If does not work then can trial antacids or alginate

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20
Q

Management of recurrent pelvic girdle pain

A

Refer to physio and consider non-rigid lumbopelvic belt

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21
Q

Management of abnormal vaginal discharge in pregnancy

A

Reassure that it is normal
If symptomatic at all then consider high vaginal swab

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22
Q

Treating vaginal candidiasis in pregnancy

A

Vaginal clotrimazole

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23
Q

Treating bacterial vaginosis in pregnancy

A

Can treat with twice daily metronidazole or intravaginal metronidazole gel
If recurrent change the treatment method

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24
Q

Management if unexplained bleeding post 13 weeks in pregnancy

A

Refer to secondary care
If rhesus negative give anti-D

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25
Ideal preparation for dating scan
Come with a full bladder
26
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
27
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
28
What does combined test include
B-HcG and PAPP-A from mothers blood Nuchal translucency
29
What does quadruple test include
B-HcG Inhibin A Unconjugated oestriol AFP
30
What indicates down syndrome on combined test
Thickened nuchal translucency High bHCG Low PAPPA-A
31
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
32
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
33
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
34
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
35
What invasive diagnostic tests are offered for screening of chromosomal disorders
Amniocentesis Chorionic villous sampling
36
What is screened for in booking visit bloods
HIV Hep B Syphillis Red cell autoantibodies Haemoglobinopathies Anaemia
37
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
38
What is sensitivity and specificity of NIPT
99%
39
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
40
How is a babies growth assessed at anomaly scan
Crown rump length Femur length Abdominal circumfrence Biparietal diameter
41
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
42
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
43
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
44
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
45
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
46
When is anti-D antibodies given
28 weeks 34 weeks Can give just at 28 weeks depends on site
47
What is done at 34 week visit
BP and urine dip Measure SFH Discuss birth plan and give information on them
48
What is done at 36 week visit
BP and urine dip Measure SFH Check presentation and offer ECV Discuss neonatal management and breastfeeding
49
What is done at 38 week visit
BP and urine dip SFH Information about prolonged pregnancy
50
What is done at 41 week visit
Measure BP and urine dip Offer induction of labour
51
When are bloods taken in pregnancy
Booking and 28 weeks
52
How long are pregnnacy VTEs treated for
3 months after
53
Management if VTE provoked by major surgery
Antenatal LMWH from 28 weeks and 6 weeks postnatally
54
What can cause folic acid deficiency
Methotrexate Phenytoin Pregnancy Alcohol IBD
55
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
56
What dose of folic acid is given to all pregnant women up until end of first trimester
400mcg
57
What is sensitisation with regards to rhesus
Process whereby fetal RhD positive RBCs enter maternal circulation when mother is RhD negative which can cause antibodies to form which haemolyse fetal RBCs
58
What is purpose of giving anti-D
If fetal RBC have entered maternal circulation then these can destroy all of them before sensitisation occurs
59
What events indicate anti-D administration
Delivery of any rhesus-D infant Any termination of pregnancy Miscarriage if gestation over 12 weeks Ectopic pregnancy managed surgically Evacuation of miscarriage ECV Antepartum haemorrhage Trauma to abdomen Amniocentesis Chorionic villous sampling
60
Post natal management of rhesus negative mothers
Cord blood taken and coombs test done Give anti-D
61
What is kleihauer test
Determines proportion of fetal RBCs present
62
If possible sensitisation event occurs in second/trimester of rhesus negative pregnancy what do
Large dose of anti-D and perform Kleihauer test
63
How is LMWH treatment for DVT monitored in pregnancy
Anti-Xa activity
64
Who is treatment with LMWH monitored in
Those at extremes of weight (under 50kg or over 90kg) Renal impairment Recurrent VTE
65
Symptoms of GDM
Polyuria and polydipsia
66
How does OGTT work
Fast for 8-10 hours including water Take fasting blood glucose Glucose drink then measure glucose 2 hours later
67
Causes of raised AFP in pregnancy
Gastro wall defects Neural defects Multiple pregnancies Pataus
68
Causes of low AFP in pregnancy
Maternal DM Edwards Downs
69
When is a kleihauer test indicated
Any sensitising event after 20 weeks
70
If want invasive testing for congenital syndromes what determines options available
Chorionic villous sampling between 11 and 13+6 Amniocentesis from 15 weeks onwards
71
What are cutoffs for treating anaemia in pregnancy
First trimester- 110 Second anf third- 105 Post partum -100
72
How is anaemia treated in pregnancy
Oral iron and recheck in 2 weeks If no response then refer to combined obs/haematology clinic where will do haematinics
73
What do if cant tolerate iron supplements
Refer to secondary care for parenteral iron
74
What is ferritin cutoff for treating IDA in pregnancy
Anything less than 30 should be treated
75
If someone is diabetic what test should be done to assess before trying to conceive
HbA1c
76
What are risks if diabetic mother
Increased miscarriage rate Risk of cardiac abnormalities Macrosomia Increased birth injuries Perinatal mortality
77
What do with thyroxine dose if hypothyroid and pregnant
Increase by 25mcg and repeat TFTs in 2 weeks to ensure euthyroid
78
When monitor TFTs if hypothyroid and pregnant
2 weeks after a dose change Once a trimester
79
What is fetal hydantoin syndrome
Constellation of symptoms caused by taking phenytoin or carbamezepine in pregnancy
80
Symptoms of fetal hydantoin syndrome
IUGR Cleft lip Intellectual disability Hypoplastic fingernails Distal limb deformities
81
What defines proteinuria
Urinary protein of over 300mg/24 hours
82
What do if hypertensive woman wants to start getting pregnant
Stop ARB/ACEi and switch to labetalol
83
If CTG questionable despite changing position and are fully dilated what do
Fetal sampling to assess lactate and pH
84
How often should women with existing DM be monitored in pregnancy
Every 2 weeks in joint antenatal diabetes
85
What volume constitutes polyhydramnios
Over 2L
86
What is best anti-epileptic during pregnancy
Lamotrigine or carbamezepine
87
Risks of using NSAIDs in pregnancy
PPHN Oligohydramnios Premature closure of DA
88
Which is best analgesic in pregnancy
Paracetamol
89
How is DVT in pregnancy treated
Treatment dose LMWH until at least 6 weeks post natally Should always be for at least 3 months
90
If metformin is not tolerated in GDM what use instead
Glibenclamide- sulphonylurea
91
What is exercise recommendation for pregnancy
30 mins of moderate exercise a day - swimming, brisk walking, strength training
92
If obese in pregnnacy how managed
BMI over 30 refer to dietitian BMI over 40 refer to obsetrician
93
What are options for rhesus administration regime
Single 1500IU dose at 28 weeks 2 500IU doses at 28 and 34 weeks
94
If taking an enzyme inducing anti-epileptic, what is important peripartum management
Take 1mg IM vitamin K
95
What is association of phenytoin in pregnancy
Cleft lip
96
What is maangement of methotrexate use if trying to conceive
Both partner and patient must stop 6 months before trying
97
What criteria determines approriateness of a screening programme for a disease
Wilson
98
Main risk to baby at birth of ICP
Meconeum ingestion
99
What are 5 points to saving babies lives bundle
Set of legislation aimed at reducing incidence of still births 1. Reducing smoking impact 2. Awareness of RFM 3. Proper monitoring in labour 4. Identifying FGR 5. Preventing pre-term
100
How is smoking in pregnancy assessed
CO testing at booking and then at 36 weeks
101
How is CO measurement assessed
Above 4ppm then offer referral to assisted smoking cessation services and serial measurements
102
Which women are inappropriate for monitoring with SFH
BMI over 35 Fibroids
103
How are women inappropriate for monitoring with SFH monitored
USS every 4 weeks from 32 weeks
104
What is management if EFW or abdo circumfrence under 10th percentile at anomaly scan
Serial USS
105
What are moderate risk factors for FGR
Previous SGA Smoker at booking Previous stillbirth Drug misuse Age over 40
106
Management if moderate rfx for FGR
USS every 4 weeks from 32 weeks
107
What are high risk factors for FGR
Medical history - Maternal medical conditions [chronic kidney disease, hypertension, autoimmune disease (SLE, APLS), cyanotic congenital heart disease] Obstetric history - Previous FGR - Hypertensive disease in a previous pregnancy - Previous SGA stillbirth Current pregnancy - PAPPA <5th centile - Echogenic bowel - Significant bleeding - EFW <10th centile
108
Management if high risk factors for FGR
Do additional uterine artery doppler
109
Assessment of additional uterine artery doppler done in high risk of FGR
Normal- serial USS from 32 weeks Abnormal with EFW above 10th percentile- serial USS from 28 weeks Abnormal with EFW below 10th percentile- discuss with feotal medicine
110
Interpretation of uterine artery doppler
Best Raised pulsatility index above 90th percentile Reduced end diastolic flow Absent end diastolic flow Reversed end diastolic flow Worst
111
Is chemo contraindicated in pregnancy
Yes in the first trimester however in the 2nd and 3rd is possible
112
How long after chemo treatment is labour recommended
2-3 weeks to allow for regeneration of the BM
113
If in question asks for investigation for PE what suggest
VQ
114
What positiion do you need to put woman in when having an eclamptic fit
Left sided tilt
115
Best way of assessning EDD before and after 14 weeks
Before 14- crown rump length After 14- Biparietal diameter
116
If refuse induction of labour at 42 weeks what is needed
Twice weekly CTG and USS
117
What is involved in triple test
AFP bHCG Oestriol
118
Triple test for downs
High bHCG Low AFP Low oestriol
119
What physiologically causes a raised AFP
A break in foetal skin normally caused by spina bifida and anencephaly
120
What condition is hypothyroidism associated with in pregnancy
Pre-eclampsia
121
What is most appropriate method for monitoring SGA
Doppler of umbilical artery
122
If SFH is noted to be faltering, what is next thing do
USS to estimate foetal size
123
What are indications to do an USS to estimate foetal size
SFH faltering SFH below 10th centile
124
Management if epileptic has seizure during labour
IV lorazepam Second line IV phenytoin and tocolysis
125
Differentiating acute fatty liver and HELLP
Anaemia only in HELLP Hypoglycaemia in acute fatty liver
126
If pregnant or peuperal comes in with suspicion of DVT what do
LMWH and duplex USS
127
What do if pregnant or peuperal woman has come in with DVT suspicion and duplex USS negative despite high suspicion
Treat anyway and rescan on days 3 and 7
128
If pregnant or peuperal woman comes in presenting with PE what do
ECG and CXR with treatment
129
If pregnant or peuperal woman comes in with PE and DVT signs what do
ECG and CXR with treatment Duplex USS
130
If pregnant or peuperal woman has comes in with DVT and PE signs with positive duplex what do
No further investigations needed
131
If pregnant or peuperal woman has comes in with DVT and PE signs with negative duplex what do
CTPA or V/Q
132
If pregnant or peuperal woman has comes in with PE and no DVT signs what do
CTPA or V/Q
133
If CXR is abnormal in PE work up what investigation do
CTPA preferred
134
What do if 2 risk factors for VTE
Anticoagulate for 10 days post partum
135
If refuse insulin what offer
Glibenclamide
136
What is biggest risk factor for stillbirth
IUGR
137
What is only thing known to reduce preeclampsia risk
Smoking
138
What can be used to treat polyhydramnios
Indomethacin

Obs (Owen) (9 decks)

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