Antepartum Care Flashcards
preconception counselling issues
- folic acid - 0.4mg x3 mo, decrease risk 70% of NTD
- age - SA, chronomosal issue, infertility
- BMI
- immunization - rubella + varicella
- genetic risk: ethnicity and fam hx
- medical conditions - optimize
- meds: no ACEi, no wafrarin, anti-epileptics
- Ob Hx - 3 SA or any mid-trimester, work-up
- ASA:
- sochx - DV, drugs, alc, smoking, exercise
when to work-up for preg loss + what to do
- 3 consecutive SA or 1 midtrimester:
- thrombophilia testing
- sonohyst
- genetics/karyotype
- ASA if inidcated
- clerclage at 13-14 weeks if insufficiency
- progesterone supplementationt
indications for ASA
- start 12-28 wks, ideally before 16 wks, continue until delivery
- high risk for pre-eclampsia:
- hx
- multiples
- chronic HTN
- t1 or t2 DM
- renal disease
- SLE or APA syndrome
- if 2+ mod RFs can consider:
- nullip
- obese
- mom or sis pre-eclamp
- african america or low SES
- 35+
- personal Hx (10 year interval, SGA, prev adverse outcome)
- hx of placental abruption or thrombosis
GI changes in preg
progesterone = smooth muscle relaxant
- GI - constipation, reflux, cholestasis
skin changes in preg
hyperpigment, spider nevi, palmar erythema, moles, skin tags
cardiovascular changes in preg
- HIGH: CO, HR, BV
- LOW: BP, venous return
renal changes in preg
renal: low BUN + creatinine, increase GFR + renal plasma flow, dilated ureters + renal pelvis –> glycosuria (less resorption, don’t use to dx D)
hematologic changes in preg
HIGHER: plasma, RBC mass, coag proteins, transport proteins
LOW: hg, tot prot, albumin (dilution)
resp changes in preg
- resp: increased CO2 sensitivity, VC same,
- HIGH: minute vent
- LOW: TLC, FRC, RV
endocrine changes in preg
higher: thyroid size, basal MR, tot thyroid (more binding glob), tot + free cortisol
- lower: tot Ca (less albumin), PTH (increased bone resportion, increased gut absortion)
- free T4 and TSH same, free Ca same
- more bone turnover but no loss in density b/c estrogen
higher cortisol –> insulin resistance
presumptive signs of preg
- amenorrhea
- chadwicks
- breast tenderness, areola darkening
- fatigue
- urinary freq
- GI issues
- quickening: 20 weeks
- chloasma
- striae
probably signs of pregnancy
abdo enlargement
uterus enlargement
hegar’s sign: cervix soft
positive signs of preg
- fetal heart
- FM by examiner
- TVUS: sac at 5 wks, pole at 6 wks, HR at 7-8 wks
- positive BhCG (serum 9 days post conception + doubles in 48 until 8-10 wks), urine (28 days GA)
GA assessment
- LMP + 280 days
- LMP - 3 mo + 7 days, adjust according to cycle length
US: +/- 5 days = 1st trim, 1-2 weeks for 2nd, 2-3wks for third
Fundus:
- symphysis - 12 wks,
- mid 16 wks
- umbilicus 20 wks
- xyphoid term
SFH in cm = wks (from 20-36)
first prenatal visit
- hx of pregnancy (LMP, EDD, OCP, bleed)
- OBHx
- med hx, surgeries
- fam hx (consanguinity, genetic)
- meds, allergies
- soc hx: substances
- ROS
- physical:
- VS, weight
- thyroid
- cardiovasc (murmurs)
- breast changes
- abdo (uterus)
- pelvic: external, spec, cultures, PAP if due - NO INTRACERVICAL BRUSH, bimanual exam (uterus/cervix/adnexa)
- periph edema/varicosities
follow-up antenatal visit schedule
first visit - 8-12 wks
every 4 wks until 28
every 2 wks until 36
every week 36 - deliv
follow up antenatal visits
- general issues
- fetal movement
- weight
- BP
- measure SFH
- doppler after 15 wks
- leopolds after 30 wks (present, lie, engagement)
prenatal labs at 1st visit
- Hep B surface antigen
- VDRL
- HIV - consent
- Rubella
- Gonorrhea + Chlamydia (urine or swab)
- CBC
- blood group + screen
- urinalysis + microscopy, culture (MSU)
- pap if due
- sickle-cell / Hg electrophoresis if at risk
others:
- TSH - ? value of routine
- Hep C if RFs (low vert transmission)
- varicella zoster titre if not immune on hx
- toxoplasmosis - cats, gardeners
- hemoglobin A1C if DM
- TB - RFs
- urinalysis by dip if high BP
- hx of HSV - give oral antiviral from 36 weeks until delivery
- low dose ASA if needed
genetic screening
- NIPT: 10+wks
- 13, 18, 21, X +Y, microarray
- eFTS: 11-14wks
- NT, PAPPA, BHCG, P1GF/AFP
- downs + trisomy 18
- Quad (MSS): 15-20wks
- CVS: 11-14 wks
- karyotype + microarray
- loss = 1-2%
- amniocentesis: 15-20wks
- loss 1/200
GDM testing
- 25-28 weeks (earlier if lots RF, repeat if needed)
Glucose Challenge Test
- no fasting
- 50 g glucose
- 1 hrs test
- 7.8 - 11 –> more testing
- over 11 = GDM
Glucose Tolerance Test
- FBS
- then 75g glucose
- 1 hr glucose
- 2 hr glucose
- if any abnormal = GDM
- FBS >= 5.3
- 1hr >= 10.6
- 2hr >= 9
GDM management
- diet, metformin or insulin if needed (usually insulin)
- counsel re risks
- multidisciplinary
- blood sugar checking
- repeat GTT at 6wks - 6months PP
Rhogam administration
- Rh neg and not sensitized
- 28 weeks
- any bleeding (SA, termination, ectopic, CVS/amnio, bleed, PP)
- protection lasts 12 weeks
- Rhogam = IgG antibody
- dose: 300 mcg IM (protects against 25mls fetal blood)
- larger bleed: Betke-Kleihauer to adjust dose
management of other antibody positive
- test father
- refer to high risk clinic
- fetal status testing?
- serial antibody titres/US for fetal anemia/hydrops
- risk depends which antibody
GBS testing
- swab at 35 - 37 wks
- earlier if TPTL or multiples
- 1 swab into vag + rectum
- if positive give prophylaxis in labour
- if GBS bacturia in preg = positive, no swab needed
BPP uses
- if post dates: twice weekly in 41st week until delivery
- or if issue
assessments of fetal well being
- growth (SFH, US)
- kick count (after 30wks)
- NST
- US
- BPP
- AFI
- Dopplers
NST antenatal NORMAL
Baseline - 110-160
Variability - mod (6-25bpm), less for <40min
Decels - none or occasional variable <30s
Accels - 2+ 15x15 in <40min
Accels <32 wks - 2+ 10x10 in <40min
Action: no further assessment needed
NST antenatal ATYPICAL
Baseline: 100-110, or >160 for <30min
Variability: absent/min for 40-80min
Decels: variable decels 30-60s
Accels: 2 or less 15x15 in 40-80mins
Accels <32: same but 10x10
Action: FURTHER ASSESSMENT
NST antenatal ABNORMAL
Baseline: >160 for >30min, or <100, or erratic
Variability: mod or min for >80min, sinusodal, >25bpm >10min
Decels: variables >60s, lates
Accels: 2 or less accels in >80 min
Accels <32: same but 10x10
ACTION: urgent! assess situation /w US or BPP, maybe deliver
when can you do NST
mid second trimester + up (around 24 wks)
US in pregnancy
- dating: first trimester, include NT if 11-14 wks
- anatomy scan - 18-20 wks, also placenta location, NTD
- growth - EFW, AC, BPD, FL, not more than every 2 wks
- third trimester: around 32 wks, no real evidence, indicated if DFM, growth, position, previa, other issue
BPP components
- must be in 30 mins
- gross movements: 3 body or limb
- fetal tone: 1x extension + flexion
- breathing: 1 30s episode
- AF: 2x2 pocket
normal AFI
5-25cm
doppler flow studies
- UA: PI (high = bad), absent EDF = admission ?deliver, reverse EDF = deliver
- MCA: PI for IUGR (shows low PI, EDF increased in brain sparing = bad sign), PSV for anemia (high)
- Uterine Artery: abnormal at 20-22 wks –> risk for placental insufficiency (IUGR) and pre-eclampsia
NVP management
- severe: r/o twins, molar preg, other causes
- check electrolytes, ketonuria, hydration status, weights
- tx: small meals, sleep, stop iron, ginger
- drugs: diclectin 2-4 tabs/day up to 8
- dimenhydrinate or promethazine, then metoclopramide, then odansatron (ADD at each step)
- severe: home care for IV drugs/fluids
dietary advice in preg
- 3-4 milk per day
- 100kCal, then 300kCal more/day
- folate, Ca, vitD, Fe, fatty acids important
optimal weight gain in pregnancy
- 2-8lbs in first trimester
- then 1 lb per week
BMI<20: 12.5-18kg tot
BMI 20-27: 11.5-16kg
BMI>27: 7-11.5 kg
smoking associated /w risk of
prematurity, IUGR, in home: SIDS
cocaine associated /w risk of
IUGR, abruption, demise, anomalies, /w drawal
= vasoactive
contraindications to exercise in preg
absolute:
- ROM
- PTL
- HTN
- incompetent cervix
- IUGR
- triplets or more
- previa after 28wks
- persistent 2nd or 3rd trim bleeding
- uncontrolled T1DM, thyroid, cardiac, resp, other
relative:
- prev SA
- prev preterm
- mild/mod CVD/resp issue
- anemia <100 Hb
- malnutricion
- twins after 28wks
- other sig med issue
vaccinations in preg
- NO: MMR, varicella, BCG (give after)
- YES: flu, Tdap (21-23wks), others not up to date
no live vaccines
SSRI in pregnancy risks + CI
- rare increased risk of PPHN + /w drawal
- paroxetine C/I, switch
common C/I medications
ACEi: renal, IUGR, oligohydraminos
Tetracycline: teeth + bone
retinoids (accutane): major malformations
DES: historical risk, clear cell carcinoma + mullerian abnormalities
Others may consider:
anticonvulsants: NTD, hydantoin syndrom, cardiac, limbs, skeletal
lithium: ebsteins anomaly (heart)
warfrin: SA, embryopathy
Prostaglandin inhib/NSAIDs: indomethacins + ibuprofen after 32 wks –> premature closure of DA
Contraindications to breastfeeding
- HIV
- HepB and HepC ok (HepB babies vaccinated)
tx of common BF issues
- nipple: lanolin cream, topical steroid
- candida - topical clotrimazole (no ketoconazole)
- engorgement: cool, expression
- mastitis: cloxacillin
- inadequate: fnugreek, domperidone (not used often)
vaginitis in preg
yeast:
- tx /w topical (monistat/canesten), use finger instead of applicator, repeat if needed
- if fails use fluconazol PO
BV:
- controversial to tx, tx if RF of PTL
- do treat if asymptomatic
- oral or vaginal metronidazole
common complaints general approach
- r/o serious cause (hx + px)
- treat with non medical, reassurance, only meds as needed
when to go to hospital for ROM
- green fluid
- GBS positive
- bloody fluid
- baby not vertex
Or if Term PROM, for induction (after x hours?)
