Case 14- Screening and antenatal care Flashcards
What are the first two antenatal appointments
First contact - Folic Acid supplementation
Booking appt- anaemia screening (sickle cell, thalassaemia)
Blood tests for syphilis, hepatitis B and HIV are offered as early as possible and can be given at any point
• BP= test for pre-eclampsia, may get pregnancy induced hypertension. For pre-eclampsia you see if they have high blood pressure, especially after 20 weeks and protein in the urine. Can cause seizures
• BMI
• Urine (dip for protein and culture for asymptomatic bacteriuria), you treat pregnant women for asymptomatic bacteriuria
• Identify women who may need additional care or have risk factors for pre-eclampsia
11-13 week antenatal scan
Down syndrome screening, dating scan for gestational age
18-20 week antenatal scan
Ultrasound scan for structural abnormalities
28 week antenatal scan
Anaemia screening, administration of anti-D if rhesus positive or unsure of status. Screen for atypical red cell alloantibodies
36 week antenatal appointment
Check position (if breech offer referral for external cephalic version- moving the baby). Offer specific information on breast feeding, care for new-borns, vit K prophylaxis to baby when born, New-born screening tests and postnatal self care i.e. baby blues.
41 week antenatal appointment
Offer a membrane sweep, separates the amniotic sac from the uterus lining to induce contractions
Main dietary supplement in pregnancy
Folic acid, prevents 50-70% of neural tube defects. 400mg of folic acid should be taken daily 1 month before conception and for the first trimester
Ectopic pregnancy
Implantation of the fertilised egg outside the normal uterine location
Main sites for an ectopic pregnancy
Ampullary - 54% Isthmic- 25% Fimbrial- 17% Interstitial- 2% Abdomen- 1.2% Ovarian- 0.5% Cervical- 0.3%
What is looked for in the 18-20 week anomaly scan
NTD Craniofacial defects severe cardiac defects Renal agenesis Abdominal wall defects
Birth defects that arise in the first week
Chromosomal abnormalities i.e. Downs. Defects that result in a spontaneous termination
When would an ectopic pregnancy occur
Between 5-9 days
How can maternal health affect foetal development
Some infections can cross the placenta i.e. Rubella can cause congenital Rubella
How maternal diet affects foetal development
1) Cheese such as blue cheese and brie because there is lots of bacteria.
2) Caffeine over 200mg/day- causes low birth rate or miscarriage
3) Shellfish- bacteria
4) Tuna- mercury
5) Cured meat- bacteria
6) Liver- contains vitamin A which causes birth defects
How can maternal behaviour affect foetal development
1) Teratogens i.e. alcohol (FAS)
2) Smoking- premature / low weight
3) Medication- thalidomide (limb defects), tetracycline, antiepileptic drugs, anticoagulants (warfarin causes NS abnormalities), lithium (cardiovascular defects)
Supplemental screening offered to vulnerable women
Women with type 1 or 2 diabetes are offered diabetic eye screening
Cervical screening
A sample of cervical cells are taken for analysis (often called a smear test). This is offered to women aged 25 -64 years
The cells are assessed for any morphological changes, or signs of cancer
Breast screening
An x-ray (mammogram) is offered to women 50 - 70 years. It can detect cancers, growths, and other changes to the tissues
New-born screening
A physical exam is offered within 72 hours of birth. A hearing test is offered by way of an automated otoacoustic emission test. A blood spot test is also completed for the heal prick test which screens for 9 rare but serious conditions (sickle cell disease, cystic fibrosis, congenital hypothyroidism, and 6 different inherited metabolic diseases).
What are the risk factors for premature delivery
previous pre-term birth, cervical surgery, pre-eclampsia, multiple pregnancy (twins etc), IUGR
Respiratory complications of premature delivery
Will need a ventilator. RDS (respiratory distress syndrome), pneumothorax, apnoea. Alveolar cells do not release surfactant causing them to collapse. Pneumothorax can be caused by incubation.
Cardiovascular complications of premature delivery
Decrease in blood pressure because the system is immature. Blood can bypass the foetal lungs if shunts don’t close (trunctus arteriosis). Anaemia if traumatic birth.
Nutritional complications of premature delivery
Necrotising enterocolitis (inflammation of bowels leading to cell death) will need a nasogastric feeding tube if struggling to feed. May need to remove the bowel
Biological consequences of foetal growth restriction
Poor growth
Cerebral palsy, gross motor and minor neurological dysfunction.
↑ chance of developing diabetes, hypertension, obesity, metabolic syndrome, coronary heart disease before adulthood.
Psychological consequences of foetal growth restriction
Lower levels of intelligence.
Lower scores on cognitive testing.
Behavioural problems: hyperactive behaviour, attention deficit hyperactivity disorder.
Poor perceptual performance, poor visuo-motor perception.
Social consequences of foetal growth restriction
Poor academic performance
Difficulties in school or requiring special education
Low social competence
Secure attachment in children
- Able to separate from parent
- Seek comfort from parents when frightened
- return of parents is met with positive emotions
- prefer parents to strangers
Insecure avoidant attachment in children
- May avoid parents
- Does not seek much comfort or contact from parents
- shows little or no preference between parent and stranger
Insecure ambivalent/resistant attachment in adults
- Reluctant to become close to others
- worry that their partner does not love them
- becomes very distraught when a relationship ends
Genetic factors that may effect embryological development
Chromosome number- Trisomy 21
Chromosome structure- i.e. deletion
Gene mutation- Achondroplasia (dwarfism)
Infections that may effect embryological development
1) Virus i.e. congenital rubella syndrome (deafness, cardiovascular and brain defects)
2) Bacteria i.e. salmonella, listeria
Ancephaly
Failure of closures of the anterior neuropore. Should occur day 25-26
Spina bifida
Failure in closure of the posterior neuropore. Should occur at day 27
Myelomeningocele
Severe type of spina bifida
Embryonic defects that arise <3 weeks of development
Gastrulation defects (i.e. spontaneous termination) Neurulation defects (e.g. anencephaly and spina bifida) Implantation defects (e.g. ectopic pregnancies, placenta praevia)
Embryonic defects that arise at 3-5 weeks of development
Ventricular septal defect (VSD), transposition of the great arteries
Tetralogy of Fallot (pulmonary stenosis, over-riding aorta, VSD, right ventricular hypertrophy)
Embryonic defects that arise at birth
Patent ductus arteriosus (failure in closure at birth), gap between the pulmonary artery and aorta
Patent foramen ovale (atrial septal defect) (failure in closure at birth)
Embryonic defects that arise during 6-10 weeks of development
Renal abnormalities- Renal agenesis, hypoplasia, ectopia, abnormal rotation
Embryonic defects that arise during 4-10 weeks of development
Gastrointestinal abnormalities- atresia and stenosis, polyhydramnios, omphalocele, umbilical hernia, malrotation, volvulus
What increases the risk of an ectopic pregnancy
Pelvic inflammatory disease, STI’s, previous ectopic pregnancies, previous surgery, fertility treatment, smoking, increasing age
Symptoms of an ectopic pregnancy
Abdominal pain, vaginal bleeding. The symptoms arise between 4-12 weeks of pregnancy (2-10 weeks of development)
NHS newborn and infant physical exam (NIPE) programme
Infants are examined by a medical practitioner within 72 hours of birth and 6-8 weeks later. Done to screen for abnormalities, monitor development and provide support to parents. Both mother and baby are checked
PCHR
After a child is born parents are given a ‘personal child health record,’ (PCHR) known as the red book. Parents should take it to all the childs appointments and it keeps a record of a child’s weight, height, immunisation etc.
6-8 week baby check
- Assessment- general appearance, behaviour, breathing
- Examination- head, thorax, abdomen, genitalia, hips and spine
- Health promotion- i.e. immunisations, feeding, car safety, dental health and reduction of SIDS risk factors
- Review of development- i.e. feeding, weight gain, height and check growth chart
- Chance for parents to express concerns
- Review vision and hearing- most babies will startle to a sudden noise and follow a face with their eyes
- Review social development- at 6 weeks most babies will spontaneously smile
Physical assessment at 6-8 week baby check
- General assessment- colour, behaviour, weight, skin i.e. jaundice
- Eyes- red reflex, visual fixing
- Spine
- Abdomen- organomegaly, feel for hernias
- Hips- skin creases in the thigh, Barlow test
- Head- measure circumference, fontanelles, symmetry
- Heart- position (feel for apex beat), murmurs, rate
- Lungs- added sounds, rate
- Genitalia- normality, testicular descent
Mothers check at 6-8 week baby check
- Assessment- abdomen, vagina (i.e. episiotomy tears, bleeding, discharge and incontinence), blood pressure
- Recommend pelvic floor exercises
- Sex and contraception- reassure its safe to have sexual intercourse, discuss if contraception is required, ‘full time breastfeeding’ provides good contraception up to 6 months. This is at least four hourly feeds in the day and six hourly feeds at night
Normal development for the baby at 6 weeks
- Gross Motor: control their head when vertical
- Fine Motor: follow a torch light with their eyes
- Language: still to voice, startle to sudden noise
- Social Skills: smile spontaneously - known as ‘social smiling’
Barlow and Ortolani’s tests
Barlow’s test - identifies hips which are dislocatable
Ortolani’s test - identifies hips which are dislocated and is used to confirm diagnosis
What vaccines should be offered to pregnant women
Influenza vaccine (October to January) Offer Pertussis vaccine from 16 weeks
What blood tests should be performed- neonatal
Bloods (ideally <10w):
• Blood group & Rhesus D status
• Haemoglobinopahies, anaemia, red-cell alloantibodies
• Hep B, HIV, syphilis
What screening tests are only offered to nuliparous women
1) 25 weeks
2) 31 weeks
3) 40 weeks
16 week scan- antenatal care
Review any screening tests done
25 week check- antenatal care, only offered to nuliparous women
Measure and plot Symphysis fundal height (SFH), done with tape measure. It’s the lowest part of the uterus (near the pubic bone) to the highest part of the uterus). This is done at all subsequent appointments. Identifies infants that are small/large for gestational age. If <10th percentile/>90th percentile/other concerns (e.g. polyhydramnios) refer for further investigation (USS/doppler).
34 week screening tests
Review tests at 28 weeks if not had 31w appointment. Offer a second dose of anti-D treatment to women who are rhesus D-negative.
38 week screening tests
Offer specific information on the risk of pregnancies that last more then >42w and options (membrane sweep or vaginal prostaglandins to induce labour).
Nuliparous women can have a screening tests at 40 weeks where they offer the same information at 38 weeks and suggest a membrane sweep
