General Antenatal Flashcards
Discuss folic acid
-Timing to take
-Dose to take
-Criteria for increased dose
-Efficacy
- Timing - 1 month prior to conception until 12 weeks
- Dose to take 800mcg (500mcg in Aus)
- Criteria for increased dose
-Take 5mg if: previously affected child with NTD, family hx of NTD, BMI >30, on anticonvulsants, pre-pregnancy diabetes, risk of malabsorption
-In multiple pregnancy or haemolytic anaemia then consider 5mg dose - Efficacy
-Decreases risk of NTD by 90% in those with no NDT hx
-Decreases risk of NTD by 70% in those with previous NTD
Discuss supplementation with
-Iodine - dose & timing
-Vitamin B12 - criteria & dose
-Fe - Criteria and dose
-Calcium - criteria and dose
-Vitamin K
- Iodine
-150mcg for whole pregnancy and lactation - Vit B12
- If vegetarian, vegan or malabsorption issue
-2.6mcg/day in pregnancy
-2.8mcg/day during lactation - Fe
-Routine supplementation not required
-Treat if ferritin <30
-Give 100-200mg daily
-Intermittent PO as effective as daily
-If low Fe but not anaemic give low dose FE 20-80mg
-Give IV if no response to PO or need rapid Hb boost - Calcium
-Supplement if intake <1000mg/day with 1000mg/day
-If at risk for PET give 1000mg per day (RR 0.45 for PET) - Vitamin K
-Should be given to women with proven cholestasis late in pregnancy
Discuss vitamin D supplementation in pregnancy
-Criteria for deficiency and insufficiency
-Findings regarding supplementation
-Recommendations for supplementation
-Recommendation for testing vit D levels
- Criteria
-Deficiency = <50nmol/L
-Insufficiency = <75nmol/L - Findings
-Deficiency associated with number of maternal and neonatal adverse outcomes. PET/GDM/CS/ IUGR/childhood asthma
-No evidence to suggest supplementation improves outcomes
-May improve childhood wheeze - Recommendations for supplementation
-All women should take 400IU as part of standard multi vit
-Exclusively breast fed infants should be given 400IU daily for first 6 months - Recommendation for testing vit D levels
-DON’T
Discuss omega 3 fatty acid suplementation in pregnancy
-Impact to fetus
-Evidence of impact to pregnancy
-Recommendation for supplementation
- Impact to fetus
-Omega 3- fatty acids are important in fetal brain and retina development - Evidence for impact on pregnancy
-No conclusive evidence that supplementation helps but may improve neurodevelopment, reduce PTL - Recommendations for supplementation
-Consider supplementation if low sea food intake
Discuss smoking in pregnancy
-Incidence
-Risk factors (6)
- Incidence
-1:8 women smoke in NZ
-44% are Maori - Risk factors
-Low SES
-Ethnicity
-Mulitparity
-Domestic violence
-Young age <21 = 30%
-Mental health disorders
Discuss the effects of smoking on pregnancy
-Physiological effects (5)
-Risks in preconception (1)
-Antenatal risks (10)
-Postnatal risks (5)
- Physiological effects
-Disrupts implantation
-Interferes with transformation of spiral arteries
-Thickens villous membranes
-Nicotine impacts amino acid transport across placenta
-Carbon monoxide decreases oxygen carrying capacity of placenta - Pre-conception risks
-Reduces fertility - Antenatal risks
-Miscarriage (33%)
-Ectopic pregnancy
-Fetal anomalies
-IUGR (200%)
-Placental abruption (200%)
-PTL and PPROM (200%)
-Placenta praevia (33%)
-Worsens PET
-VTE
-Stillbirth (accounts for 10% of stillbirths) - Postnatal risks
-SIDs (300%)
-Respiratory disease
-ENT infections
-Childhood cancer
-Cognitive development
How should women who smoke be managed in pregnancy (8)
- Screen for smoking/ recent quitting/passive smoking and other drug use
- Educate mother to quit
- Offer programmes which aid in quitting
- Offer NRT after discussing risks and benefits
-Better if not patch but gum or lozenge to avoid continuous nicotine exposure to fetus. Remove patches at night if chosen
-Cochrane shows no impact to health of mother or fetus with NRT
-Avoid Zyban or Champix - Support family and partner to quit
- Continue support in postnatal period - 50-70% resume smoking after a yr
- Support safe sleeping to reduce SIDS
- E cigarettes and vaping is not recommended. Nicotine causes perinatal damage
Discuss neonatal abstinence syndrome
-Cause (2)
-Timing (3)
-Clinical features (5)
-Long term risks (3)
-Treatment (4)
- Cause
-Withdrawal to drugs that the fetus was exposed to in utero
-Worse with opiates and heroine but happens with all drugs - Timing
-Onset around 48hrs
-Can take up to 2 weeks to develop
-Cocaine and benzos can delay onset - Clinical features
-High pitched cry, GI dysfunction, tremors, irritable, poor feeding
-Usually resolves in a few days but can take up to 3 months - Long term risks
-SUDI
-Behavioural problems
-Delayed cognition - Treatment
-Avoid naloxone - makes worse
-Treat with morphine or methadone
-Treat seizures
-Less than 50% need treatment
How should women with substance abuse disorders be managed in pregnancy
-Antenatal
-Intrapartum
-Postpartum
- Antenatal management
-MDT with social work, addiction services, neonatologists
-Support to attend appointments
-Nutritional support
-Hx of all substance use
-Review mental health and domestic violence
-Screen for blood borne viruses
-Anatomy scan
-Growth scans
-Check BP and urine - Intrapartum care
-Continue methadone if taking
-Continuous fetal monitoring
-May have higher anaesthetic requirement
-Paeds input - Postpartum management
-Observe for neonatal abstinence syndrome
-Encourage breast feeding
-Discuss contraception
-Social services input / OT for ? uplift / support
Discuss alcohol use and pregnancy
-Incidence (3)
-Pregnancy risks (4)
-Risk factors for ongoing alcohol use in pregnancy (2)
- Incidence
-1% of women report using alcohol in pregnancy
-50% of women consume alcohol before knowing they are pregnant
-25% of women continue to use alcohol in pregnancy - Pregnancy risks
-Miscarriage 2-3 times higher
-Still birth
-LBW
-PTB - Risks for ongoing alcohol use
-Higher SES
-Higher education
How should women with alcohol use disorder be managed in pregnancy
-Antenatal (10)
-Intrapartum (3)
-Postpartum (4)
- Antenatal
-Screen all women with T-ace screening tool
-Screen for other psychosocial risks (domestic violence, other drug use, mental health)
-Involve MDT
-Offer management of withdrawal
-Educate - no known safe level
-Screen for blood borne viruses and syphillis
-Consider 100mg thiamine in heavy drinkers
-Fetal anatomy scan
-Serial growth scans
-Update child protection and social work - Intrapartum
-May need higher doses of analgesia
-Be vigillent for withdrawal
-Continuous CTG - Postpartum
-Monitor for withdrawal - both mother and baby
-Contraception
-Encourage breastfeeding
-Ongoing social work support
Discuss the impact of alcohol to the fetus
-General points about alcohol (4)
-Birth defects (4)
-Neonatal effects (1)
-Long term effects (5)
- General points
-Alcohol is teratogenic
-Alcohol reaches the fetus in similar amounts as is experienced by the mother
-Has a dose related effect
-There is no known safe limit in pregnancy or breast feeding - Birth defects
-Congenital heart disease - ASD/VSD
-Renal anomalies - hypoplasia, hydronephrosis, bladder diverticular
-Short stature and skeletal deformities
-Fetal alcohol spectrum disorder - Neonatal effects
-Withdrawal - Long term effects
-Increased neglect and abuse
-Attention and memory deficits
-Hyperactivity
-Learning impairment
-Behaviour and conduct problems
Discuss fetal alcohol spectrum disorder
-Incidence (4)
-Diagnostic features
- Incidence
- 1-3% of births affected by the spectrum
- 0.1% have fetal alcohol syndrome
- 4% of heavy drinkers have babies with FAS - likely multifactorial
-Most common form of mental impairment - Diagnostic criteria
-Alcohol exposure + severe impairment in 3 domains
Domain 1: dysmorphic features - short palpebral fissures, thin upper lip, smooth phillrum, flat mid face
Domain 2: Growth restriction - SGA, failure to thrive
Domain 3: CNS involvement - reduced cranial size, structural brain abnormalities, neurological signs (motor function, poor gait, hearing loss)
What is the impact of amphetamines
-Fetal impact (4)
-Pregnancy impact (4)
-Neonate impact
- Fetal impact
-Cardiac malformations
-Gastrochesis
-Cleft lip if prior to 7 weeks
-IUGR - Pregnancy impact
-PTL
-HTN
-Abruption
-PET - Neonate impact
-Neonatal abstinence syndrome
-Reduced growth
-Poor school performance
What are the RANZCOG recommendations for substance use in pregnancy (5)
- Screen women to identify substance use
- Refer to MDT for management
- Refer to mental health services if indicated with mental health screening or previous Hx
- Screen with T-ace if harmful alcohol use is suspected and refer as necessary
- Re-screen for blood borne viruses