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
Discuss influenza vaccination
-Type of vaccination (1)
-When to give (3)
-Benefits (5)
-Risks (1)
-Absolute contra-indications (1)
- Type of vaccination
-Killed virus - When to give
-Give each year
-If pregnancy span 2 flu seasons give vaccinations for both seasons
-Optimal time to give early in flu season but any time is fine - Benefits
-Protects mother against serious influenza complications
-Protects baby up to 6 months against neonatal influenza by 60%
-Reduces risk of still birth
-Reduces lab confirmed influenza by 50%
-Prevents 1-2 hospitalisations /1000 vaccinated women - Risks
-No risk of teratogenicity, growth or poor neurological outcomes - Absolute contra-indications
-Anaphylaxis to previous vaccine
Discuss whooping cough vaccination
-Type of vaccine (1)
-How it works (2)
-Timing of vaccine (3)
- Type of vaccine
-Inactivated toxoid from bacteria - How it works
-Direct passive protection by transplacental transfer of antibodies
-Infants get vaccinated but antibodies not sufficient till after 3rd dose at 5 months - Timing of vaccine
-Optimal 28-32 weeks
-Can give from 16 weeks to 2 weeks before delivery
-Give at every pregnancy even if close together
Discuss air travel in pregnancy
-Timing
-Impact to pregnancy
-VTE risk and management
-Radiation exposure
- Timing
- Not recommended if risk of PTL after 32/40
-Most carriers say not after 32/40
-Travel >4 hrs not recommended after 36/40
-Safest time to travel is second trimester - decreased risk miscarriage - Impact on pregnancy
-No evidence air travel increases pregnancy complications - VTE risk
-Increased risk lasts up to two weeks following travel
-Hydrate, mobilise, avoid tea and coffee
-Consider LMWH in those with increased baseline DVT
-TEDS if >4hrs - Radiation exposure
-Minimal with flying or with body scanner
Discuss vaccination in pregnancy
-Absolutely contra-indicated in pregnancy
-OK if necessary
-Recommended
- Absolutely contra-indicated vaccines
-Live attenuated vaccines
-MMR, BCG, Typhoid, Rota virus, HPV, Varicella
-If receive accidently then reassure. Not a cause for abortion - OK if necessary
-Inactivated bacterial or viral vaccines
-Meningococcus, pneumococcus, Hep B - Recommended
-Boostrix, tetanus, influenza, COVID
Discus preconception screening for infection and immunity
-What should be routinely screened for pre conception (7)
-What should not be screened for preconception (3)
- What should be routinely screened for
-Rubella - then vaccinate and wait 28 days prior to trying
-Hep B and C
-HIV and syphilis and STI
-Varicella IgG and offer vaccination if negative - What not to screen for
-CMV, Parvovirus, Toxoplasmosis
Discuss exercise in pregnancy
-Contra-indications to exercise in pregnancy (2)
-Recommendation for exercise frequency (1)
-Recommendation for exercise duration (2)
-Recommendation for exercise intensity (3)
-Types of exercise to avoid (3)
- Contra-indication to exercise
-Cardiovascular disease, poorly controlled asthma or thyroid disease
-Placenta praevia, PET, gHTN, Increased risk of PTL, IUGR - Recommended frequency
-Most days - Duration
-300 mins per week or 30 mins per day.
-If inactive build up to 30mins per day - Recommended intensity
-Exercise to increase heart rate and breathing
-Don’t exercise so much can’t complete sentences
-If already very fit can continue on at usual intensity - Types of exercises to avoid
-Walking lunges - pelvic instability
-Team sports with risk of trauma or where balance is required
-Running, bouncing, jumping exercises - can damage pelvic floor
Discuss exercise in pregnancy
-Benefits
-Risks
- Benefits
-Prevents excess weight gain
-May help with PET and GDM - Risks
-No evidence exercise is risky in pregnancy
Discuss risks of obesity in pregnancy
-Maternal impact antenatally (9)
-Maternal impact intrapartum (6)
-Maternal impact postpartum (4)
- Maternal impact - antenatal
-Decreased fertility
-Increased miscarriage rate (2 x if BMI >40)
-Increased diabetes risk (7% GDM if BMI >40)
-HTN and PET
-VTE (x10 if BMI >40)
-Still birth BMI >30
-PTB
-OSA
-Maternal death - Maternal impact Intrapartum
-Labour dystocia
-Increase IOL rates and failed IOL
-Poor fetal monitoring
-Difficult labour analgesia
-Difficult fetal monitoring
-Increased risk of instrumental delivery
-Increased risk of shoulder dystocia
-Increased risk of CS (40% if BMI >40) - Maternal impact postpartum
-PPH
-Wound infection
-Postnatal depression
-VTE
Discuss obesity in pregnancy
-Impact to fetus (8)
-Increased fetal anomalies - cardiac, NTD, abdominal wall
-Macrosomia
-SGA
-Prematurity
-Stillbirth and neonatal death
-NICU admission
-Obesity and metabolic issues in later life
-Cardiometabolic issues and neurodevelopmental issues
What are the risks of being underweight in pregnancy (3)
- Decreased fertility
- PTB
- Low birth weight
What is the recommended weight gain in pregnancy
-BMI <18.5
-BMI 18.5-24.9
-BMI 25 - 29.9
-BMI >30
- BMI <18.5 12.5 - 18kg
- BMI 18.5 - 24.9 11.5-16kg
- BMI 25-29.9 7-11.5kg
- BMI >30 - 5-9kg
Discuss management of obesity in pregnancy
-Pre-conception (3)
-Antenatal (8)
-Intrapartum (6)
-Postpartum (3)
- Pre-conception
-Folic acid 5mg
-Advise and support weight loss
-Discus risks and outcomes
-Avoid weight loss meds if trying to conceive - Antenatal
-Early dating scan as LMP often inaccurate
-Advise appropriate weight target
-Folic acid 5mg, Vit D 400IU
-Consider aspirin for PET prophylaxis
-NT and anatomy scan
-OGTT
-Anaesthetic review
-VTE prophylaxis if high risk through pregnancy
-Serial growth scans - Intrapartum
-Alert senior obstetrician and anaesthetics
-Early cannulation
-Early epidural
-Continuous fetal monitoring - consider FSE
-Confirm presentation with USS
-Active management third stage - Postpartum
-VTE prophylaxis according to risk
-Contraception - jadelle impacted by weight
-Review mental health
Discuss Caesarian section technique for raised BMI
-Incision types
-Pros of incision types
-Cons of incision types
-Other considerations
- Incision types
Suprapubic transverse
-OK if wt <180kg
-Use manual retraction of pannus
-Con: Increased wound infection
-Pro: More familiar technique
Supra-umbillical
-If weight >180kg
Cons: Reduces exposure to lower segment
Pros: Lower wound infection rates, lower blood loss, decreased OT time, less OP pain - Other considerations
-Increased cephazolin dose 2g if >80kg, 3g if >120kg
-VTE prophylaxis 40mg if <90kg, 60mg if 90-130, 80mg if >130kg
Discuss caesarian section technique for raised BMI
-Closure type
-Use of drains
-Choice of dressing
- Closure type
-If midline aim for mass closure
-Close adipose layer if >2cm
-Can close skin with subcut or staples - Use of drains
-Not advised - Use of dressing
-Negative pressure dressing
Discuss pregnancy post bariatric surgery
-Timing of pregnancy (1)
-Benefits of bariatric surgery for pregnancy (4)
-Risk of bariatric surgery to pregnancy (2)
-Antenatal considerations (3)
- Timing
-Avoid pregnancy for 12-24 months post OP
-COC/POP may not be ass effective for contraception. - Benefits
-Improved fertility
-Reduced risk GDM
-Reduced PIH and PET
-Reduced macrosomia - Risks
-IUGR
-Stillbirth - Antenatal considerations
-Refer to dietician
-Consider additional vitamin supplements - esp. in gastric bypass
-Increase monitoring of minerals and vits during pregnancy
-Avoid OGTT do BSL for 4-7/7 as OGTT can cause dumping syndrome
-Consider Fe infusion for better absorption if required
What are the RANZCOG recommendations for exercise in pregnancy (6)
- Women without contra-indications w=should participate in regular aerobic and strength exercises
- Women should be advised that regular exercise is not detrimental
- Assess women for possible contraindications for exercise in pregnancy
- Consider frequency, mode, intensity of exercise
- Consider baseline fitness and previous exercise experience
- Exercise for pregnant women should take into consideration physiological adaptations
Discuss incarcerated uterus
-Definition
-Incidence
-Risk factors
- retroflexed uterus fails to ascend into the abdomen as pregnancy progresses and is trapped under the sacral promontory
- Incidence
1:3000 - Risk factors
-Endometriosis
-Uterine abnormalities
-Posterior fibroids
-Adhesions
-Placenta accreta
Discuss incarcerated uterus
-Clinical presentation
-Examination findings
-USS features
- Clinical presentation
-50% present with lower back pain
-PVB
-Urinary sx
-GI symptoms - constipation/ tenesmus - Examination findings
-Cervix is anterior and under the pubic symphysis
-Bulge in the posterior fornix
-Fundus palpable within the curvature of the sacrum - USS features
-Fetus positioned in POD
-Maternal bladder malpositioned
What are the RANZCOG recommendations for Obesity management in pregnancy (16)
- Preconception BMI evaluation, optimisation of weight and information about risk factors for obesity in pregnancy should be undertaken
- Women with a BMI >30 should take 5mg folic acid as they have an increased risk of NTD
- Women who have undergone weight loss surgery require additional supplements and should avoid pregnancy at times of rapid weight loss
- BMI should be assessed in the first trimester and retaken at least once a trimester
- Pregnancy women should be offered advice about increased risks with obesity and plans to mitigate risks
- Local protocols should be available for managing obesity in pregnancy
- Provide advice around healthy weight gain and exercise in pregnancy. Refer to dietician if obese
- Obese women should be offered early screening for GDM and be informed of increased risk of no result NIPT
- Influenza and COVID vaccines are strongly recommended for pregnant women with obesity
- Obese women esp. those more than BMI 40 should have an anaesthetic referral
- Consider calcium and aspirin supplementation if other risk factors
- Offer serial growth scans if obese but remember sens is low for detecting IUGR on scan in obese women
- Inform obese women of the increased risk of complications and failure of VBAC
- Women with BMI >50 should be offered delivery before their due date. No consensus on when tho. Aim 39/40
- Obese women should be informed of their increased risk of EMCS
- Intrapartum risks including PPH and shoulder dystocia should be planned for and mitigated as possible
