General Pregnancy Care

Question 1

Routine antenatal care

Answer 1

• Offer to perform swabs and smear now.
• Booking bloods; FBC, HbA1c, G&S, serology for rubella syphilis Hep B/C and HIV.
• Discuss vaccinations in pregnancy: COVID 19, pertussis, influenza.
• Prescribe folic acid and iodine
• Discuss food safety, hygiene practices, diet and exercise and GWG recommendations.
• Discuss GCS and aneuploidy screening.
• Anatomy scan at 20 weeks.
Normal BMI weight gain 11-16kg

Question 2

Rhesus negative

Answer 2

Prophylaxis at 28 + 34 weeks. Attend for further dose of Anti-D any sensitising events. Will need cord blood and if baby Rhesus positive will get Anti-D dosed to a Keilhauer.

Question 3

VZV exposure

Answer 3

Infective 48 hours prior to the rash and until it has crusted over usually around 5 days. Has an incubation period of 1-3 weeks. Significant exposure is living in the same household, face to face contact for 5 mins or the same room for 1 hour. Treatment is aimed at reducing maternal morbidity and mortality from disease (4-13% mortality if primary infection in pregnancy). Those exposed <96 hours VZIG + valcyclovir if >96 valcyclovir alone. Neonatal VZIG if maternal chicken pox <7 days prior to delivery or within 2 days of delivery.
Fetal Varicella Syndrome
• <12 weeks 0.4%
• 12-20 weeks 2%
Regular fetal USS for developing abnormalities is recommended (5 weeks after infection)
o Limb deformity, microcephaly, hydrocephalus, soft tissue calcification, IUGR
Consider amniocentesis:
-ve VZV PCR may be reassuring
Presence of VZV DNA is NOT synonymous with development of FVS

Question 4

Post dates

Answer 4

Approximately 1:4 pregnancies go post dates. The risk of stillbirth and early neonatal death increases with gestational age after 40 weeks.
Offer IOL between 41+0 and 42+0 to women with an uncomplicated pregnancy to reduce the risks of perinatal death, c-section, 5min APGAR <7 and meconium aspiration.
Cochrane systematic review in 2014 including 50 trials of 12479 women comparing IOL to expectant management.
Significantly fewer perinatal deaths occurred in the IOL group. NNT was 426. No difference in timings of outcomes 37-42 weeks in subgroup analysis.
In those induced over 41 weeks there were significantly fewer c-sections
Women allocated to induction were more likely to indicate they would chose the same arm again.
Index - multicentre RCT Netherlands
Compared IOL at 41 weeks with expectant management awaiting labour till 42 weeks
Primary outcome was a composite of adverse perinatal outcomes
Results - increased perinatal risk in expectant management group NNT 69 IOLs.
No significant difference in maternal outcomes
C-section rate was the same

Question 5

IV Drug use in pregnancy

Answer 5

Stop smoking / drinking / drugs
Try to change from heroin to methadone
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minimise risks to baby.
Referral to CADS/SW/tertiary team specialising in A&D use in pregnancy and for assistance with transition to methadone, housing, finances, preparing for baby etc
Re: IV heroin use
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counsel re risks to baby. Can do damage
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control by switching to methadone maintenance then planned withdrawal in the neonate. Neonatal withdrawal likely so will need neonatal unit admission and likely a weaning programme. Avoid giving the baby naloxone if needs resuscitation

Question 6

Hep C in pregnancy

Answer 6

Re: Hep C
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counsel re transmission ~5%, stop alcohol, HCV RNA levels then LFT’s each trimester, safe for vaginal birth, need for neonatal follow
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up, avoidance of invasive procedures in pregnancy and labour ie FBS, FSE, difficult instrumental, safe to breastfeed