Module 8 - Antenatal Care Flashcards
Indications for LDA in pregnancy
What are the high risks?
How many do you need to initiate LDA in pregnancy?
What dose of LDA?
Any one of:
1) Chronic HTN
2) Previous HTN disease in pregnancy (PIH or PET)
3) Diabetes (Type I or II)
4) Autoimmune disease (i.e. SLE or APS)
5) Chronic Kidney Disease
Aspirin 75-150mg OD from 12/40 until delivery
Indications for LDA in pregnancy
What are the Moderate risks?
How many do you need to initiate LDA in pregnancy?
What dose of LDA?
≥2 of:
1) Primigravida
2) FH of PET
3) Maternal age ≥40
4) Pregnancy interval >10 years
5) Multiple pregnancy
6) BMI >35 at booking
Aspirin 75-150mg OD from 12/40 until delivery
When can you perform a history-indicated elective cervical cerclage?
In history-indicated women from 11-14 weeks
Women with a hx of 3 or more pre-term births or 3 or more late miscarriages
When can you perform an emergency cervical cerclage?
16 - 27+6 weeks
If dilated cervix with exposed membranes - but no SROM, bleeding, contractions or signs of infection
What is the risk of requiring an EMCS following ECV?
1 in 200 (0.5%)
Emergency c-section is typically due to placental abruption or evidence of fetal compromise on CTG
What is the incidence of breech presentation at term?
3-4%
What are the chances of spontaneous version to cephalic after 36/40 if currently breech?
8% with nulliparous women
What are the chances of successful ECV?
50%
40% for nulliparous women
60% for multiparous women
What are the chances of reverting back to breech after successful ECV?
<5%
What are the chances of reversion to cephalic after unsuccessful ECV?
<5%
When should ECV be performed?
36/40 - nulliparous women
37/40 - multiparous women
What percentage of pregnancies are affected by PET?
3%
What is the incidence of hypertensive disorders in pregnancy?
8-10%
Approximately what percentage of women in the UK are GBS carriers?
20-40%
What is the main cause of AKI in pregnancy?
PET
AKI causes what percentage of maternal admissions to hospital in the UK?
1.4%
What percentage of all live births are twin pregnancies?
3%
What is the increased mortality with twin neonates vs singletons?
3x increased mortality rate
Twin pregnancies 3x greater perinatal mortality than singleton pregnancies
What percentage of twin pregnancies deliver before 37 weeks?
50%
What percentage of twin pregnancies deliver before 32 weeks?
10%
What is the risk of Laparoscopic transabdominal cerclage performed during pregnancy being converted to an open procedure?
10%
What are the indications for transabdominal cervical cervlage?
Indications:
1) Grossly disrupted cervix
2) Absent vaginal cervix
3) Previous failed elective vaginal cerclage
4) History of mid trimester loss
What is the incidence of pulmonary embolism in the UK in pregnancy and the puerperium?
1.3 in 10,000
In which gestational period does radiation carry the highest risk for CNS abnormalities?
10-17 weeks
There is no proven risk before 10 weeks or after 27 weeks
In which gestational period does radiation carry the highest risk for fetal growth restriction?
3-10 weeks
When should Type I diabetics in pregnancy test their CBG?
Fasting, pre-meal, 1 hour post-meal, at bedtime
When should Type 2 DMs or GDM patients on multiple daily dose Insulin test their CBG?
Fasting, pre-meals, 1 hour post-meal, at bedtime
What is the estimated number of children at risk of FGM in the UK each year?
20,000
Whooping cough can be especially dangerous in newborns, whom are at a greater risk of complications. It can lead to death if they catch the infection before they are routinely immunised from two months of age.
What is the optimum time for the routine whooping cough vaccine in pregnancy?
16 - 32 weeks
A woman is found to be pregnant with MCDA twins at 9 weeks.
At what gestation do you start monitoring for TTTS?
16 weeks
At booking which risk factors would prompt antenatal testing for GDM?
1) BMI >30
2) Previous macrosomic baby >4.5kg
3) Previous hx of GDM
4) Family history of diabetes (1st degree relative)
5) Ethnicity with a high prevalence of diabetes
Offer 75g OGTT at 24-28 weeks
If previous GDM offer 75g OGTT at booking (or early self-monitoring) and 28 weeks
Which SSRI anti-depressant should be avoided in pregnancy?
Paroxetine
Increased risk of fetal heart malformations
What investigations do you perform for recurrent miscarriage?
1) TVS Pelvis
2) APS screen
3) Karyotype of POC
A woman has a cervical length measured at 20 weeks which is <25mm. What is her risk of pre-term delivery before 28 weeks?
25%
A woman has a cervical length measured at 20 weeks which is <20mm. What is her risk of pre-term delivery before 32 weeks?
42%
What are the 5 elements of the Saving Babies Lives Care Bundle 2016?
1) Reducing smoking in pregnancy
2) Recognition and surveillance of pregnancies at risk of FGR
3) Raising awareness of reduced fetal movements
4) Prevention of pre-term birth
5) Effective fetal monitoring in labour
When do you offer prophylactic vaginal progesterone?
If you have both:
1) Previous pre-term birth <34/40
OR
Previous pregnancy loss from >16/40
AND
2) TVS 16-24/40 which shows cervical length <25mm
How long do patients remain on prophylactic vaginal progesterone for?
Start at 16-24/40 and continue until at least 34/40, aim for 36/40
Cyclogest 400mg BD - threatened miscarriage (up until 16/40)
Cyclogest 400mg OD - pre-term birth (16-36/40)
When do you offer prophylactic cervical cerclage?
In women who have had a TVS scan at 16-24/40 showing a cervical length <25mm with a high risk indication or intermediate risk indication
What are the high risk indications for vaginal cervical cerclage?
High risk:
1) Previous pre-term birth or 2nd trimester loss (16-34/40)
2) Previous PPROM <34/40
3) Known uterine variant
4) Intrauterine adhesions
5) Previous cerclage
6) Previous hx of trachelectomy
Offer serial TVS scans from 16-24 weeks
Every 2-4 weeks
If cervical length <25mm, offer cervical cerclage or vaginal progesterone
What are the intermediate risk indications for vaginal cervical cerclage?
Intermediate risk:
1) Previous full dilatation CS
2) Previous cone biopsy, LLETZ with depth >1cm or >1 procedure
Offer at a single TVS scan 18-22 weeks as a minimum
What is the additional risk of miscarriage when amniocentesis or CVS are performed by an apprporiately trained operator?
<0.5%
What is the additional risk of miscarriage in a twin pregnancy when amniocentesis or CVS are performed by an apprporiately trained operator?
1%
When should chorionic villus sampling (CVS) be performed?
11 - 13+6 weeks
Consider: 14 - 14+6 weeks
Don’t perform <10/40 gestation
To reduce the risks of technical challenges perform CVS from 11/40 onwards
When should amniocentesis be peformed?
From 15/40 gestation wards
Do not perform amnio <15/40. Increased risk of fetal talipes and respiratory morbidity
What are the increased risks with amniocentesis performed <14/40?
1) Increased risk of miscarriage
2) Increased risk of fetal talipes
3) Increased risk of respiratory morbidity
When is the combined test performed?
10 - 14 weeks
Can attempt it twice (same day or alternate). If unable then perform quadruple test from 14 - 20 weeks
What compromises the combined test?
1) NT
2) PAPP-A (low in Downs)
3) B-hCG (high in Downs)
When is the quadruple test performed?
14 - 20 weeks
What compromises the quadruple test?
1) AFP
2) Unconjugated estriol
Both low in T21
3) b-hCG
4) Inhibin-A
Both high in T21
When is the dating scan performed?
10 - 14 weeks
When is the anomaly scan performed?
18 - 20+6 weeks
For babies where invasive testing has diagnosed a genetic condition, what are the 4 options?
1) Continue the pregnancy to KEEP the baby
2) Continue the pregnancy for ADOPTION
3) Continue the pregnancy with a view for PALLIATIVE CARE in cases of life-limiting illness
4) TERMINATION OF PREGNANCY
How many amniocentesis’ or CVS’ do trained operators need to complete per year to maintain adequate skill?
20 or more
What is the risk of pre-term labour <34/40 with amniocentesis in the 3rd trimester?
3-4%
What is the risk of blood-stained samples with amniocentesis?
5-10%
What is the risk of culture failure with 3rd trimester amniocentesis?
10%
This risk increases as the gestation increases (because the AFI decreases)
Risk is 40% from 36-40/40
How do you screen for Downs syndrome in triplet pregnancies?
Maternal age + NT
When can you perform fetal genotyping in a woman with Rh antibodies?
Anti-D, Anti-c, Anti-E - 16/40
Anti-K - 20/40
