Obstetrics Flashcards
What is the main purpose of antenatal care?
Identify mothers who do need medical attention, to prevent maternal and fetal morbidity and mortality
Name some components of preconceptual care that mothers should do
- Health check (treat any undetected problems such as cervical smear abnormalities or cardiac disease)
- Optimize health in women with chronic disease (e.g ensure that there is strict preconceptual glucose control in diabetics)
- Optimize medication for pregnancy (e.g epileptic medications)
- Routine folic acid
What is the purpose of routine folic acid?
Reduced chance of neural tube defects
When should the booking visit be?
Before 10 weeks gestation
Name 5 risk factors in women that can increase the chance of complications happening during pregnancy
- Age (less than 17 and more than 35 have increased risk of obstetric and medical complications)
- Past obstetric complications have a significant recurrence rate (e.g SGA, stillbirth, postpartum haemorrhage)
- Past gynaecological surgery may influence delivery options
- PMH : hx of HTN, DM, autoimmune, haemoglobinopathy, thromboembolic disease, cardiac or renal disease
- contraindicated drugs
- FHx (gestational diabetes, preeclampsia)
What examination do you do at booking visit / what screening can you offer?
Examination
- BMI
- Baseline BP
- Find out if woman is at increased risk of gestational diabetes or preeclampsia
- Ask about mood
- Blood group and serum antibodies
Offer early gestational scan (10+0 - 13+6 gestation)
If woman says yes to screening
- Bloods (FBC for anaemia, haemaglobinopathies, red cell alloantibodies, syphilis, HIV, hep B)
- Urine (MC&S, urinalysis for protein, glucose and nitrites)
- Down’s Syndrome screening (combined test : USS at 11+0 - 13+6 weeks for nuchal translucency test plus bloods [beta-hCG and pregnancy associated plasma protein A])
- Offer the 20 week anomaly scan
Why do we microscopy and culture urine at booking?
To assess if there is any underlying asymptomatic bacteriemia as this can commonly lead to pyleonephritis in pregnant women
For a nulliparous woman how many antenatal appointments will she have?
- Booking
- 16 weeks
- Anomaly scan (18-20 weeks)
- 25 weeks
- 28 weeks
- 31 weeks
- 34 weeks
- 36 weeks
- 38 weeks
- 40 weeks
What happens at 16 week appointment
- Review and discuss and record the results of the screening and identify women who need extra care
- If they booked late and still want the chromosomal abnormalities screening you can offer the serum screening (triple) test at 15 weeks - 20+0
- If anaemic consider starting iron supplement
- BP and test urine for protein
What happens at the 20 week scan
Sonographer is looking for structural abnormalities. Specifically looking for 11 rare conditions.
If placenta is seen to be low, further scan at 32 weeks
What happens at 25 week antenatal appointment
Nulliparous appointment
Routine BP and urine for proteinuria
Measure fundal height
What blood tests do women get at the 28 week antenatal appointment?
FBC - anaemia
Group and Save - blood group
Serum antibodies
Offer anti-D prophylaxis for Rhesus negative women
What happens at 31 week antenatal appointment
Nulliparous
BP + urine
Fundal height
What happens at 34 week antenatal appointment
Offer 2nd dose of anti-D to Rhesus negative women
BP and urine
Fundal height
What happens at the 36, 38 and 40 week antenatal appointments?
- BP and urine
- Fundal height
- Check fetal lie and presentation. If baby is breech refer for external cephalic version (ECV)
What happens at 41 week antenatal appointment?
Offer membrane sweep, induction of labour
BP + urine
Fundal height
What babies can have extra growth scans?
If doctor is concerned about baby’s growth can arrange for serial growth scanning.
If baby is below the 3rd centile - growth scans from 28 weeks every 4 weeks up until delivery
If baby is abover 3rd centile - growth scans from 32 weeks every 4 weeks
What dose of vitamin D are pregnant women advised to take?
10 micrograms a day
When can the combined test be offered?
11 + 0 up to 13 +6
What is the combined test, what does it look for?
Down’s syndrome
Nuchal translucency + beta-hCG + pregnancy associated plasma protein A
What risk factors for gestational diabetes need to be determined at the booking appointment?
BMI > 30
Previous macrosomic baby weighing 4.5kg or more
Previous gestational diabetes
- FHx of diabetes
- Family origin with a high prevalence of diabetes (south asian, black caribbean, middle eastern)
Women with any one of these risk factors should be offered testing for gestational diabetes
When should women be offered an early USS for gestational age assessment?
Between 10 + 0 and 13 + 6
Can also detect multiple pregnancies
How is gestational age determined?
Crown-rump length measurement. If the crown-rump measurement is above 84mm the gestational age should be estimated using head circumference
What is the recommended dose of folic acid to be taken at the beginning of pregnancy?
0.4milligrams per day
When should women be taking folic acid supplement?
before conception and the first 12 weeks
What vitamin supplements should women not take?
Vitamin A above 700micrograms
Liver products might contain vitamin A so should avoid that
What information can be given to women to reduced the risk of food acquired infections?
Avoiding listeriosis
- Drink only pasteurised or UHT milk
- not eating ripened soft cheese (e.g camembert, brie)
- Don’t eat pate
- Don’t eat undercooked or undercooked ready-prepared meals
Avoiding salmonella
- Avoid raw or partially cooked eggs
- Avoid raw or partially cooked meat
What are two risks of smoking during pregnancy?
SGA
Preterm labour
In what women would you advise an increased dose of folic acid (5 milligrams a day)
BMI > 30 Diabetes Sickle disease Malabsorption On antiepileptics
When do most cases of nausea and vomiting in pregnancy resolve?
16 - 20 weeks
What is a non-pharmacological intervention that is effective in reducing nausea symptoms?
Ginger
P6 wrist acupressure
What is a pharmacological intervention that is effective in reducing nausea symptoms?
antihistamines
What lifestyle advice is given to pregnant women?
- Diet - balanced with daily intake of 2500 calories. Avoid alcohol. Give smoking cessation advice.
- Dental check up
- Advice on how to avoid food acquired infection
- Exercise is advised (contact sports/very heavy exercise should be avoided)
- Sleep in left lateral position from 28 weeks
- Seatbelt advice
When is sexual intercourse contraindicated during pregnancy?
Rupture of membranes
placenta is praevia
What Hb levels would you investigate further for a pregnant woman when screening for anaemia?
Booking - 11g/100ml
28 weeks - 10.5g/100ml
What are red cell alloantibodies?
Alloantibodies are immune antibodies that are only produced following exposure to foreign red blood cell antigens. Produced by exposure to foreign red cell antigens which are non-self antigens but are of the same species. They react only with allogenic cells. Exposure occurs through pregnancy or transfusion.
What is the purpose of the anomaly scan?
identify fetal abnormalities and allow
- reproductive choice (TOP)
- parents to prepare (treatment/disability/palliative care/TOP)
- managed birth at specialist centre
- intrauterine therapy
What risk factors need to be determined at booking for preeclampsia?
- Age 40 or over
- Nulliparity
- Pregnancy interval or more than 10 years
- FHx of preeclampsia
- Previous history of preeclampsia
- BMI > 30
- Pre-existing vascular disease such as HTN
- Pre-existing renal disease
- multiple pregnancy
If a woman’s placenta extends over the internal cervical os when should they be offered another scan?
Following the anomaly scan, they are offered another scan at 32 weeks.
When does fetal presentation become important?
36 weeks
Which women are exempt from being offered an external cephalic version for a breech presentation?
Women in labour Women with a uterine scar or abnormality Fetal compromise Ruptured membranes Vaginal bleeding Medical conditions
Name 5 ‘minor’ conditions in pregnancy
- Itching
- Pelvic girdle pain
- Abdominal pain
- Heartburn
- Backache
- Constipation
- Ankle oedema
- Leg cramps
- Carpal tunnel
- Vaginitis
- Tiredness
What is pelvic girdle pain
Causes varying degrees of discomfort in the pubic and sacroiliac joints
What can help pelvic girdle pain
Physiotherapy, analgesics
Usually cured after delivery
What can help relieve heartburn in pregnancy?
More pillows to sit up from the supine position
Antacids
What can help backache in pregnancy?
Physiotherapy
Advice on posture and lifting
Firm mattress
Most cases resolve after delivery
Why is carpal tunnel syndrome more common in pregnancy?
Fluid retention compressing the median nerve
How do you treat vaginitis due to candida in a pregnant woman?
Clotrimazole pessary for symptomatic infection
