One in the oven

Question 1

What is the definition of obesity?

Answer 1

Obesity describes a person who is very overweight with high body fat.
BMI – A measure of whether healthy weight for height. 18.5 – 24.0 healthy weight. Over 25 – overweight. 30 and above – obese. Weight in kg/[height m]2

Question 2

How might obesity complicate pregnancy?

Answer 2

• Miscarriage (BMI over 30 25% chance)
• Gestational diabetes – if your BMI is 30 or above, you are 3 times more likely
• High blood pressure and pre-eclampsia
• Blood clots
• The baby’s shoulder becoming “stuck” during labour (shoulder dystocia)
• Post-partum haemorrhage
• Having a baby weighing more than 4kg (8lb 14oz)
• More likely to need an instrumental delivery
• Baby being born early
• Still born
• Higher chance of neural tube defect

Question 3

What affects the age a woman becomes a mother?

Answer 3

Governed by a number of complex personal, social, professional and life circumstances.
Age at which women first become mothers in the UK continuing to rise.

Question 4

What are the risks associated with pregnancy of an older woman?

Answer 4

Higher risk of miscarriage due to chromosomal abnormalities
Higher risk of twins or triplets (complications)
Increased risk of gestational diabetes
Increased risk of congenital abnormality like down’s syndrome
Increased risk of pre-eclampsia - possible link with ageing of uterine blood vessels meaning placenta doesn’t develop properly
Increased risk of complications during delivery – prolonged labour, need for assisted delivery, c-section or still birth

Question 5

How to manage the implications of pregnancy in an older mother?

Answer 5

Individuals should be aware of the recommendations
Have an awareness of the risks of genetic disorders and the screening tests available
A woman’s health should be as optimal as possible prior to pregnancy, which means maintaining a healthy weight and eating a balanced diet, taking regular exercise, limiting alcohol and not smoking.
Ensuring that folic acid and vitamin supplements are taken around the time of conception.

Question 6

What is pre-eclampsia?

Answer 6

A condition/complication of pregnancy that some women develop, characterised by high blood pressure and protein in urine. Effects up to 6% of pregnancies, severe cases 1-2% pregnancies.

Question 7

When does pre-eclampsia occur?

Answer 7

Rarely happens before 20 weeks. Most cases from 24-26 weeks, tend to be nearer end of pregnancy. Can also develop post partum up to 6 weeks after birth.

Question 8

What causes pre-eclampsia?

Answer 8

Specific cause not known – thought to be when problem with placenta
Theory:
Placenta overproduces proteins that inhibit angiogenesis enter maternal circulation, their concentrations rise in circulation weeks to months before pre-eclampsia develops. Lead to high blood pressure, kidney, liver and coagulation abnormalities. Disease not only depends on action of circulating factors from the placenta, but also health of mother including diseases that effect the vasculature – e.g pre existing hyper tension, diabetes, obesity.

Question 9

What are the risk factors for pre-eclampsia?

Answer 9

Existing medical problem – such as diabetes, kidney disease, high blood pressure, lupus or antiphospholipid syndrome
Previous pre eclampsia – approximately 16% chance
Two or more of the following:
First pregnancy, 10 years since last pregnancy, family history of pre-eclampsia, over age of 40, obese, expecting multiple babies.

Question 10

What are the symptoms of pre-eclampsia?

Answer 10

Initially causes hypertension and proteinuria
Difficult for mothers to distinguish between pregnancy symptoms and pre-eclampsia
As it progresses - severe headaches, vision problems, nausea or vomiting, pain below ribs, feeling unwell, excessive weight gain due to fluid retention, sudden increase in oedema.
If pre-eclampsia not diagnosed and monitored - severe pre-eclampsia.
Without prompt treatment – serious complications: convulsions (eclampsia), HELLP syndrome, stroke.

Question 11

What is HELLP syndrome?

Answer 11

A rare liver and blood clotting disorder that can affect pregnant women. H” is for haemolysis – this is where the red blood cells in the blood break down, “EL” is for elevated liver enzymes (proteins) – a high number of enzymes in the liver is a sign of liver damage, “LP” is for low platelet count.

Question 12

How to manage pre-eclampsia?

Answer 12

At risk: 75mg dose of aspirin daily from 12 weeks pregnant – birth
Treatment for pre-eclampsia focuses on lowering blood pressure and managing the other symptoms.
Mild – managed by frequent antenatal appointments to check blood pressure, proteinuria and other symptoms. Having baby at about the 37th to 38th week of pregnancy is recommended.
Severe pre-eclampsia – admitted to hospital for closer monitoring and treatment – involving monitoring blood pressure, proteinuria, blood tests, ultrasound scans, babies growth rate and heart rate monitored. Treatment in hospital – bed rest, anti-convulsant medication.
Complications can sometimes develop a few days later

Question 13

What is Gestational diabetes?

Answer 13

Gestational diabetes is high blood sugar (glucose) that develops during pregnancy and usually disappears after giving birth.
More common in the second or third trimester.
It happens when your body cannot produce enough insulin to meet your extra needs in pregnancy.

Question 14

What are the symptoms of gestational diabetes?

Answer 14

Increased thirst, needing to pee more often than usual, a dry mouth, tiredness.

Question 15

How to determine whether the patient is at risk of gestational diabetes?

Answer 15

During first antenatal appointment around week 8 to 12 of pregnancy the HCP will ask questions to determine whether individual at an increased risk.
If 1 or more risk factors, patient needs oral glucose tolerance test (OGTT). It involves having a blood test in the morning, after no food or drink for 8 to 10 hours, then given a glucose drink. After resting for 2 hours, another blood sample is taken to see how your body is dealing with the glucose.
Performed again at 24 and 28 weeks.

Question 16

What problems can gestational diabetes cause?

Answer 16

Baby growing larger than usual – this may lead to difficulties during the delivery and increases the likelihood of needing induced labour or a caesarean section.
Polyhydramnios – too much amniotic fluid which can cause premature labour or problems at delivery
Premature birth
Pre-eclampsia
Baby developing low blood sugar or yellowing of the skin and eyes (jaundice) after he or she is born, which may require treatment in hospital.

Question 17

What’s the treatment for gestational diabetes?

Answer 17

Aim to control blood sugar levels whether through diet, exercise of medication
It’s best to give birth before 41 weeks. Induction of labour or a caesarean section may be recommended if labour does not start naturally by this time. Earlier delivery if sugar levels not controlled.

Question 18

What are the different types of birth?

Answer 18

Labour and vaginal delivery
Assisted delivery
Caesarean section
Post C section deliveries
Breech and transverse birth
Induced birth

Question 19

What is labour and vaginal delivery?

Answer 19

First stage of labour - contractions that cause the cervix to dilate. It is usually the longest stage.
Second Stage of Labour – cervix is fully dilated to the birth of the baby.
Third Stage of Labour – womb contracting and the placenta being delivered.

Question 20

What is Assisted delivery?

Answer 20

Involves the use of instrumental device
- Ventouse: An instrument that attaches to the baby’s head by suction. It is a soft or hard plastic or metal cup that is attached by a tube to a suction device (not used before 34 weeks).
- Forceps: smooth metal instrument that looks like a large spoon or tong. They join together by the handles and are carefully positioned around the baby’s head
Usually involves a local anaesthetic to the vaginal area if haven’t already an epidural and can involve an episiotomy.

Question 21

What is Caesarean section?

Answer 21

Making an incision through the abdomen into the womb to remove the baby.
Can include both planned procedure or emergency procedures if a vaginal birth is thought to be too risky.
Involves a spinal or epidural anaesthetic and the whole procedure usually takes around 40 to 50 minutes.
Recovery is usually longer than a vaginal birth and means that the patient may need to avoid activities such as driving for up to 6 weeks.

Question 22

What is a Post C section delivery?

Answer 22

VBAC – When a patient gives birth vaginally having previously had a C section in the past this includes normal delivery and assisted deliveries. Fewer complications but may need emergency C section or blood transfusion.
ERCS - An elective repeat caesarean section that takes place after 39 weeks. Advantages of this include smaller risk of uterine scar rupture and also knowing the date of planned birth. Disadvantages include the repeat C section being longer and increased risk of DVT and PE.

Question 23

What are Breech and transverse births?

Answer 23

Breech baby - baby laying bottom or feet first. If the baby is still in this position at 36 weeks then other delivery options can be discussed. An external cephalic version can be offered and options for a C section can take place.
Transverse birth - baby is lying sideways across the womb. Can lead to hospital admission due to complication with the umbilical cord. A C section delivery is encouraged if the baby in the transverse position nearing the due date or start of labour.

Question 24

What is an Induced birth?

Answer 24

An artificial start to labour.
Reasons for induction including pre eclampsia, patients being overdue or if the patients waters break more than 24 hours before labour starts.
Usually planned and scheduled in advance.
A membrane sweep can be offered pre induction in an attempt to start labour.
Induction itself is a small pessary or gel inserted into the vagina to kick start labour and can sometimes be included with an oxytocin drip in order to speed up the process.

Question 25

What is Preconceptual care?

Answer 25

The provision of biomedical, behavioural and social health interventions to women and couples before conception. It aims to improve maternal, paternal and child health, in both the short and long term.

Question 26

What behaviours are assessed in preconceptual care?

Answer 26

Healthy behaviours – include a healthy diet, folic acid supplements, regular physical activity, promoting emotional wellbeing and ensuring cervical screening, sexual health checks and immunisations are up to date.

Question 27

What risk factors are assessed in preconceptual care?

Answer 27

Risk factors – include smoking, alcohol, substance misuse, obesity, long term physical and mental health conditions, previous pregnancy complications, genetic risks, maternal age, adverse childhood experiences, domestic abuse, migrant health factors.

Question 28

Other than health behaviour and risk factors, what else does preconceptual care assess?

Answer 28

Includes relationships and support, education, housing, employment financial stability, environment, community safety and cohesiveness.

Question 29

What is the preconceptual dietary advice?

Answer 29

Healthy, varied diet is KEY Pregnant women should only eat an extra 200kcal in the last trimester. Avoid excessive weight gain. Should take folic acid supplements before conception and during pregnancy - helps lower the risk of neural tube defects in the foetus. Vit D is also recommended - allow optimal bone development of the unborn child and to help avoid rickets during childhood. Iron rich foods in order to prevent iron deficiency. Don't take supplements containing Vit A, liver Liver products should be avoided. Stop drinking Caffeine limitations

Question 30

What is the preconceptual dietary advice for men?

Answer 30

Only drink recommended allowance – affects sperm quality Stop smoking – smoking reduces sperm quality. Aim to lose weight obese – healthy body weight increases chances of conceiving Eat healthy and balanced diet – important for male fertility

Question 31

How often will a woman have antenatal appointments?

Answer 31

1st child - 10 antenatal appointments Have had child before – 7 but sometimes more e.g. with medical condition

Question 32

What happens at antenatal appointments?

Answer 32

Likely to be asked at appointments - date of the first day of your last period, general health, any previous illnesses and operations, ethnic origin of you and partner, job, partner’s job, what kind of accommodation you live in, how you’re feeling and if you have been depressed. Information that should be given at appointments - Making birth plan, preparing for labour and birth, how to tell if you’re in active labour, induction of labour if baby is overdue, baby blues, postnatal depression, feeding your baby, Vitamin K, screening tests for newborn babies, looking after yourself and baby.

Question 33

What happens at the 24 week pregnancy appointment?

Answer 33

Check BP and urine Feel abdomen to check baby’s position Measure uterus to check baby’s growth Listen to baby’s heartbeat (optional)

Question 34

When do Ultrasound scans/Sonography happen?

Answer 34

First scan 8-14 weeks – dating scan. Estimates due date based on baby's measurements. Nuchal translucency scan which is part of combined screening test for Downs syndrome. Second scan 18-21 weeks – checks for 11 physical conditions in Bones, Heart, Brain, Spinal cord, Face, Kidneys, Abdomen

Question 35

What happens in the ultrasound scan/sonography appointment?

Answer 35

Whether there is one baby or more Detect physical conditions Position of baby and placenta Check growth of baby is normal

Question 36

What antenatal investigations are performed?

Answer 36

Weight and height used to calculate BMI Urine sample BP tests – checked at every antenatal visit Blood tests – HIV, syphilis, Hep B at 8-12 weeks Blood group and rhesus status Screening for sickle cell and thalassemia Anaemia screening – at 28 weeks Gestational diabetes – risk factors increase risk Antenatal screening tests to find out chance of e.g. Down’s Syndrome

Question 37

Which patients will benefit most from antenatal investigations?

Answer 37

Patients who’s pregnancies have gone beyond delivery date Patients with diabetes or chronic hypertension Pregnancies demonstrating intraurine growth restriction Those who have had multiple pregnancies or bleeding during pregnancy Patients who have too much/little amniotic fluid Patients with children with congenital abnormalities

Question 38

What is Downs syndrome?

Answer 38

A chromosomal disorder whereby there is an extra copy of chromosome 21. In the majority of cases, this isn’t inherited, it’s simply a one-off genetic variation in the sperm or the egg. Three major types – trisomy 21 (94% cases, where every cell in body has extra copy of chromosome 21) cases, translocation or mosaicism.

Question 39

What are the clinical features of Downs syndrome?

Answer 39

Certain common physical features – reduced muscle tone, small nose and mouth, flat back of head. Mild to severe learning difficulties – delayed development, may take children longer to learn to walk, other difficulties include ADHD or problems effecting bowel and thyroid.

Question 40

What causes Downs syndrome?

Answer 40

No identified causal factors - main factor that increases the chances of having a baby with Down’s syndrome is the age of the mother at the time of pregnancy. Increased incidence in babies with older mothers or parents/sibling’s with Down’s syndrome.

Question 41

What are the different tests for Downs syndrome?

Answer 41

All optional Screening tests – combined test and quadruple test. Diagnostic tests – chorionic villus sampling, amniocentesis.

Question 42

What is the Combined test?

Answer 42

10-14 weeks pregnant or when baby’s crown-rump is 45-84mm Involves a blood test and a nuchal translucency ultrasound scan. Also used to screen for Edwards’ syndrome and Patau’s syndrome. Blood test is to look for increased levels of human chorionic gonadotropin and decreased levels of pregnancy-associated plasma protein as these abnormal levels can be indicative. Nuchal translucency is a collection of fluid under the skin at the back of the baby's neck. Babies with Down’s syndrome often have a greater volume of fluid so an ultrasound scan can assess the levels present. Results from these tests are analysed and factors such as age, weight and medical history are taken into account. The results will show whether there is higher chance that the baby has down’s syndrome (1 in 150) or a lower chance (below 1 in 150). The results are usually available within 2 weeks, although it may be quicker if it is found that there is a higher chance of Down’s syndrome.

Question 43

What is the quadruple test?

Answer 43

Used if nuchal translucency can’t be analysed (depends on babys position) or if mother is +14 weeks Less accurate but can give idea of likelihood. Blood test that looks for increased levels of human chorionic gonadotrophin (hCG) and alpha fetoprotein (AFP) and decreased levels of inhibin-A and unconjugated oestriol. The results from this test are analysed along with information about age, weight and medical history. Important to understand that if the mother smokes or has had an assisted pregnancy using a donor egg or frozen embryo, the levels of these components may be affected, giving a skewed result.

Question 44

What is Chorionic villus sampling?

Answer 44

Carried out between the 11th and 14th week of pregnancy, although can be performed later than this if necessary. Sample of chorionic villi are removed from the placenta. This can be done transabdominally whereby a needle is inserted in the tummy, or transcervically whereby a tube or small forceps are inserted through the cervix to remove a sample of cells. Chorionic villi are villi that sprout from the chorion, the outermost fetal membrane around the embryo. They are a key site of exchange of oxygen, nutrients and waste products between the maternal and fetal circulation. The chorionic villi share the baby’s genetic makeup so give a good idea about the presence of any chromosomal disorders. The test takes about 10 minutes in total, and is often described as uncomfortable rather than painful. Risks associated: miscarriage and infection Results available within 3 working days

Question 45

What is Amniocentesis?

Answer 45

The procedure involves inserting a long, thin needle into the abdominal wall, guided by an ultrasound image so that the needle is a safe distance from the baby. This needle passes into the amniotic sac and a small sample of amniotic fluid is removed for analysis for a number of different proteins. Usually performed between the 15-20th week of pregnancy but you can have it later if necessary. test only takes about 10 minutes. Results should be available within 3 working days.

Question 46

What are the risks of amniocentesis?

Answer 46

1% risk of a miscarriage and because it is an invasive process there is always a small risk of infection, but this is generally very rare. If the mother is HIV positive, there is a greater risk of transmission of the infection to the child. If the mother is Rhesus negative, she will be given an injection of anti-D immunoglobulin afterwards, to prevent the mother developing antibodies against the baby’s blood cells.v

Question 47

What are the options following the tests for Downs syndrome?

Answer 47

If the diagnostic tests reveal that the baby has down syndrome: Some wish to continue with the pregnancy and prepare for the needs of their newborn baby, Some may decide to terminate the pregnancy.