Pregnancy Planning and Preconception Care Flashcards
1
Q
What is the Developmental Origins of Disease Concept?
A
An approach emphasising the role of prenatal exposure to environmental factors in determining the development of human diseases in adulthood
E.g. obesity, diabetes, CVD, and certain cancers may be linked to early life nutritional status and/or exposures to environmental chemicals, drugs, infections, lifestyles or stress
2
Q
Periods of fetal development
When is the most vulnerable time for CNS development?
A
Weeks 3 to full term
3
Q
Periods of fetal development
When is the most vulnerable time for ear / hearing development?
A
Weeks 4.5 to 20
4
Q
Periods of fetal development
When is the most vulnerable time for eye / visual development?
A
Weeks 4.5 to term
5
Q
Periods of fetal development
When is the most vulnerable time for heart development?
A
Weeks 3.5 to 9
6
Q
Periods of fetal development
When is the most vulnerable time for teeth development?
A
Weeks 6.5 to full term
7
Q
Periods of fetal development
When is the most vulnerable time for palate development?
A
Weeks 6.5 to 16
8
Q
Periods of fetal development
When is the most vulnerable time for limb development?
A
Weeks 4.5 to 9
9
Q
Periods of fetal development
When is the most vulnerable time for external genitalia development?
A
Weeks 7 to full term
10
Q
When can a teratogen affect a fetus?
A
- Organ formation occurs in first 12 weeks of pregnancy - therefore teratogenic drugs taken in this period tend to cause structural defects
- After 12 weeks, teratogens tend to cause growth defects or developmental delay
- If exposure occurs before differentiation of the three germ layers, either embryonic death results or no abnormalities are apparent
11
Q
Describe the use of ACE inhibitors in pregnancy
A
- Relatively safe in 1st trimester
- In 2nd and 3rd trimester can cause renal tubular aplasia and IUGR
- Some evidence of PDA
- Oligohydramnios (due to reduced renal function)
- If on ACEi and planning a pregnancy, should ideally switch to another medication
- Extra growth scans will be required in those who continue to use ACEi
12
Q
Describe the use of beta blockers in pregnancy
A
- Generally don’t cause birth defects, stillbirth or preterm birth
- Concern that the fetus will be SGA/IUGR
- Neonatal hypoglycaemia can occur
- If continued on propranolol, will need extra growth scans
13
Q
Describe the use of statins in pregnancy
A
- Not recommended due to theoretical risk of reduced cholesterol production needed for normal development of fetus and placenta
- Recommended to stop 3 months prior to conception
- Temporary suspension of statins shouldn’t compromise maternal health
14
Q
What advice should be given to a pregnant epileptic on carbamazepine?
A
- Take 5mg/day folic acid
- Some reports of neonatal withdrawal
- All babies should be given vit K injection in case of pancytopenia
15
Q
What abx can be used for UTI in pregnancy?
A
- Penicillins and cephalexin are fine
- Trimethoprim should be avoided in 1st trimester (is a folate antagoninst)
- Nitrofurantoin should be avoided at term due to risk of haemolytic anaemia in the newborn
16
Q
Can you use doxycycline in pregnancy?
A
No, particularly in 2nd and 3rd trimester as causes discolouration of teeth (adult teeth are unaffected)
17
Q
What advice is given re. ibuprofen in pregnancy?
A
- Not advised, especially if over 30 weeks pregnant as may cause PDA to close in utero
- Unlikely to harm before 30 weeks
- Links to persistent pulmonary HTN if PDA closes
- May also result in oligohydramnios
18
Q
What advice is given re taking warfarin in pregnancy?
A
- Risk of fetal warfarin syndrome / warfarin embryopathy
- Switch to LMWH before pregnancy or ASAP
- Continued use of warfarin may need to be considered in patients with mechanical heart valves
19
Q
What are the features of fetal warfarin syndrome / warfarin embryopathy?
A
- Nasal hypoplasia, skeletal abnormalities (short limbs and digits)
- Critical period is 6-12 weeks, 30% of fetuses exposed in this time will develop fetal warfarin syndrome
- Exposure in 2nd trimester can be associated with CNS and eye anomalies
- Exposure in 3rd trimester increases risk of placental, fetal or neonatal haemorrhage
20
Q
What advice is given re. taking carbimazole in pregnancy?
A
- 98% of women on carbimazole do not experience these birth defects, but it can include:
– Choanal atresia
– Heart / GI / abdominal wall defects
– Scalp defect called asplasia cutis - Can cause neonatal hypothyroidism
- Propylthiouracil (PTU) should be used instead in 1st trimester, and then switched to carbimazole for rest of pregnancy
- Avoid pregnancy for 6 months after radioactive iodine
21
Q
What advice is given to women who take SSRIs in pregnancy?
A
- QoL is important ++ and the mental health of the woman
- Some studies have linked SSRI use to preterm delivery or low birth weight
- Neonatal withdrawal can occur
- Rarely can cause persistent pulmonary hypertension of the newborn
- Higher risk of PPH
- Some links to autism
22
Q
What advice is given to pregnant women on lithium?
A
- Avoid in pregnancy, especially in 1st trimester
- Can cause abnormality of heart valves (Ebstein’s anomaly)
- All women on lithium should have a high-resolution USS and fetal echo at 18-20 weeks
23
Q
What advice is given to women on azathioprine / mercaptopurine in pregnancy? (used in IBD, lupus, severe eczema, RA, psoriasis, transplant rejection)
A
- No evidence of fetal harm
- No further scans necessary (although underlying condition may require these)
24
Q
Why is smoking harmful in pregnancy?
A
- Miscarriage, premature delivery, IUGR/SGA (reduced blood supply to placenta)
- 2x likely to have a stillbirth
- Increased risk of SIDS and childhood illnesses
- Birth defects include
– Craniosynostosis (fusion too early)
– Gastroschisis
– Defects of urinary tract
– Heart defects
– Congenital diaphragmatic hernia
– Talipes
25
Explain how alcohol is a teratogen
- Interferes with normal development by restricting blood flow and triggering cell death
- Nearly all aspects of fetal development can be disrupted by exposure to alcohol
- Brain and CNS are most vulnerable to interference
- Facial dysmorphologies occur in first trimester
26
What effect does cannabis have on the fetus?
- Increases risk of preterm delivery
- Increases risk of low birth weight
- May affect long-term learning and behaviour
- May have withdrawal at birth
27
What effect does cocaine have on the fetus?
- Increases risk of stillbirth
- Increases risk of premature delivery
- Increases risk of low birth weight (restricts placental blood vessels and increases placental abruption)
- Withdrawal symptoms at birth
- Long-lasting growth restriction in the child's height too
28
What advice is given re opioid use in pregnancy?
- No evidence that opioid use causes birth defects
- Possibly higher chance of stillbirth
- May have withdrawal symptoms at birth (jitteriness, sleep disturbance, seizures, poor feeding, digestive problems, vomiting)
- Transient tachypnoea of newborn
- Possible link to learning and behavioural problems in the child
29
What advice is given to women of childbearing age who are on isotretinoin (roaccutane)
- Women must use 2 methods of contraception, have a neg PT one month before starting, have a neg PT before repeat px, and a negative PT one month after stopping
- 3/10 women who conceive on this will miscarry
- 1/5 women will have a birth defect
30
What current pregnancy 'problems' will categorise a woman as a high risk pregnancy?
- Multiple pregnancies
- Gestational diabetes
- HTN
- Low-lying placenta
- Raised BMI
- IUGR
- Breech
- Oligo/polyhydramnios
- Anaemia
- Infection
- Preterm labour / PROM
31
What previous pregnancy problems would categorise this pregnancy as high risk?
- Previous c-section
- PPH
- Shoulder dystocia
- PET
- Eclampsia
- Retained placenta
- Stillbirth / IUFD
32
What maternal medical conditions would categorise her pregnancy as high risk?
- Diabetes
- Heart disease
- Renal disease
- HTN
- Stroke
- Asthma
- Cystic fibrosis
- Sickle cell
- Thrombophilia
- Haemophilia
- Hyperthyroidism
- Blood borne viruses
- Liver disease
- Epilepsy
- Mental health illness requiring hospitalisation
33
What minimum interpregnancy interval is recommended and why?
- At least 12 months between childbirth and conceiving again
- Less than this is associated with increased risk of preterm birth, low birth weight and SGA
34
What adverse maternal and fetal outcomes are increased with diabetes in pregnancy?
- Increased rates of hypoglycaemia, DKA, worsening diabetic retinopathy and nephropathy
- Increased risk of miscarriage, macrosomia, obstetric complications and growth abnormalities, stillbirth
35
What HbA1c monitoring is needed pre-pregnancy, and what levels are to be aimed for?
- Pregnancy should be avoided if above 86 mmol/mol (10%)
- Measure HbA1c monthly
- Aim for pre-pregnancy level of 48mmol/mol (<6.5%) to reduce risk of congenital malformation
36
What blood sugars should be aimed for in pregnancy for someone with T1DM?
- Fasting of 5-7mmol/L on waking
- 4-7mmol/L before meals
37
What other preconception advice is given to women with diabetes?
- Take 5mg folic acid until week 12 of pregnancy
- Perform a retinal assessment (unless within last 6 months)
- Check U&E and albuminuria before stopping contraception
- Measure TSH, free T4 and TPO antibodies in women with T1DM
38
What pre-conception advice is given to someone with hyperthyroidism?
- Refer to endocrinologist (even subclinical hyperthyroidism) for pre-conception counselling
- Check TSH and free T4 levels, consider TPO antibodies too
- Delay conception until thyroid function has normalised and she has been seen by a specialist
39
What post-partum investigations are done for someone with hyperthyroidism?
- Recheck TFTs post delivery
- Recheck TFTs again 6-8 weeks postpartum if the woman has a goitre / history of postpartum thyroiditis / autoimmune thyroid disease such as Graves
40
What preconception advice is given to women with hypothyroidism?
- Delay conception until euthyroid on levothyroxine
- Likely to have an increased demand for thyroxine during pregnancy, and dose may need to be adjusted early on
- Check TFTs immediately once pregnancy confirmed (interpret using pregnancy-related reference ranges)
- Specialist review (can be obstetrician with a special interest)
41
Post-partum, what should be done for someone with hypothyroidism?
- Levothyroxine dose should be reduced to pre-pregnancy levels
- Repeat TSH done at 6 weeks
42
What things should be discussed with a woman preconception who has psychiatric illness?
- How might pregnancy and childbirth affect her mental health
- How might her mental health/treatment affect her baby
- Risks of not treating her condition before conception and during pregnancy
- Refer women with severe mental health to perinatal mental health service
43
What is NICE / MHRA guidance for valproate for bipolar disorder in women of childbearing age?
NICE
- If already taking valproate, be advised to gradually stop the medication over 4 weeks due to risk of fetal malformation
MHRA
- Do not prescribe to female children/teens/child-bearing adults for bipolar, unless no alternative option
44
What preconception advice is given to women with epilepsy?
- Folic acid 5mg until 12 weeks
- Risk 2-3x higher of having congenital malformation than general population
- Highest risk to fetus is in 1st trimester
- Risk of sudden unexpected death in epilepsy (SUDEP) in the mother if she does not take her antiepileptic medication
45
What are obese women at higher risk of during pregnancy (maternal and fetal)
- Increased risk of PET, gestational diabetes, VTE, c-section, death
- Increased incidence of congenital anomalies, macrosomia, diabetes in later life, stillbirth, neonatal death
- Higher risk of neural tube defect and so 5mg folic acid is recommended in the month prior and throughout all of first trimester
46
What advice is given to women with BMI >30 who wish to become pregnant?
- Optimise weight before pregnancy
- Motivational interviewing
- Folic acid 5mg
- 10 micrograms vitamin D
47
Which vaccines are contraindicated in pregnancy?
Live attenuated (such as rubella, polio, MMR)
48
What vaccinations can a travelling pregnant person have?
- Tetanus is safe
- Meningococcus is unknown but can consider if high risk
- HBV is safe
- Avoid cholera, hep A, rabies and yellow fever
49
When should a woman be offered MMR vaccine?
- Not in pregnancy
- In fertility clinic if not immune to rubella (rubella immunity should be checked)
Notifiable disease, protection is usually given as part of UK MMR vaccine at 1 years old and again at 3 years and 4 months old
50
What can happen if a pregnant person is exposed to rubella?
- If 8-10 weeks, 90% chance of congenital rubella syndrome
- Beyond 20 weeks, no published case reports of congenital rubella syndrome
51
What are the clinical features of congenital rubella syndrome?
- Eye defects (cataracts)
- Hearing impairment
- PDA
- Pulmonary artery stenosis
- CNS defects
- Progressive panencephalitis
- IUGR
52
What can be increased if a pregnant person is exposed to toxoplasma gondii (or in the few months before conception)?
- Miscarriage
- Stillbirth
- Birth defects (hydrocephalus, microcephaly, blindness, epilepsy)
53
If a pregnant person comes into contact with cytomegalovirus, what is the risk of harm to the fetus?
- 40% of fetuses will be infected
- 90% of these will be normal at birth
- but 20% of these will develop later, minor sequalae
54
What are some CMV-associated congenital defects?
- IUGR
- Microcephaly
- Hepatosplenomegaly and thrombocytopenia
- Jaundice
- Chorioretinitis
- Sensorineural deafness
55
What treatment options are there for pregnant women exposed to chickenpox / varicella zoster / HHV 3?
- If unsure of previous hx of chickenpox, test for VZV IgG
- If not immune and has had a serious exposure, offer VZV asap (effective for up to 10 days post exposure)
- Offer oral aciclovir for women who are over 20 weeks with chickenpox
56
What are the risks to the fetus if a pregnant person gets chickenpox / varicella zoster / HHV 3?
- If develops chickenpox in first 28 weeks pregnancy, small risk of fetal varicella syndrome
- Refer these women to fetal medicine specialist
- If exposed in last 4 weeks of pregnancy, significant risk of varizella infection in the newborn
- Try to avoid a planned delivery in 7 days after exposure to allow passive transfer of maternal antibodies to baby
57
When do pregnant people have rhesus screening and then receive routine anti-D?
- Check blood group and FBC at booking
- Recheck at 28 weeks due to second red cell antibody screening test done in pregnancy
- Routine anti D should be given at 28 weeks (single dose) [or two dose regime at 28 and 34 weeks]
- This is in addition to and regardless of any other anti-D given
58
What advice is given re. anti D and sensitising events under 12 weeks?
- Only indicated following ectopic pregnancy, molar pregnancy, surgical TOP, or heavy, repeated PV bleed and abdo pain
- Minimum 250 IU
- No need to test for fetomaternal haemorrhage (FMH)
59
What advice is given for anti-D and sensitising events between 12 and 20 weeks?
- Minimum dose of 250 IU
- FMH testing not required
60
What advice is given for anti-D and sensitising events after 20 weeks?
- Minimum dose of 500 IU
- FMH testing should be performed
61
What postpartum management is given re. Anti D?
- ABO and Rh D typing should be performed on cord blood
- Is baby is Rh positive, all negative women should be offered at least 500 IU within 72 hours of delivery
- Maternal samples for FMH testing should be taken
62
When should anti D be given after a sensitising event?
- Within 72 hours
- Exceptionally up to 10 days
63
If a woman is in a high prevalent area for sickle cell and thalassaemia, what screening is recommended for these conditions?
- High prevalence = 2%+ of antenatal screening tests for sickle cell and thalassaemia received by the lab are positive
- All women are screened
64
If a woman is in a low prevalent area for sickle cell and thalassaemia, what screening is recommended for these conditions?
- Low prevalence = <1% of antenatal screening tests are positive for sickle cell and thalassaemia
- Only test for these if abnormality found in FBC, or
- High risk family origin
65
When would the father be offered a screening test for sickle cell or thalassaemia?
- If the mother has sickle cell or thalassaemia, or is a carrier
66
When is optimum time for Downs and Edwards and Patau's screening?
- Down's between 10+0 and 20+0
- Edwards and Pataus between 10+0 and 14+1
67
When can screening for 11 physical conditions as part of 20 week anomaly scan be performed?
- Between 18+0 and 20+6 (or up to 23+0)
68
What is the combined screening test?
- Screening test for trisomies
- Maternal age + bhCG + PAPP-A + nuchal translucency and CRL
- Eligibility to use CRL is if it is between 45.0mm and 84.0mm
- If NT cannot be measured, offer the woman the quadruple test
69
What is the quadruple test?
- Screening test for trisomy 21 only
- Offered when NT cannot be measured, or CRL >84.0 and HC is between 101.0mm and 172.0mm
- Maternal age + AFP + bhCG + inhibin A + unconjugated estradiol
- Can be offered between 14+2 and 20+0 weeks
70
What is a NIPT?
- Non-invasive prenatal testing
- Screening for T21, T18 and T13
- Offered following a higher chance result (between 1/2 and 1/150) from either a combined or quadruple test
71
What is the purpose of the 20 week screening scan?
- To identify any benefit from treatment before or after birth
- To identify a need for specialist treatment after birth to improve health outcomes
- To identify those babies who may die shortly after birth
- To lead to a discussion about options of continuing or terminating a pregnancy
72
What can compromise the 20 week scan?
- BMI
- Uterine fibroids
- Abdominal scarring
- Baby/babies in suboptimal position
73
What are the 11 physical conditions screened for at the 20 week scan?
- Anencephaly
- Spina bifida
- Cleft lip
- Congenital diaphragmatic hernia
- Gastroschisis
- Exomphalos
- Congenital heart disease
- Bilateral renal agenesis
- Severe skeletal dysplasia
- Edward's syndrome
- Patau's syndrome
74
What 6 specific anatomical sections should be archived at the 20 week scan?
- HC measurement at atrium of lateral ventricle
- Suboccipitobregmatic view (meassurement of transcerebellar diameter)
- Coronal view of lips with nasal tip
- AC measurement
- FL measurement
- Sagittal or coronal view of spine including sacrum
75
What does the fetal cardiac protocol include at the 20 week scan?
- 4 chamber view
- Aorta/left ventricular outflow tract
- Pulmonary/right ventricular outflow tract
- 3 vessel and trachea view
76
What are the indications for amniocentesis?
- Undertaken from 15 weeks gestation
- Karyotyping if screening suggests aneuploidy
- DNA analysis if parents are carriers of a gene i.e. cystic fibrosis
- Enzyme assays looking for inborn errors of metabolism
- Diagnosis of fetal infections such as CMV or toxo
77
What are the risks and benefits of amniocentesis?
Benefits
- Lower risk of miscarriage than CVS
- Less risk of maternal contamination
Risks
- Miscarriage risk of 1%
- Failure to culture cells risk of 0.5%
- Full karyotyping may take 3 weeks
78
What are the indications of chorionic villus sampling?
- Performed between 10- and 13- weeks gestation
- Karyotyping if 1st trimester screening is high risk for aneuploidy
- DNA analysis if parents are carriers of a specific gene
79
What are the risks and benefits of chorionic villus sampling?
Benefits
- Allows 1st trimester TOP if abnormality is detected
Risks
- Miscarriage 1%
- Risk of vertical transmission of BBV
- False negative results from maternal contamination
80
What can be done for the newborn/infant to prevent vertical transmission of Hep B from mother?
- Will need 6 hep B vaccines (at birth, 4 weeks, 8, 12 and 16 weeks, and at 1 year)
- Should have first hep b vaccine within 24 hours of birth
- Baby may need HBIG at the same time if a higher risk of transmission
- Baby will be offered heel prick test for Hep B at 1 year
81
How does carrier status of Hep B determine risk of vertical transmission?
- If HbsAg and HbeAg positive: 95% risk of transmission
- If HbsAg positive and HbeAg negative: <15% risk of transmission
82
When does most vertical transmission of Hep B occur?
- At delivery
- <5% could be due to transplacental bleeding in utero
83
When should a viral load be checked for women living with HIV who commence combined ART in pregnancy?
- 2-4 weeks after commencing cART
- At least once every trimester
- At 36 weeks
- At delivery
84
What VL can a woman living with HIV plan for a vaginal delivery?
- If VL <50 at 36 weeks (in the absence of other obstetric complications)
85
What VL should a c-section be considered or recommended?
- If 50-399, pre-labour c-section should be considered
- If >400, recommend c-section
86
What is recommended if a woman living with HIV experiences pre-labour SROM?
- If VL <50, immediate induction and deliver baby within 24 hours
- If VL>50, consider immediate c-section
87
When do you give intrapartum IV zidovudine?
- VL >1000 (or unknown)
- Consider if VL between 50-1000
88
When do you give infant PEP?
- Commence for all infants within 4 hours of birth
- Very low risk: 2 weeks of zidovudine
- Low risk: 4 weeks zidovudine
- High risk: combination PEP
89
Who is offered a glucose tolerance test in pregnancy?
- Previous GDM
- FH diabetes
- Previous macrosomic baby
- Previous unexplained stillbirth
- Obesity
- Glycosuria >1 occasion
- Polyhydramnios
- LGA fetus
90
What are the names of some weight loss programmes available on NHS?
- Free NHS weight loss plan (app)
- NHS digital weight management programme (12 week online behavioural and lifestyle management)
91
What smoking cessation programmes are available on the NHS?
- NHS community pharmacy smoking cessation service
- Local stop smoking service
- Stop smoking treatments via GP (i.e. nicotine replacement)
92
What drug and alcohol services are available on NHS?
- Via GP
- Frank website / Frank drugs helpline
- Charitable treatments - Adfam website
