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Anna and louise > Routine antenatal care > Flashcards

Routine antenatal care Flashcards

1
Q

Aetiology of alcohol use in pregnancy

A

48% of women reported consuming alcohol in pregnancy prior to knowing pregnant
25% consumed alcohol while pregnant, after knowledge of their pregnancy

Higher incidence amongst women who are:
Older
- 50% of pregnant women >36y continue to drink 
- 90% of those <25y stopped 
Higher socio-economic status
Higher educational status
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2
Q

Why don’t drink in pregnancy?

A

Alcohol freely passes through the placenta and reaches concentrations in the fetus that are as high as those in the mother
Fetus has minimal ability to metabolise alcohol

All types of alcohol can be harmful, but risk to fetus more likely to occur if:

  • Alcohol is consumed frequently throughout the pregnancy, or
  • High levels of alcohol are consumed throughout the pregnancy

No alcohol = no risk
No consensus on safe level, therefore advise none

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3
Q

Impact of alcohol on pregnancy

A 
Miscarriage
Stillbirth
Low birth weight
Premature birth
Brain damage and birth defects
FASD
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4
Q

Breastfeeding and alcohol

A

Alcohol enters the breast milk and may stay there for several hours
May affect milk production
Advise women to:
- Not drink alcohol during the first month after baby is born and until breastfeeding is well established
- Limit alcohol intake after this first month to no more than 2 standard drinks a day (if they choose to drink), and
- Avoid drinking immediately before breastfeeding
- Option to express should be discussed

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5
Q

Define fetal alcohol spectrum disorder

A

Umbrella term for diagnoses related to antenatal exposure to alcohol
1% = FASD
0.5% = FAS

FAS is the leading preventable cause of mental retardation and birth defects

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6
Q

Fetal alcohol syndrome (FAS)

A 
Prenatal alcohol exposure
Measurable deficits in 3 categories
1. Growth restriction
2. Facial malformations
3. Brain and CNS disorders

Become more obvious with age

  • Poor memory
  • Impaired language and communication
  • Problems with abstract thinking
  • Poor impulse control
  • Poor judgement
  • Mental, social and emotional delays
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7
Q

FAS facial features

A 
Thin upper lip
Elongated philtrum 
Small, wide set eyes
Low nasal bridge 
Micrognathia
Flat mid face
Short nose
Epicanthal folds
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8
Q

Conditions under the FASD umbrella

A

Fetal alcohol syndrome (FAS)

Partial FAS

Alcohol-related neurodevelopmental disorder (ARND)

Alcohol-related birth defects (ARBD)
- Most commonly cardiac, skeletal, ear, or eye abnormalities

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9
Q

General principles of care for substance abuse

A

Work with social worker to overcome barriers

  • MDT
  • Integrate care from different services
  • Address fears about involvement of children’s services and potential removal of their child
  • Address feelings of guilt

Offer referral to appropriate substance misuse programme
Address other comorbidities
Associated health risks with IVDU (past or present) - e.g. blood-borne infections, thrombosis, injection at injective sites
Referral to indigenous / cultural support
Liase with paeds pre birth - early counselling on outcomes for baby
Screen for DV
Discuss contraception

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10
Q

Key features of neonatal abstinence syndrome

A 
CNS features:
- Irritability, high-pitched cry
- Increased muscular tone
- Tremors and seizures
Autonomic features:
- Sweating
- Yawning
- Sneezing
- Increased RR
Gastrointestinal features:
- Excessive sucking
- Poor feeding

Onset of symptoms within 24-72h of birth
- Can occur up to 2/52 after birth
Management: supportive
Breastfeeding reduces the severity of NAS

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11
Q

Methadone in pregnancy

A

Methadone = full opioid agonist
Can be introduced at any time during pregnancy as it carries a lower risk than illicit drug use
Maintenance at a dose that prevents illicit drug use should be the aim, rather than withdrawal during pregnancy

Encourages antenatal attendance and no evidence of teratogenicity

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12
Q

Marijuana in pregnancy

A

Self reported prevalence 2-5%
Crosses the placenta rapidly
Little evidence that cannabis alone causes adverse effects

Evidence of neurodevelopmental deficit or delay in offspring
Evidence of higher rates of use in low SES, remote communities, causing financial hardship and an increased rates of mental health disorders

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13
Q

Opioid use in pregnancy

A

Opioid use in pregnancy affects the capacity for self-care and for safe parenting
Opiates do not cause congenital abnormalities

If injected, risks to mother of:

  • VTE
  • Sepsis - local and systemic
  • Blood-borne viruses - hepatitis B and C, HIV

Treatment:
MDT
Methadone
Second trimester best time for withdrawal
Detoxification is generally not recommended at other times in pregnancy
- Increased risk of miscarriage in the first trimester
- Increased risk of fetal complications in the third trimester due to maternal and fetal withdrawal

Likely to need more analgesia in labour

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14
Q

Meth in pregnancy

A

Higher incidence of PTB and LBW, especially if used continuously during pregnancy
- stopping MA use at any time during pregnancy improved birth outcomes

Effect of drugs can mimic obstetric complications
Increased risk of mental health disorders

confounding factors

  • Other drug use, including tobacco
  • Poverty
  • Poor diet
  • Lack of prenatal care
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15
Q

benzodiazepines in pregnancy

A

Antepartum exposure associated with:

  • Teratogenic effects- Facial cleft and skeletal abnormalities
  • Current data leaves the level of risk uncertain
  • Neonatal withdrawal has been described in those taking high doses - Similar to those with neonatal abstinence syndrome
  • Neonatal hypotonia

Avoid abrupt cessation
Can cause seizures

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16
Q

Cocaine in pregnancy

A

Adverse outcomes associated with use of cocaine in pregnancy:
- Placental abruption
- Prematurity - PTB, PROM
- FGR
- Microcephaly
- Neurobehavioral abnormalities
Adverse effects thought to be related to vasoconstrictive effects on the placenta

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17
Q

Folic acid

A

> 800mcg OD
If increased risk of NTD or malabsorption: 5mg OD

1 month before conception
First 12 weeks of pregnancy

Increased risk NTD:

  • Anticonvulsant medication
  • T1DM or T2DM
  • Previous child or FHx NTD
  • BMI >30

Increased risk malabsorption:

  • Multiple pregnancy
  • Haemolytic anaemia
  • Monitor FBC and treat if evidence of folate deficiency
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18
Q

Vitamin B12

A

Those with vegetarian or vegan diets should be supplemented for pregnancy and lactation

Untreated maternal B12 deficiency reported to cause neurological sequelae in exclusively breastfed infants

RDI in pregnancy: 2.6 mcg/day
RDI during lactation: 2.8 mcg/day

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19
Q

Vitamin D supplementation in pregnancy

A

All pregnant women, irrespective of skin pigment and/or sun exposure, should take vitamin D
400 IU vitamin D OD as part of multivitamin
Essential for absorption of calcium from the gut and bone mineralisation
Functions as a hormone

Sources:

  • UVB exposure in sunlight
  • Ingested as food / supplement

Do not test levels as part of routine pregnancy screening, regardless of maternal risk factors
Do not re-test, irrespective of previous level
Usually asymptomatic

Deficiency <50nmol/L
Insufficiency <75nmol/L

Low calcium and vitamin D levels have been associated with adverse health outcomes in mother and child, but it is unclear whether low levels are the causal factor or a marker of poor health

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20
Q

Outcomes of vitamin D supplementation in pregnancy

A

In systemic reviews and 2 large RCTs, AN vitamin D supplementation at varying doses has not consistently been shown to improve maternal or neonatal outcomes:

  • Increases maternal and cord blood levels of vitamin D
  • Does not improve maternal obstetric outcomes, infant vitamin D levels, neonatal measures of bone density at 2/52
  • 20% reduction in the rate of childhood wheezing at 3y
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21
Q

Vitamin D supplementation in infants

A

Risks for children with severe vitamin D deficiency

  • Hypocalcaemic seizures
  • Rickets

Exclusively breastfed infants: 400 IU OD
If formula, do not routinely require supplementation

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22
Q

Clinical features of maternal vitamin D deficiency

A 
Bone loss, reduced weight gain
Hypocalcaemia
Osteomalacia
Myopathy
GDM
HTN, PET, SGA
Increased risk of CS

Fetal / neonate:

  • May adversely affect fetal bone health
  • Reduced neonatal calcium +/- tetany
  • Subsequent childhood asthma / atopy
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23
Q

Risk factors for vitamin D deficiency

A 
Pigmented skin
Those who are covered
Behaviours that avoid sun exposure
Those who adhere to a vegan diet
Several pregnancies with a short interbirth interval
Obesity
Malabsorption
Medications: Anti-epileptic drugs, highly active anti-retroviral therapy
Renal disease
Liver disease
Alcohol abuse
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24
Q

Calcium supplementation

A

Supplement >1000mg OD
If women avoids dairy or doesn’t consume alternative high calcium foods, give supplement

Cochrane review:

  • > 1000mg/day a/w reduced incidence of hypertensive disorders and PTL
  • Effect on PET was greater for women with low baseline calcium intake
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25
Q

Omega 3 fatty aid

A

2-3 serves (150g per serve) of fish per week
More not recommended as concern about intake of pollutants (mercury)

If low dietary intake (e.g. minimal seafood), consider supplement
Important building blocks for the developing fetal brain and retina

No conclusive evidence of benefit using fish oil supplementation in pregnancy is confirmed

26
Q

Exercise during pregnancy

A

Physical benefits - fitness, prevention of excessive weight gain, lifelong benefits (reduced CVD, T2DM, some cancers)
Psychological wellbeing - reduced Sx of depression
No evidence detrimental to fetus or woman
Regular exercise during pregnancy has been a/w shorter and less complicated labour, and fewer neonatal complications (but inconclusive evidence)
Active (30 mins) on most, preferably all days each week
Strengthening exercise 2x a week
No heavy lifting or lying on back after 1st trimester

Active on most, preferably all days each week
- E.g. ligament laxity, increase in metabolic rate - avoid exercising at high temperatures and humidity, increased loading at the joints with weight change

27
Q

Booking bloods

A 
FBC
Blood group and antibody screen
Rubella antibody status
Syphilis serology
HIV
Hepatitis B serology
Hepatitis C serology

Varicella (Au)
HbA1c (NZ)

Others to consider

  • Screening for haemoglobinopathies (low MCV)
  • CMV (pending job)
  • TSH (T1DM)

Maternal Mental Health Screening
Family violence

28
Q

Tests of fetal wellbeing after 41 weeks

A

Lack of high-level evidence on routine surveillance between 41 and 42/40
Advise women to be vigilant of a change in fetal movements
From 41/40, may be reasonable to offer twice weekly CTG and USS to assess AFI for surveillance of fetal wellbeing (RANZCOG)
Detailed and frequent assessment of fetal wellbeing, including liquor volume, is strongly recommended in pregnancies at or beyond 42/40

29
Q

What is population carrier screening ?

A

The detection of carrier status of autosomal and x-linked recessive diseases in couples or people who do not have an a priori increased chance of being a carrier based on their or their partners’ personal or family history
- Does not refer to testing an individual with a strong FHx

Most common inherited conditions for which prenatal diagnosis is currently performed:

  • Thalassaemia
  • Cystic fibrosis
  • Fragile X syndrome
30
Q

Reproductive options after carrier screening if both carriers or woman is a carrier for an X-linked condition

A
  1. Having child and testing after birth
  2. Conceiving naturally and having diagnostic testing during pregnancy (amniocentesis or CVS)
  3. IVF and testing embryos by preimplantation genetic diagnosis
  4. Using donor sperm, egg or embryo from unaffected individuals
  5. Adoption
  6. Not having children
31
Q

RANZCOG recommendations for genetic carrier screening

A

FHx to identify relatives with heritable genetic disorders, or presence of consanguinity
- If positive, offer referral to a genetic counselling

Basic screening for thalassaemic carrier status

  • FBC
  • Screening with specific assays for haemoglobinopathies should be considered in high probability ethnic or population groups

Offer information on carrier screening for other genetic conditions to all women planning pregnancy or in the first trimester

  • Panel for a limited selection of the most frequent conditions (e.g. CF, spinal muscular atrophy, fragile X syndrome)
  • Expanded carrier screening - identifies max no. of carrier, but identifying variants of uncertain significance. Should have robust counselling options if this is chosen

Screening will not identify carrier status for all mutations
Risk of identifying the individual tested as affected by one of the conditions screened for

32
Q

Types of genetic carrier screening

A

Sequential screening (two step)
- One member of the couple is screen, and the second only screened if the first member is a carrier
Advantages:
- Reduces overall cost for most couples
- Allows for cascade testing of relatives of carriers

Couple screening (one step)
- Both members screened at the same time
- May or may not be informed of the individual results of carrier testing
Advantages:
- Faster
- Far fewer individuals/couples require genetic counselling
- Anxiety from waiting for the partner result is minimised
Disadvantages:
- Test costs are higher
-Opportunity for cascade testing is largely lost
- Results become invalid if they change reproductive partners in future pregnancies

33
Q

Carrier frequency and affected individual rate of:

  • CF
  • Spinal muscular atrophy
  • Fragile X syndrome
A

Cystic fibrosis

  • 1 in 35
  • 1 in 4900

Spinal muscular atrophy (severe muscle weakness, death usually during childhood)

  • 1 in 50
  • 1 in 9900

Fragile X syndrome (intellectual disability, autism )

  • 1 in 330
  • 1 in 7100
34
Q

Reasons for prenatal testing

A

Prenatal knowledge of the presence of conditions allows:

  • Changes to the management of the pregnancy to permit delivery in an appropriate location
  • Rapid access to neonatal treatment
  • Appropriate antenatal care
  • Option of abortion
  • Can help couple prepare
35
Q

Components of MSS1

A

11+0 to 13+6

Maternal age
USS assessment of nuchal translucency
- Additional markers of aneuploidy - improve detection rates to 96% and lower false positive rate to 2.5% - nasal bone, ductus venosus waveform, tricuspid valve flow

Maternal serum markers

  • Pregnancy-associated plasma protein A (PAPP-A) - product of the placenta and decidua
  • Beta human chorionic gonadotropin (beta HCG)
36
Q

Pros and cons of MSS1

A

With 1 in 300 cut off for trisomy 21, 13 and 18

Sensitivity 85%
Specificity 95%
PPV ~7-10%

Additional advantages of USS at this gestation:
- Confirm fetal number, gestation, viability, structural development

37
Q

Cell-free DNA (cfDNA)-based screening
Also known as non-invasive prenatal testing (NIPT)
- when to test
and how it works

A

> 10/40
DNA sequencing or array based technology to detect aneuploidy in placenta tissues by measuring cfDNA in maternal plasma

Adequate fraction 3-4% of total maternal cfDNA

cfDNA is cleared rapidly after birth, therefore specific to current pregnancy

Works by sequencing a portion of each DNA fragment in maternal plasma (both maternal and fetal)
Counting the number of fragments arising from each chromosome
- If trisomy in fetus, then extra sequences will map to chromosome 21, 18 or 13

38
Q

Indications (as per RANZCOG)

for NIPT

A

A primary screening test for fetal aneuploidy

A secondary screen for women with an increased risk result on a primary screening test, who do not want diagnostic testing

Any woman with probability below the traditional threshold for offering diagnostic testing but who wishes to self-fund further testing

39
Q

Pros and cons of NIPT

A

Highest sensitivity and specificity of all screening tests for Down syndrome
- sensitivity and specificity - 99%
- PPV 45%
Lower false positive rate
- Therefore fewer invasive procedures
Risk assessment is less dependent of gestational age
cfDNA is cleared rapidly after birth, therefore specific to current pregnancy
Not confounded by smoking or IVF
Allows for detection of sex chromosomal conditions

LIMITATIONS

  • Not funded
  • Unable to provide result in 1-6%
  • Maternal weight can affect technical performance
  • Does not have sufficient diagnostic accuracy to replace invasive testing
  • False positives - occur in approx 0.3%
  • still need USS for structural assessment
  • risk of findings maternal abnormalities
40
Q

MSS2

A

15+0 to 20+0 weeks

Maternal age
Maternal serum markers:
	- Alpha-fetoprotein
	- Beta HCG
	- Unconjugated estriol
	- Inhibin A

Sensitivity 70-75%
Specificity 93%
PPV ~2-3%

41
Q

Confounding maternal factors for screening

A

Maternal weight
Smoking
IVF
- Pregnancies conceived using ART have low levels of PAPP-A –> increased likelihood of receiving false positive results
- Higher risk of cfDNA test failure for IVF pregnancies compared with spontaneous conceptions (5.2% vs. 2.2%)
Particularly affect the level of serum markers

42
Q

Nuchal translucency

A

Nuchal translucency (ASUM):

  • Perform 11+0 - 13+6
  • CRL 45-84mm

Abnormal if >3-3.5mm but correlate with GA

43
Q

Screening for structural conditions

A

Affect 2-3.5% of all pregnancies
Offer USS assessment to all patients in the mid trimester (18-22/40)
- While up to 50% of major conditions may be identifiable in the first trimester, many cases will require second trimester review to clarify diagnosis and / or prognosis

44
Q

Diagnostic testing complications / risk

A

Fetal loss rate may be as low as 1 in 900

  • No difference between CVS and amniocentesis
  • operator and experience-dependent
Sepsis
Bowel injury
Fetal injury
Placental mosaicism (in CVS)
Anti D if Rh(D) neg
Haematoma

Even a ‘diagnostic test’ is not a test for every disease and a normal result does not exclude the chance of the baby having a chromosomal or genetic disease

45
Q

Process of amniocentesis

A

Percutaneous transabdominal puncture of the uterus during pregnancy to obtain amniotic fluid
From 15/40
Optimal timing 15+0 to 17+6
Cells shed from the amnion and the lower fetal urinary tract

Should not be performed before 15/40 because of the increased risk of adverse outcomes such as talipes
? respiratory morbidity

46
Q

Process of CVS

A

Sampling of the placental chorionic villi
11 to 14 weeks
Although CVS can be performed >14/40, amniocentesis is preferred from 15/40 as technically easier, more comfortable for patient and avoids placental mosaicism
Transabdominal or transcervical
>5mg of villus tissue required
Prior to 11/40, CVS a/w increased risk of limb reduction defects
Placenta location (posterior) may not be accessible

47
Q

Placental mosaicism

A

Confined placental mosaicism = a discrepancy between the genotype of the placenta and the genotype of the fetus
CVS has a higher risk of confined placental mosaicism than amniocentesis (2.3 versus 0.4 %)
Mosaicism on CVS has both diagnostic and prognostic implications because placental function can be affected, leading to miscarriage, fetal growth restriction, fetal death, or stillbirth
Identified in 1-2% of CVS samples, but confirmed in the fetus in only 11-13%

48
Q

Assessment of fetal chromosomes following amniocentesis or CVS

A

Conventional karyotyping

Rapid aneuploidy tests - FISH
- Can use for diagnosis of specific microdeletion syndromes

Chromosomal microarray analysis
- Detects significantly more aneuploidies than conventional karyotype following structural fetal condition identification on USS, therefore 1st line

49
Q

Medication in pregnancy - classification of risk

A

ADEC Classification
A Well controlled trials have shown no teratogenicity

B1 Limited number of women with no problems, animals OK
B2 As B1 though animal studies inadequate
B3 As B2 though animal studies show increased risk

C May cause effects but no malformation
D ? Increased malformations
X Should not be used in pregnancy

50
Q

Definition of domestic abuse

A

an incident of threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional) between adults (>16y) who are or have been intimate partners or family members

51
Q

Rate of DV In pregnancy

A

4-9% of women experience domestic abuse during pregnancy or after birth
~30% of domestic abuse starts in pregnancy (UK)
Pregnancy is time when DA is known to increase

Prevalence of domestic abuse is increased amongst:

  • Women <24y
  • Women who are divorced
  • Those with a long-term illness or disability
  • Those in the lowest household income brackets
52
Q

Effect of DV on pregnancy

A

A women who is a victim of domestic abuse if more likely to:

  • Book late or have a concealed pregnancy
  • Be a teenager
  • Have bleeding in early pregnancy
  • Experience preterm labour
  • Develop chorioamnionitis
  • Have a low birth weight baby
  • Have an unexplained stillbirth
  • Suffer from perinatal depression, anxiety and PTSD
53
Q

Define perceived fetal movements

A

The maternal sensation of any discrete kick, flutter, swish or roll
Provides an indication of the integrity of the CNS and musculoskeletal system

54
Q

Normal maternal perception of fetal movements

A

Perception of FM usually from 16-20/40
- From 16/40 for multip, 18-20 weeks for primip
There is diurnal changes in fetal movements
Periods of activity and also of rest and sleep
- Sleep cycles usually 20-40 mins, rarely exceed 90 mins in a healthy fetus

Afternoon and evening periods are the peak of activity
The number of spontaneous FMs increase and then tend to plateau at 32/40, but there is no reduction
- Evidence does not support that the number of FM decreases as pregnancy advances or prior to the onset of labour
- Type of movements may change

Correlation between maternal perception of FM and FM concurrently detected on USS show wide variation - 37-88%

55
Q

Reduced FM

A

No universally agreed definition

RFM is linked to adverse perinatal outcomes, such as:

  • Neurodevelopmental disability
  • Infection
  • Feto-maternal haemorrhage
  • Emergency delivery
  • Umbilical cord complications
  • SGA
  • FGR

The majority of women (55%) experiencing a stillbirth perceived a reduction in FM prior to diagnosis

56
Q

Advice for women

A

All pregnant women should be routinely provided with verbal and written information regarding normal FM during the antenatal period
- Include info on the changing patterns of movement as the fetus develops, normal wake / sleep cycles and factors which may modify perception of FM (e.g. high BMI, placental position)

If women are unsure whether FM are reduced after 28+0, they should be advised to lie on their left side and focus on FM for 2h. If FM abnormal, they should contact their midwife or maternity unit immediately

There is insufficient evidence to recommend formal fetal movement counting using specified alarm limits to reduce adverse outcomes

57
Q

Investigation of FM >28+0

A

Should happen within 2h
Assess for risk factors a/w stillbirth
Review fundal height, abdo exam (uterine tone, tenderness), maternal HR and BP, temp
CTG
USS for fetal biometry and AFV should be considered
-Timeframe guided by clinical circumstances - preferably within 24h
Consider Kleihauer

58
Q

Risk factors for stillbirth

A 
Previous stillbirth 
Previous PTB with SGA
FGR
Previous reporting of DFM
BMI >25
Smoking
AMA
IVF
Parity of 0 or >/=3
Pre-existing diabetes 
APH
Indigenous ethnicity
Low SES
Maternal conditions
Obstetric cholestasis
59
Q

Brief overview of AFFIRM trial - Awareness of fetal movements and care package to reduce fetal mortality

A

stepped wedge, cluster-randomised trial
Education package for patients and staff, CTG within 2h, growth within 24h
IOL from 37/40 if SGA or persistent RFM

Package of interventions did not reduce the incidence of stillbirth
The intervention increased the frequency of IOL and birth by CS and prolonged NICU admission period

60
Q

Air travel in pregnancy

A

Most domestic airlines will not permit pregnant women to travel for >4 hours after 36 weeks gestation
International flights restrict travel from 32 weeks
Consider VTE risk

Anna and louise (28 decks)

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