WCS18 Perinatal Medicine, Antenatal Care And Pre-pregnant Counselling 1 Flashcards
Care during pregnancy
- Pre-pregnancy care
- Antenatal care
- Perinatal care
- Intrapartum period
- Neonatal period
Pre-pregnancy care
Aim:
1. Assess risk of getting pregnant
- Risk on mother
- Risk on baby
2. Optimise woman’s health before conception
Target patient:
1. General population
2. Women with medical disorders
3. Women with complication in previous pregnancy
Content:
1. Screening (for general population)
- **Thalassaemia carrier (MCV)
- **Rubella immune status (Rubella Ab)
- Fertility (Menstrual history, Semen analysis)
- Effect of medical disorders / medications on pregnancy + Vice versa (for women with medical disorders)
- **DM / Thyrotoxicosis
- **SLE / RA
- Post-organ transplant - Fetal abnormality / Obstetric complication (for women with complication in previous pregnancy)
- Severe pre-eclampsia
- Preterm delivery
- Pregnancy loss
- Previous baby with congenital abnormalities
Providers:
1. Physicians
2. Primary health care doctors
3. Obstetricians
When:
1. Before conception
2. Following adverse pregnancy outcome
Things to do in Pre-pregnancy counselling
- Risk assessment
- modifiable factors - Optimised control of pre-existing medical disorder
- Adjustment of medication
- Optimal timing of pregnancy
- ***Folate supplement before 12 weeks
- 0.4 mg/day (Felix Lai)
- 5 mg/day: previous infant with neural tube defect, DM patients, patients on anti-epileptic drugs (Felix)
- 5 mg/day throughout whole pregnancy: Thalassaemia trait (to prevent maternal anaemia) - Option of prenatal diagnosis
Antenatal care
Aim:
1. Conduct baseline **assessment of pregnancy
2. Detect / **Manage complications during pregnancy
3. ***Optimise condition of both mother and baby before delivery
Importance:
1. Early identification of risk factors
2. Prompt management of complications
Target patient:
1. Pregnant mother
2. Father-to-be
Provider:
1. Obstetricians
2. Midwives
3. Family physicians
4. Community care: Maternal and Child Health Centres
When:
From the time when pregnancy known —> Till onset of labour / prelabour C-section
Content:
1. Maternal screening
2. Fetal screening
3. Prenatal diagnosis
4. Regular monitoring
5. Education
6. Psychological support
7. Planning of delivery
1st Antenatal visit
***Before 14 weeks
1. Establish EDC (expected date of confinement) —> Ascertain gestational age
2. Obtain history
3. Conduct physical examination
***Frequency of antenatal visits
- Up to 28 weeks: Every 4 weeks
- 28-36 weeks: Every 2 weeks
- 37 weeks-Delivery: Every week
More frequent if risk factors / complications present
Baseline assessment in Antenatal care
- History taking
- past OG history
- past medical history
- problem with current pregnancy - Physical examination
- general exam including breast
- abdominal exam
- pelvic exam - Antenatal routine investigations
- CBC: Hb, MCV, platelet
- Blood group: Rh
- Rubella Ab
- HBsAg
- Syphilis (VDRL (Non-treponemal specific test) / EIA (Treponemal specific test))
- HIV Ab
- Cervical smear (opportunistic screening)
Blood pressure monitoring
Normal
SBP: 90-140
DBP: 60-90
1st Antenatal visit: Note baseline BP
- if on antihypertensive —> consider switching to one suitable for pregnancy
After 20 weeks: ↑ BP alerts close monitoring for Pre-eclampsia
Hb level and MCV
- Antenatal Hb level: >10.5 g/dL (< indicate anaemia)
- MCV < 82 fL: ***Fe deficiency / Thalassaemia
- Maternal MCV <82 —> Test partner’s MCV
- Couple’s MCV <82 —> Hb studies, exclude Fe deficiency +/- Molecular study for Thalassaemia
Pregnant woman / partner is carrier —> Offspring 1/2 chance being carrier
Both having SAME type of Thalassaemia—> Offspring 1/4 chance of having Thalassaemia major
Blood group (Rh factor)
Rh blood group: Majority of Han Chinese Rh+
Rh incompatibility: Haemolytic disease of fetus / newborn —> referral for prenatal diagnosis is indicated
Hepatitis B virus
Mother HBsAg +ve
—> Risk of perinatal HBV transmission
- Hep B vaccine + Hep B Ig (HBIG) asap after birth (within 12 hours)
- Antenatal antiviral e.g. Tenofovir —> ↓ vertical transmission rate in mothers with ***high HBV DNA level
Syphilis
- Positive serological testing for syphilis requires confirmation testing
- Mother-to-child transmission of syphilis in pregnancy
—> ***Congenital syphilis, Neonatal death, Stillbirth, Preterm birth - Parenteral Penicillin: effectively prevents vertical transmission of syphilis
HIV
Women with HIV infection risk transmission of HIV during
- pregnancy
- delivery
- breastfeeding
↓ risk of vertical transmission:
1. Antiretroviral therapy
2. C-section
3. Avoid breastfeeding
Fetal screening in Antenatal care
- Thalassaemia
- MCV - Down syndrome
- Maternal age
- **Nuchal translucency
- Biochemical test: Maternal serum markers
- **Fetal DNA from maternal plasma - Fetal structural abnormality
- Morphology scan (~ 20 weeks)
USG exam for screening
< 11 weeks
- Intrauterine pregnancy
- Fetal pulsation, number, size
11-13 weeks
- Nuchal translucency
- Uterus, Adnexae (to assess any abnormality)
- Viability (SpC Revision)
- Gestational age
- Major structural abnormality (e.g. anencephaly)
20 weeks
- Fetal morphology
> 30 weeks
- Fetal growth
- Placental location
- Liquor
Prenatal diagnosis
- Targeted diagnosis
- known family history
- previous affected pregnancy
- known environmental risk factor - USG scan (targeted / diagnostic)
- ***Chorionic villus sampling / Amniocentesis
- Chromosomal / Molecular / Biochemical study
Regular monitoring in Antenatal care
- Antenatal visit
- ***BP
- ***Urinalysis (Protein + Sugar)
- ***Maternal weight
- ***Fetal growth (Symphysio-fundal height +/- scan)
- ***Screening for gestational DM, GBS colonisation
Desirable weight gain
Based on pre-pregnant BMI
<18.5: 12-18 kg
18.5-24.9: 11-16 kg
25-29.9: 7-11 kg
>=30: >=7 kg
Twin pregnancy: 16-20 kg
First 3 months: total gain ~1-2 kg
Thereafter monthly gain: ~1-2 kg
Distribution of weight gain:
- Fetus
- Placenta
- Uterus
- Amniotic fluid
- Breast
- Blood
- Extracellular fluid
- Maternal fat
Education in Antenatal care
- Antenatal talk
- Pregnancy
- Labour and delivery
- Baby care
- Parenthood - Dietary advice
- Physiotherapy
Psychological support in Antenatal care
- Anxiety
- Parenthood
- Financial burden
- Complications of pregnancy / delivery
- Labour pain - Hormonal change
Provider:
- Midwives / Obstetricians
- Clinical psychologists / Psychiatrists
Planning of delivery
When?
- Any need of delivery before spontaneous labour
- Use of steroid if preterm
How?
- Safety of vaginal delivery
Where?
- Need of referral to tertiary centre
Intrapartum care
Aim:
1. Safe labour + delivery
2. Minimise pain of mother
3. Minimise anxiety of mother and family
Target patient:
- Mothers in labour
Provider:
1. Midwives
2. Obstetricians
- In labour ward
When to be arranged:
- From onset of labour (Regular uterine contraction resulting in progressive cervical dilatation / descent of fetal head)
—> Delivery of placenta (3rd stage of labour) (+/- repair of episiotomy / perineal tear)
Content:
1. Pain relief
2. Psychological support
3. Monitoring
4. Intervention when complication arises
Pain relief in Intrapartum care
- Antenatal education (what to anticipate during labour)
- Companion of significant family members
- Breathing and relaxation exercise
- Mobilisation
- Massage, Acupressure
- TENS (Transcutaneous Electrical Nerve Stimulator)
- Birth ball
- ***Entonox (Nitrous Oxide)
- ***Opioid (e.g. pethidine)
- ***Epidural analgesia
Psychological support in Intrapartum care
- Companion of significant family members
- Encouragement by labour ward staff
Monitoring in Intrapartum care
- Maternal condition
- ***Vital signs (BP, pulse, urine output, SaO2) - Fetal condition
- **Cardiotocogram (CTG)
- **Liquor status (meconium stained / blood stained)
- Fetal scalp blood pH - Progress of labour
- **Cervical dilatation
- **Descent of fetal head
- Use of Partogram
Intervention in Intrapartum care
Need if complications arise
1. Maternal distress
- Fever
- Unstable haemodynamic status
- Fetal distress
- Unsatisfactory fetal heart monitoring
- Abnormal fetal scalp blood pH - Poor progress of labour
- Deviation from expected rate of cervical dilatation / descent of fetal head - Third stage complications
- Primary postpartum haemorrhage
- Retained placenta
- Perineal tear
Types of intervention:
1. Fluid replacement
- Antibiotics
-
**Labour augmentation
- Surgical: **Artificial rupture of membranes
- Medical: ***Syntocinon (aka Oxytocin: enhance uterine contraction) - ***Operative delivery
- Ventouse extraction
- Forceps delivery
- Caesarean delivery - Active management of third stage
- ***Oxytoxics (Syntometrin / Syntocinon)
- Prompt delivery of placenta when separated from uterus
