Womens health - antenatal care Flashcards
What is considered term?
37-42 weeks
What are the subcategories of preterm deliveries (3)?
- Moderately preterm = 32-37
- Very preterm = 28-32
- Extremely preterm = <28
How is the number of times a woman has been pregnant and the number of births she has had denoted?
- Gravida = number of pregnancies
- Parity = number of pregnancies carried to viable gestational age (24 weeks)
How are twins denoted in Gravida and parity?
Classed as one birth - so a woman with one pair of twins delivered at 39 weeks would be G1P1
What is the terminology for first pregnancy, multiple deliveries, never birthed, first delivery?
- First pregnancy = pimigravida
- Multiple deliveries (2 or more) = multiparous
- Never birthed = nulliparous
- First delivery = primiparous
What are the functions of the placenta (5)?
- Excretion
- Nutrition
- Circulation (HbF has high O2 affinity)
- Immunity
- Hormonal
What hormones does the placenta produce during pregnancy (4)?
- Progesterone
- Ostrogen
- BhCG (beta human chorionic gonadtotropin)
- hPL (human placental lactogen)
What does BhCG and hPL do in pregnancy (2)?
- BhCG - stimulates the production of progesterone
- hPL - regulates metabolism + stimulates breast development (prepares for lactation)
When does the foetus begin producing surfactant and when is a sufficient amount of surfactant produced by the foetus?
- Begin at 24 weeks
- Sufficient amount by 34 weeks
When should steroids be given to the mother until during pregnancy if she is going to give birth?
Up to 34 weeks (sometimes afterwards)
What is often given to a preterm baby if they are premature?
Surfactant
What can be given to mother to protect the baby from cerebral palsy?
MgSO4
When is MgSO4 given until in pregnancy?
Until 30 weeks
What are some changes to the maternal body that happen during pregnancy (8)?
- Increased cardiac output
- Decreased BP in first 2 trimesters
- Dysmotility –> constipation + GORD
- Decreased immune response (so don’t attack baby)
- Poor glycemic control –> GDM
- Increased renal excretion
- Hormonal changes
- Skin changes
What hormonal changes happen in pregnancy (6)?
Raised:
* Progesterone
* Oestrogen
* Prolactin
* T3/4
* BhCG
* ALP
also ESR/ CRP
What are some skin changes that happen during pregnancy (3)?
- Linea nigra (dark line on stomach)
- Striae gravidarum (stretch marks)
- Polymorphic eruptions of pregnancy (red rash on abdomen)
How is gestational age determined?
- Before dating scan = first day of last menstrual period
- After dating scan = CRL
When is each trimester between?
- 1st = 0-12
- 2nd = 13-26
- 3rd = 27+
When should foetal movements be felt?
Begin before 22 weeks
How many appointments are given to pregnant women?
- 8 for parous
- 11 for nulliparous
What are the key appointments?
- Before 10 + 0 = Booking
- 10 - 14 weeks = Dating
- 18 - 21 = Anomoly
- 16, 25, 28, 31, 34, 36, 38, 40, 41 = Antenatal appointments
What happens at the booking visit (6)?
- BMI
- Screening offered
- BP
- Urinalysis
- Assess risk scores
- Vaccines offered
What happens at dating scan (2)?
- Gestational age calculated (crown rump length)
- Multiple pregnancies identified
What happens at anomaly scan (2)?
- Anatomical anomalies identified (e.g. CHD, NTD, gastroschisis, omphelocele)
- Placenta position identified
What happens at general antenatal appointments (4)?
- Urinalysis
- BP
- Symphyseal-fundal height (SFH)
- Foetal presentation (after 36 weeks)
What risks are assessed at booking visit (5)?
- GDM
- Pre-eclampsia
- Foetal Growth Restriction
- VTE
- FGM (female genital mutilation)
What vaccines are given (2)?
- Whooping cough (pertussis) - from 16 weeks
- Influenza - seasonal (autumn + winter)
What are the 3 elements of pregnancy screening at the booking and dating appointment?
- Infectious diseases
- Sickle cell and thalassaemia
- Genetic abnormalities
What 3 infectious diseases are screened for at the booking appointment?
- HIV
- Syphilis
- Hep B
What genetic abnormalities are screened for in pregnancy (3)?
- Downs syndrome (T21)
- Edwards syndrome (T18)
- Patau’s syndrome (T13)
What test is used to screen for genetic abnormalities between 11 and 14 weeks?
Combined test
What test is used to screen for downs syndrome after 14 weeks?
Quadruple test
What are the parameters of the combined test (4)?
- Maternal age
- Beta-hCG
- PAPP - A (pregnancy associated plasma protein - A)
- Nuchal translucency (on USS)
What results are suggestive of genetic disorders (3)?
Low PAPP-A + high NT
AND
* High B-hCG = downs syndrome
* Low B-hCG = T18,13
How are genetic abnormalities identified as high risk further screened for (3)?
- Nothing
- Non-invasive prenatal testing (mum’s blood DNA tested)
- Chorionic villus sampling (11-14 weeks)/ amniocentesis (15+)
What is in the quadruple test for downs syndrome?
- BhCG (raised)
- AFP - alpha fetoprotein (low)
- E3 (low)
- Inhibin A (raised)
What additional appointments/ tests are sometimes offered to those in pregnancy (4)?
- OGTT at 24 - 28 weeks
- Anti-D injections at 28, 34 weeks
- USS at 32 if placenta praevia
- Growth scans if high risk of FGR
What additional things are pregnant mothers advised about general advice/ lifestyle advice (6)?
- Take folic acid 400mcg from before pregnancy –> 12 weeks
- Vitamin D
- Stop smoking + drinking
- Healthy eating (low vitamin A - teratogenic)
- Avoid unpasteurised milk, soft cheeses, avoid undercooked meat + eggs (due to risks of salmonella and listeriosis)
- No flying after 37 weeks (32 weeks if multiple pregnancy)
What medications are important to know about avoiding in pregnancy (9)?
- NSAIDs
- Beta blockers
- ACE-i + ARBs
- Opiates
- Warfarin
- Sodium valproate
- Lithium
- SSRIs
- Isoretinoin (retinoids)
What effects can NSAIDs have on pregnancy (2)?
- Premature closure of PDA
- Delay labour
What effects can beta blockers have on pregnancy (3)?
- FGR
- Hypoglycaemia in the neonate
- Bradycardia in neonate
be aware of this for labetalol
What effects can ACE-i + ARBs have in pregnancy (2)?
- Oligohydramnios (low amniotic fluid)
- Hypocalvaria (incomplete formation of skull bones)
What effect can opiates have in pregnancy?
Neonatal abstinence syndrome
What effects can warfarin have during pregnancy (3)?
- Miscarriage
- Congenital malformations
- Bleeding during pregnancy/ delivery
What effects can sodium valproate have during pregnancy (2)?
- Neural tube defects
- Developmental delay
What effect does lithium have during pregnancy?
Ebsteins anomaly
What is ebsteins anomaly?
Tricuspid valve set lower on right side of heart
What effects can SSRIs have on pregnancy (3)?
- CHD
- Persistent pulmonary hypertension (in neonate)
- Withdrawal in neonate
What effects can isotretinoin have in pregnancy?
Highly teratogenic + congenital defects
What are the common conditions affecting the placenta in pregnancy (4)?
- Low lying placenta
- Vasa praevia
- Placenta accreta
- Placental abruption
What is placenta praevia?
Placenta covering internal os
What is a low lying placenta?
Placenta within 20mm of internal os, but NOT covering
What are the grades of a low lying placenta/ placenta praevia (4)?
- Within 20mm of internal os
- Touching/ reaches internal os
- Partially covering internal os
- Fully covering internal os
Why does placenta praevia cause bleeding?
Bastocyst implants into lower uterus –> trauma (e.g. cervical dilation in labour) causes bleeding, can also be spontaneous
What are some risk factors for placenta praevia (6)?
- Previous caesarean
- Previous placenta praevia
- IVF
- Older age
- Smoking
- Multiple pregnancy
What can be the presentation of placenta praevia (2)?
- Painless PV bleeding (antepartum haemorrhage)
- Non-tender uterus
quite common, usually no symptoms however
How is placenta praevia diagnosed?
Identified at anomaly scan at 18-21 weeks
How is placenta praevia monitored?
32 and 36 week follow up scans
What is important not to do on a woman with placenta praevia?
Don’t give PV exam
How is placenta praevia managed (2)?
- Corticosteroids given at 34-36 weeks to mature foetal lungs
- C-section 36-37 weeks
can consider vaginal delivery if grade 1
What are some complications of placenta praevia (3)?
- Preterm
- Maternal shock –> death
- Morbidly adhered placenta (placenta accreta)
What is vasa praevia?
Malformation of foetal vessels –> run through placental membranes instead of umbilical cord
What is the presentation of vasa praevia (2 types)?
- Antepartum haemorrhage (painless)
- Labour - vaginal bleeding after SROM with foetal distress
What are the 2 types of vasa praevia?
- Type 1 = foetal vessels connected to foetal membranes (velamentous)
- Type 2 = foetal vessels connect to accessory (succenturiate) lobe of placenta
What protects the blood vessels in umbilical cord?
Wharton’s jelly
How is vasa praevia sometimes detected?
Ultrasound antenatal scans
What are some risk factors for vasa praevia (3)?
- Low lying placenta
- IVF
- Multiple pregnancy
What might be found on vaginal examination of those with vasa praevia?
Pulsating vessels
How is vasa praevia managed (2)?
- Corticosteroids from 32 weeks
- C-section 34-36 weeks
What is placenta accreta?
The placenta implants deeper through the endometrium
What are the 3 types of abnormally invasive placenta?
- Superficial placenta accreta
- Placenta increta
- Placenta percreta
What are the different extents of invasion of the placenta (3)?
- Accreta = surface of myometrium
- Increta = deeply in myometrium
- Percreta = past myometrium and perimetrium (serosa) reaching other internal organs
What are some risk factors for placenta accreta (5)?
- Previous c-section/ uterine surgery
- Previous accreta
- Low lying placenta
- Increased age
- Multigravida
How is placenta accreta diagnosed?
Routine USS (loss of retroplacental zone)
Women with previous acreeta are screened
How is placenta accreta managed (4)?
- Hysterectomy (recommended)
- Uterus preserving surgery (myometrium resected with placenta)
- Expectant management (very risky)
- Group + save + transfusions if needed!!
What are some complications of placenta accreta (3)?
- Preterm
- Severe haemorrhage (PPH)
- Infection of uterus (if no hysterectomy)
What is placental abruption?
Premature separation of the placenta from the decidua
What are some risk factors for placental abruption?
- Previous abruption
- Pre-eclampsia
- Abdominal trauma
- Smoking
- Cocaine
What are the types of placental abruption (3)?
- Concealed - blood remains behind placenta
- Revealed - blood escapes from behind placenta = PV bleed
- Mixed - clot forms behind placenta
What is the presentation of placental abruption (4)?
- Antepartum haemorrhage (dark red blood)
- Sudden abdo pain
- ‘Woody’ hard contracted uterus
- Shock
How is placental abruption diagnosed?
Clinical diagnosis
USS not very helpful
How is placental abruption managed if massive blood loss (5)?
- 2 x grey cannula
- FBC, U&E, LFT, coagulation studies
- Group + save
- Fluid/ blood resuscitation
- Monitor CTG
- C-section
What are some complications of placental abruption (3)?
- DIC
- Prematurity
- Maternal/ foetal death
What is antepartum haemorrhage?
PV bleeding after 24 weeks gestation but before labour
What are the most common causes of antepartum haemorrhage (5)?
- Placenta praevia = MC
- Placental abruption = second MC
- Vasa praevia
- Uterine rupture
- Cervical causes (e.g. cervicitis, polyps)
What are the different severities of antepartum haemorrhage?
- Minor < 50ml
- Major 50 - 1000ml
- Massive > 1000ml
How is antepartum haemorrhage investigated (4)?
- FBC + Group & save
- Kleinbauer test (foetal Hb in mother peripheral blood)
- USS
- CTG
What is defined as small for gestational age (SGA)?
Being below the 10th percentile
What is severe SGA?
Being below 3rd percentile
How is foetal size assessed (3)?
- Estimated foetal weight
- Foetal abdominal circumference
- Head circumference
- Symphyseal fundal height
What two categories can the causes of SGA be divided into?
- Constitutionally small (mother/ father is small)
- Foetal growth restriction
What are the two categories of foetal growth restriction?
- Placenta mediated growth restriction
- Non- placenta mediated growth restriction (due to genetic/ structural abnormality)
What causes placenta mediated growth restriction (6)?
- Idiopathic
- Pre-eclampsia
- Smoking/ alcohol
- Anaemia
- Malnutrition
- Infection
What causes non-placenta mediated growth restriction (3)?
- Genetic abnormalities
- Structural abnormalities
- Foetal infection
What are some other signs/ symptoms of foetal growth restriction (4)?
- Reduced foetal movements
- Abnormal CTG
- Abnormal doppler (decreased blood flow)
- Reduced amniotic fluid volume