Antenatal care
Cases
Condensed curriculum
• Curriculum statement 10:1 women’s health
• Abnormal lies, placenta praevia
• Aph/abruption
• Anaemia, Hyperemesis, reflux, back pain, spd, varicose
veins, haemorrhoids
• DVT/PE
• Miscarriage, Intrauterine death, Preterm labour
• Gestational diabetes
• Multiple pregancy
• Preeclampsia, hypertension
• Rhesus/Anti D
Jo’s misc stuff
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Preconception counselling
1st pregnancy consultation
Infections and pregnancy
Chickenpox, slapped cheek, hand foot mouth,
rubella, herpes, hiv
• Flying and pregnancy
• Up to 33 wks, letter, scan, due date, within 2
wks, singleton.
Case 1
• A lady comes to see you having seen the
midwife,
• Blood results:
• Hb = 10.7
• Ferritin = 18
• What do you want to know?
• What is your plan?
Points to consider
• Hb dilutional effect
• Asymptomatic anaemia needs no
treatment
• Iron supps are not known to be harmful in
early pregnancy
• Iron supps often not tolerated,
Iron levels/Hb
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Dilutional effect,
Iron will be low,
Higher requirements of fetus and placenta
Higher RBC mass
No evidence that supplementation benefits
mother/fetus
• S/Effects iron = heartburn, nausea
• Only treat if Hb<10 + mcv<84 or extreme
tiredness
• Increase dietary iron first
Case 2
• Midwife knocks on your door:
• BP 140/88
• Dipstick 2+ proteinuria
• What do you need to know?
• Gestation 34 weeks,
• Booking BP = 110/72
• BP changes in pregnancy
• Differential = essential hypertension
• Gestational hypertension, preeclampsia
• Proteinuria = refer
• This baby is viable, need to DELIVER
Blood pressure
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Gestational hypertension
>20/40 no proteinuria
>140/90 or >30/15 rise from booking
Restores 3/12 post delivery
Pre-Eclampsia
BP >140/90 + proteinuria >20/40
Chronic Hypertension
Preexisting hypertension, or BP up before
20/40
Hypertension
• All types increase cardiovascular risk and
future blood pressure risk
Pre Eclampsia Risk factors
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40 yrs or >
Nulliparity
>10 yrs since pregnancy
Fhx of pre eclampsia (or personal hx)
BMI>30
Preexcisting hypertension/renal disease
Multiple pregnancy
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Severe headache
Visual problmes (blurring/falshing)
Severe pain below ribs
Vomiting
Sudden swelling of face hands or feet.
Emesis
• Nausea and Vomiting of pregnancy
• Normal ( esp 7-12 wks)
• ?Severe ?singleton ?Hydatidiform
mole?UTI
• Small meals, avoid fat
• Consider ginger, vit B6 acupressure,
antihistamines
(metoclopramide/prochlorperazine)
• ?Ketones, consider admission, IV’s
Common annoyances
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Haemorrhoids
Stress incontinence
DVT/PE
Back pain SPD
Gestational Diabetes
• Includes Impaired glucose tolerance and
diabetes
• Fasting glucose >6.1 <7
• OGTT if >7.8 after load =positive test
• Prior to insulin 50% perinatal mortality now
2%
• 6/52 post partum rpt OGTT
• Increased risk diabetes in later life.
• Lifestyle advice and annual glucose
Flying
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>36/40 not permitted
>32/40 not advised
<12000ft
Letter ‘ within 2 wks’
Gestation, EDD, singleton, uncomplicated
pregnancy
• Return date <32/36 wks
Multiple pregnancy risks
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Prematurity
Twins norm 37/40, Triplets 33/40
IUGR
Pre eclampsia
Anaemia
Polyhydramnios
Congenital malformations x2
Downs syndrome
Maternal
age
<20 yrs
>45 yrs
Risk as a
ratio
% risk
Infections in pregnancy
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Slapped cheek/Erythema Infectiosum
(parvovirus B19, 5th disease)
50% adults exposed can be asymptomatic
If exposed in pregnancy 10% increase risk
fetal death
• <20/40-3xmiscarriage risk, fetal hydrops
• Check parvovirus serology
• If positive in first 20 wks reg uss to monitor
Case
• Martha is worried that there was a child at
her sons nursery who has chickenpox, she
comes to your morning emergency
surgery asking for your advice
• What do you need to establish?
• What action would you take?
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Ascertain duration of exposure
Has mum had chicken pox before?
Test mum for IgG
Get the child seen by a doctor to confirm
that it is chicken pox
• Advise all cases of chicken pox to avoid
pregnant women and immunosuppressed.
• School exclusion is 5 days from rash onset
Chicken Pox in pregnancy
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2-12 wks risk Fetal varicella risk 0.4%
12-28 wks risk = 1.4%
28 wks onwds =0
Within 7 days < delivery or 28>, risk of Neonatal varicella
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There is a 0.3% risk of chicken pox in preg
90% of women have IgG
IgG crosses placenta and protects fetus (28-30wks)
Pregnant women with chicken pox 5 x greater mortality
If exposure occurs
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Varicella IgG assay urgent
If rash/neg IgG consult microbiologist
VZIG likely within 10 days of exposure
Consider oral aciclovir
Regular rvw if develop chicken pox
Consider IV aciclovir
VZIG to neonate if risk time -7-+28
Tell all chickenpox cases to avoid pregnant
women and immunosuppressed.
Asymptomatic Bacteuria
• Diagnosed on culture of
>10^5organisms/ml
• 4x>risk of UTI
• E-coli usually
• Associated with preterm delivery and low
birthweight