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Antenatal care

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

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Antenatal care

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  1. Antenatal care Cases

  2. 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

  3. Jo’s misc stuff • 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.

  4. Case 1 • A lady comes to see you having seen the midwife, • Blood results: • Hb = 10.7 • Ferritin = 18

  5. What do you want to know? • What is your plan?

  6. 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,

  7. Iron levels/Hb • 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

  8. Case 2 • Midwife knocks on your door: • BP 140/88 • Dipstick 2+ proteinuria

  9. What do you need to know?

  10. Gestation 34 weeks, • Booking BP = 110/72

  11. BP changes in pregnancy • Differential = essential hypertension • Gestational hypertension, preeclampsia • Proteinuria = refer • This baby is viable, need to DELIVER

  12. Blood pressure • 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

  13. Hypertension • All types increase cardiovascular risk and future blood pressure risk

  14. Pre Eclampsia Risk factors • 40 yrs or > • Nulliparity • >10 yrs since pregnancy • Fhx of pre eclampsia (or personal hx) • BMI>30 • Preexcisting hypertension/renal disease • Multiple pregnancy

  15. Severe headache • Visual problmes (blurring/falshing) • Severe pain below ribs • Vomiting • Sudden swelling of face hands or feet.

  16. 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

  17. Common annoyances • Haemorrhoids • Stress incontinence • DVT/PE • Back pain SPD

  18. 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

  19. Flying • >36/40 not permitted • >32/40 not advised • <12000ft • Letter ‘ within 2 wks’ • Gestation, EDD, singleton, uncomplicated pregnancy • Return date <32/36 wks

  20. Multiple pregnancy risks • Prematurity • Twins norm 37/40, Triplets 33/40 • IUGR • Pre eclampsia • Anaemia • Polyhydramnios • Congenital malformations x2

  21. Downs syndrome

  22. Infections in pregnancy • 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

  23. 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?

  24. 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

  25. Chicken Pox in pregnancy • 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 • 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

  26. If exposure occurs • 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.

  27. Asymptomatic Bacteuria • Diagnosed on culture of >10^5organisms/ml • 4x>risk of UTI • E-coli usually • Associated with preterm delivery and low birthweight

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