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Antenatal care
Pre conception counselling
Smoking
Alcohol
Drugs
Diet
Exercise
Folic acid
Pre conception counseling
Family history
Personal history
Past obstetric history
Folic acid
Rubella status
First visit
LMP EDD
POH
MH
PMH
Drugs
Allergies
First visit
Smoking
Alcohol
FH
Advise
Exemption card
Referral
Low risk pregnancies 12-14/52 hosp visit
Routine blood testsBlood group + rhesus factorFbc + haemoglobinopathies if indicatedRandon blood sugarTreponemal antibodyHep bHiv pappa
Low risk pregnancies
Hosp visit 12-14/52
History
Nuchal transluceny scan
Low risk pregnancy
15 weeks
Serum AFP and downs screening
If booking scan not done before 14 weeks
Low risk pregnancy
23 weeks – anomally scan 26 weeks – midwife/gp 28 weeks – fbc + antibodies 30 weeks – midwife/gp 34/36/38/40 weeks – midwife/gp 41 weeks - hosp
Exercise
Non – contact sport only after 16/52
Intensity decreased by 25%
HR under 140/min
Core temp < 38
Strenuous exercise limited to 15-20 mins
Antenatal visits
Weight gain 12-15kg in total BP dias. >90 or increase > 20 from first visit is
significant Urinalysis watch for protein glucose uti Fetal movements Uterine size Fetal lie presentation
Common discomforts
Pelvic pains – ligamental stretch
Urinary frequency - ? Uti
Ankle swelling – ivc compression
Varicosities – support stockings
Heartburn – posture antacids
Constipation – fluids, fibre, fybogel
Common discomforts
Low back pain – posture and relaxin
Dental decay – see dentist
Skin changes – chloasma
Itch – iron def, cholestasis antihistamines
Stretach marks - moisturisers
First trimester
Ectopic preg
Sharp pain
Irregular vaginal bleeding
Abdo tenderness
Dizziness or fainting
Ectopic pregnancy
Diagnosis
Pos preg test
Serial hcg levels they increase more slowly
Progesterone level lower than normal
Ultra sound scan vaginally/abdominally
Ectopic pregnancy risk factors
PID Previous tubal preg or tubal surgery Endometriosis IUD Multiple induced abortions Drugs that stimulate ovulation
Ectopic pregnancy treatment
Tube not ruptured
Methotrexate
Salpinostomy flushng the tube out
Laparoscopic removal
Ectopic pregnancy treatment
Tube ruptured
Laparoscopic removal of embryo and tube
Miscarriage
Symptoms
Pv bleeding
Colicky pain
Refer to EPAU
hyperemesis
1 in 300 preg
Weeks 8-20
Cause unknown – high oestrogen & hcg
More commom multiple preg obesity first babies
Treatment
Exclude other causes Drink small amounts frequently Diet high in cho and proteins Admit for iv fluids if severe, dehydrated or
electrolyte imbalance Drugs -
Anaemia
Symptoms
Fatigue weakness
Pallor
Dizziness or fainting
SOB
palpitations
Anaemia
Treatment
Diet
Pregaday
Does not alter outcome in most cases
Infection in pregnancy
Chicken pox – only 2% of infections age > 20yrs 3% risk of fetal damage in first 20/52
If mum’s rash develops 1/52 before delivery or to 4/52 after
baby can get sever infection needs protection
No risk between 20/52 and term
If no history of cp check varicella antibodies
If non immune needs VZ Ig no later than 10 days from exposure
Infections in pregmnancy
Rubella – 2-10/52 90% chance of featal damage Toxoplasma gondii 89% adults not immune If fetus infected 10% chance of fetal damage Avoid kittens particularly litter trays Eat well cooked meat Wash vegetables Listeria – soft cheeses, pate. Cookchill foods
Pre eclampsia
Raised BP
Proteinura
XS swelling
Pre eclampsia
3-4% pregnancies
!% very severe
50,000 deaths world wide
Pre eclampsia Risk factors
Young mothers teenagersOlder mothers > 35 yrsFamily historyFirst pregnancyNew fatherDiabeteshypertension
Pre eclampsia
Serious adverse effectsFitsStrokePulmonary oedemaKidney failureLiver damageD I C
Pre eclampsia Warning signs
Raised bpProteinuriaXs swellingHeadcaheFlashing lightsVomiting Upper abdo pain
Pre eclampsia
TreatmentLower bpMagnesium sulphateDeliver babyAspirinMetabolic syndrome
Gestational diabetes
Plenty of insulin, but insulin malfunctioning Macrosomia > 4500g Problems with labour and delivery Newborn has low blood sugar Increased risk stillbirth Proper management prevents increased risk
ofcomplications
Risk factors
Incidence 1%-3% pregnancies Family history Obesity Maternal age > 30 yrs Previous large baby Prior icidence of gestational diabetes Ethnic group – south asians, mexican american
Treatment
Control blood sugar
Exercise
Diet
Blood glucose monitoring
A few will need insulin
Intra uterine growth retardation
Birth weigth < 2500g
Causes
Smoking
Poor nutrition
Placental factors
Maternal ill health
Risk factors
Smoking Drug and alcohol use Severe malnutrition Maternal high bp, or pre eclampsia Infections – cmv, rubella, toxoplasma Chronic maternal disease – diabetes,
rheumatological
Diagnosis
Fundal height – 18-34/52 height = distance in cm
Ultra sound – ratio of head circumference to abdo
Treatment
Stop smoking
Good nutrition
Bed rest on left side
Fetal movement chart
Serial ultrasound scans
Volume of amniotic fluid
Hydatidiform mole
Incidence 1 in 2000 preg
Increased risk with age
Abnormalities in sperm chromosome
Abnormalities of egg
Hydatidiform mole
Signs
Uterus larger than date
Vaginal bleeding
Diagnosis
Ultrasound
Hcg higher than normal
Hydatidiform mole
Treatment
Suction curettage
Monitor hcg for several months due to risk of choriocarcinoma
Postpone preg for a year
APH
Placenta abruptio
1% of all deliveries
Vaginal bleeding in 3rd trimestre
Constant back or abdo pain
Contractions tenderness or rigidity of uterus
Risk factors
Smoking Pergnancy induced hypertension Alcohol or drug use Increased maternal age >40 yrs Premature rupture of membranes Injury to mother
Diagnosis
No clear test
May or may not show on ultrasound
Exclusion of other causes of bleeding – placenta
praevia
Treatment
Evaluate maternal well being
Monitor
Evaluate fetal well being
If severe bleeding or fetal distress cesarean
Placenta previa
4-8% placentas low lying Only 10% remain low Marginal – placenta near edge of os Partial – placenta covers cervical opening Total – placent completely covers os All need cesarean
Placenta previa
SignsPainless bright red vaginal bleeding
Risk factorsSmokingFirst preg after lscsPrevious placenta previaAdvanced maternal age
Placenta previa
Diagnosis
Ultrasound
Treatment
lscs
Post term pregnancy
> 42/52 Risks
Reduced amniotic fluid increased risk of cord compression
Meconium in liquor inhlaed by baby causing pneumonia
Too large baby > 4500g
Management
Monitor babyToo large baby
Decreased amniotic fluid
Deliver if cervix ripe try oxytocinon
If cervix not ripe try prostaglandin gel
Otherwise lscs
Pre term labour
Labour before end of 36th week preg
Low birth weight < 2500g
8-12% of all pregnancies
Signs and symptoms
Regular uterine contractions for more than 1 hr
Backache
Intestinal cramping with or without diarrhoea
Spotting or blood tinged discharge
Thin cervix, dilation beyond 1 cm, contractions
Risk factors
Smoking alcohol drugs Previous pre term delivery 3 or more 1st trimestre miscarriages Cervical incompetence Placenta previa Serious maternal infection Low maternal weight < 45 kg
Postnatal care
Maternal Lochia xs bleeding = pph admit Breasts – engorgement lasts 2-3 days mild temp
fell fluey Nipple pain- camomile creams daktarin if
candidal Mastitis – empty breast flucloxacillin
Postnatal care
Blood pressure
Fundal height
Perineum
Symptoms of depression
Contraceptive advice
Postnatal care
FetalMethod of delivery
Length of gestation
Weight
Feeding
concerns
Postnatal care
Fetal examinationFontanelles Eyes- cataractSclera – jaundiceHsLungsAbdo - masses
Postnatal care
Fetal exam
Genitalia
Hips
Femoral pulses
Spine
Birth marks
6 week exam Maternal
Feeding DepressionLochiaContracptionBpAbdo examSmear if due
6 week exam
FetalAccording to chs schedule
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