Pregnancy & Antenatal Care – UK Guidelines Summary

Pregnancy is a normal physiological state but requires careful monitoring to optimize maternal and fetal health. UK antenatal care (NICE NG201, 2021) emphasizes early risk assessment at booking (usually 8–12 weeks) and a tailored schedule of routine visits (10 visits for first pregnancies, 7 for subsequent). Key interventions include screening for *infections* (HIV, syphilis, hepatitis B), anaemia, Rhesus status and sickle-cell/thalassaemia at booking; *fetal anomaly* scan at 18–20 weeks; combined screening for Down’s syndrome (trisomy 21), Edwards’ and Patau’s syndromes at ~11–14 weeks (nuchal translucency ultrasound + maternal serum markers); and gestational diabetes screening (OGTT at 24–28 weeks if risk factors). Women are counselled on diet (5 mg folic acid until 12 weeks), exercise and avoidance of teratogens (alcohol, smoking, illicit drugs) during pregnancy. A **pregnancy risk assessment** (past obstetric history, medical, social risk factors) is done at booking to stratify high-risk women (e.g. chronic hypertension, diabetes, thrombophilia, prior pre-eclampsia) for enhanced surveillance. NICE encourages discussing and documenting *place of birth* and *birth plan*. This report covers each major topic in detail. For each, we highlight **core knowledge (must/should/know-of)**, presentation/differential, diagnosis (history, exam, investigations), management (incl. UK/NICE pathways, meds in BNF terms), referral criteria, emergencies and red flags, UK-specific protocols, and patient info. We cite up-to-date NICE and RCOG guidance with dates. Notably, **Tables and Flowcharts** help summarise screening schedules and management algorithms (pre-eclampsia, reduced fetal movements).

## Normal Pregnancy - **Core:** Understand physiological changes: *cardiovascular* (↑blood volume, ↓BP early pregnancy), *respiratory* (↑tidal volume, mild respiratory alkalosis), *renal* (↑GFR, mild glycosuria), and *haematological* (hypercoagulable state, ↑clotting factors). **Symptoms** of normal pregnancy include nausea/vomiting (morning sickness), fatigue, breast tenderness, urinary frequency, mild ankle oedema. Weight gain ~11–16 kg (25–35 lbs) is typical for BMI 18.5–24.9. - **Presentation/Differential:** First-trimester bleeding or pain requires differentiation (ectopic, miscarriage vs benign implantation spotting). Nausea/vomiting vs hyperemesis (see below). Normal labour signs vs false labour, braxton-hicks. - **Examination/Investigations:** Booking bloods: FBC, blood group, antibody screen, syphilis serology, HIV, hep B, (NICE NG201). Urinalysis for protein, glucose, nitrites. Ultrasound to confirm viability, gestation and basic anatomy at 12 weeks (dating scan) and detailed anomaly scan at 20–22 weeks. Fundal height measurements plotted on standard growth charts (UK–WHO curves). Fetal heart auscultation from ~10–12 weeks (Doppler) and baseline heart rate 110–160 bpm. - **Management:** Reassurance if all is well. Advice on antenatal vitamins (Folic acid 400 µg to 5 mg preconceptually and up to 12 weeks; vitamin D10 µg throughout pregnancy) per NHS guidelines. Dietary guidance to avoid listeria (unpasteurized cheeses, deli meats) and high-mercury fish. Ensure up-to-date immunisations: influenza (from any trimester, during flu season) and pertussis (to 16–32 wks). Offer smoking cessation services; advise abstinence from alcohol (NHS: “no amount is known to be safe”). - **UK Pathways:** NICE NG201 details routine booking schedule and monitoring. NHS maternity units use risk scoring at booking (e.g. RCOG tools) to identify women needing consultant-led care. - **Red Flags:** Vaginal bleeding, severe headache, visual disturbance, epigastric pain (see pre-eclampsia), reduced fetal movements (see below), signs of infection (fever, dysuria), chest pain or leg swelling (consider PE), and any deterioration prompt urgent review.

## Antenatal Care & Screening - **Schedule:** NICE NG201 (2021) recommends *at least* 10 antenatal contacts for first pregnancies (7 for others). Typical schedule: booking at 8–12w, 16w, 25w, 28w, 31w, 36w, 38w, 40w, plus postdates as needed. Visits include blood pressure, weight, urine dipstick (for protein/glucose), fundal height, fetal heartbeat. - **Screening Tests (UK)** – see table below. Key points: **Down’s syndrome** screening (trisomy 21) via *combined test* (maternal serum free β-hCG and PAPP-A + nuchal translucency US at 10–14w). If pregnancy is already >14w, do the *quadruple test* (AFP, β-hCG, uE3, inhibin-A at 14–20w). High-risk *result* (e.g. >1:150) leads to offer of cell‐free fetal DNA (non-invasive prenatal testing) or definitive diagnostic test (CVS at 11–14w or amniocentesis from 15w). A **20-week anomaly scan** (NHS) is offered to all to screen for structural problems (neural tube defects, congenital heart disease, kidneys, etc). All women are also offered **gestational diabetes** screening: those with risk factors (e.g. BMI≥30, FHx, previous GDM) get a 75 g 2‐h OGTT at 24–28w. NICE NG201 also specifies antenatal screening for anaemia, blood group/Rh, sickle cell and thalassaemia carrier status, and infections (HIV, syphilis, hepatitis B). Fetal growth is monitored by fundal height and serial scans if concerns. - **Screening Table:** | **Test/Condition** | **Timing** | **Method** | **Next Step if Positive** | |-------------------------------------|-------------------------|--------------------------------------------|----------------------------------| | Down’s/Edwards/Patau’s syndromes | 10–14 wk (11–14 wk common) | Combined test (NT ultrasound + maternal serum β-hCG, PAPP-A); if >14 wk, Quadruple serum test (14–20 wk). | If high-risk result: offer cell-free DNA (NIPT) or invasive CVS/amniocentesis. | | Neural tube defects (NTDs) | 15–20 wk | Maternal serum AFP (in quad test) + anomaly scan. | If raised AFP or US suspicion: targeted ultrasound, maternal blood tests (AChE), offer amnio. | | Anomaly scan (heart, kidneys etc) | 18–21 wk (20 wk) | High‐resolution fetal ultrasound. | If anomalies found: referral to fetal medicine for detailed scan and counselling. | | Gestational diabetes mellitus (GDM) | 24–28 wk (as per risk) | 75 g OGTT: fasting ≥5.6 mmol/L or 2h ≥7.8 mmol/L. | If diagnosed: refer to joint diabetes-antenatal clinic; diet, exercise, glucose monitoring and pharmacotherapy as below. | | Blood group & antibodies | Booking (8–12 wk) | Blood test. | If RhD– mother of RhD+ fetus: give anti-D immunoglobulin at 28 wk and after delivery/bleeding. | | Anaemia (FBC), Thalassaemia carrier | Booking | FBC, blood count. | Treat anaemia; if carriers, partner testing. | | HIV, Syphilis, HepB, Rubella IgG | Booking | Serology. | If positive: specialist referral (early ART for HIV, penicillin for syphilis, antivirals for hepatitis B, immunoglobulin for rubella exposure). | | Sickle cell & Thalassemia screen | Booking | Haemoglobinopathy screen. | If positive carrier: partner testing, offer prenatal diagnosis. | - **Patient Information:** Women are counselled on the meaning of screening (chance vs diagnosis) and choices. If a screening result is *higher risk*, NICE advises offering timely discussion and onward testing. All screening is opt-in; women may decline at any time.

## Pregnancy Risk Assessment and High-Risk Pregnancy - **Booking Assessment:** Every woman is asked about past obstetric history (previous obstetric complications, stillbirth, growth-restricted baby, GDM, pre-eclampsia), medical conditions (HTN, diabetes, thyroid disease, renal/liver disease, antiphospholipid syndrome), medications (e.g. warfarin), family history (thrombophilia), social factors (BMI>30, smoking, substance use, domestic abuse) and current pregnancy details (e.g. multi-fetal pregnancy). NICE NG201 and RCOG recommend stratifying these into “high-risk” or “moderate-risk”. High-risk women (e.g. chronic hypertension, insulin-treated diabetes, previous severe pre-eclampsia) are referred to obstetric specialists early. Most others remain in midwife-led care. - **High-Risk Conditions:** These include chronic maternal illness (heart disease, kidney disease, respiratory disease, psychiatric illness), autoimmune disease (lupus, APLS), obstetric history (previous PPH, stillbirth, placenta praevia, preterm birth), and major fetal concerns (e.g. known anomalies). Each of the conditions below (diabetes, hypertension, VTE risk, obesity, infection, etc.) is separately discussed as a high-risk group. - **Management:** High-risk pregnancies often involve extra antenatal visits, growth scans, CTG monitoring and lower thresholds for admission or induction. Decisions on timing of birth are individualized (e.g. aim for 37–38 wk in stable chronic HTN; 37 wk if severe ICP or diabetes with complications; 34–37 wk if severe pre-eclampsia with deteriorating condition).

## Obesity in Pregnancy - **Core (Must Know):** Obesity (BMI≥30) is common (21% of UK antenatal women) and increases risks: *gestational diabetes, pre-eclampsia, caesarean*, wound infection, thromboembolism, macrosomia, and challenges in imaging/examination. BMI ≥40 (morbid obesity) adds even greater risk. - **Presentation/Differential:** Obesity alone is not a “presentation” but is noted at booking. Differentiate obesity-related dyspnoea or fatigue from other pathology. Fundal height may overestimate fetal growth in obese women, so lean on ultrasound. - **Assessment:** All pregnant women have BMI calculated at booking. For BMI≥30, NICE and RCOG advise extra care: referral to obstetrician if BMI≥40, and consider consultant care if BMI≥50. Blood pressure and glucose screening are particularly important. Early OGTT is offered due to high GDM risk. Weight gain is monitored (<9 kg gain recommended for BMI ≥30). - **Management:** Prepregnancy: advise weight loss and optimize comorbidities. During pregnancy: ensure thromboprophylaxis (see VTE) and consider calcium 1g daily (some evidence reduces pre-eclampsia). Early anaesthesia consult if neuraxial anaesthesia expected to be difficult. At delivery: low threshold for early anaesthetic input. Experienced staff for fetal monitoring. Consider 3rd or 4th trimester growth scans (24, 32 wk) because of risk of growth disorders. Offer dietetic input. Always prescribe low-dose aspirin (75–150 mg from 12 wk) for those with additional risk factors (BMI≥35 by NICE NG133 moderate risk criteria or RCOG guidelines). - **Medication:** Weight-adjust LMWH prophylaxis (if used) based on actual BMI. BNF weight-based dosing for magnesium sulfate if pre-eclampsia. No specific drug treatments just for obesity. - **Referral:** BMI≥40 at booking triggers consultant-led care. Any new issues (e.g. gestational diabetes, hypertension) follow standard referral thresholds. - **Red Flags:** Obese women have increased risk of shoulder dystocia in labour if fetal macrosomia; shoulder dystocia management protocols apply. Also, note diminished perception of fetal movements (due to adipose tissue) – advise counting kicks. - **Patient Info:** Discuss risks in neutral tone. Emphasize healthy lifestyle and offer referral to specialist services (dietitian, weight management).

## Diabetes in Pregnancy (Type 1, Type 2, Gestational) - **Core:** Diabetes complicates ~5–10% of UK pregnancies. NICE NG3 (2020) covers *pre-gestational (type 1/2)* and *gestational diabetes (GDM)*. Poor glycaemic control increases miscarriage, fetal malformation, stillbirth, macrosomia and neonatal hypoglycaemia. *Type 1 and Type 2 diabetes* require tight preconception control (HbA1c <48 mmol/mol if possible) and specialist care. *Gestational diabetes* is new-onset hyperglycaemia, usually diagnosed in mid-pregnancy (OGTT criteria below). Risk factors for GDM: obesity, previous GDM, PCOS, FHx Type 2 diabetes, South Asian/African/Caribbean ethnicity, age >40. - **Presentation/Differential:** Usually asymptomatic; GDM is found on routine screening. Type 1/2 may present with classic symptoms (polydipsia, polyuria). DKA is an emergency (abdominal pain, vomiting, dehydration, altered mentation) – always consider if any type of diabetic woman is unwell. Post-meal glycosuria can also be normal in pregnancy. - **Diagnosis:** Early OGTT (75 g) is done at booking for women with previous GDM or high-risk; otherwise at 24–28 wk if any risk factors. Diagnosis of GDM: fasting ≥5.6 mmol/L or 2h ≥7.8 mmol/L. All women with pre-existing diabetes get HbA1c at booking and ocular/renal assessment. Continual capillary glucose monitoring is taught. NICE NG3 recommends targets: pre-meal <5.3 mmol/L, 1h post-meal <7.8, 2h <6.4 mmol/L. - **Investigations:** In addition to glucose: check full blood count (infection risk with glycosuria), U+Es (renal function), TFT (if type 1), lipids. Fetal ultrasound every 2–4 weeks from 28 weeks to monitor growth (macrosomia or IUGR) and amniotic fluid. - **Management:** - *Diet & Lifestyle:* All diabetics need individualized dietetic advice and moderate exercise unless contraindicated. - *Monitoring:* Self-monitoring of blood glucose at least fasting and 1h postprandially (type 1 and insulin-treated type 2: four times daily; diet-controlled GDM: at least fasting and postprandial). - *Medication:* For GDM not controlled by diet in 1–2 weeks, **offer metformin** (off-label). Metformin is started 500 mg BD and titrated (max ~2 g/day) under specialist guidance. If further control needed or if fasting glucose ≥7.0 mmol/L at diagnosis, **insulin** is indicated. In UK, insulin regimens: twice-daily mixed or basal-bolus regimens; common preparations are human insulin or analogues (aspart, lispro). Metformin side effects: GI upset, rarely lactic acidosis (caution if renal impairment). Safety in pregnancy: Metformin crosses placenta but data show no increase in malformations; is NOT licensed for GDM in UK (BNF “off-label” notice). - *Insulin in Type 1/2:* Pre-existing diabetics on insulin continue with tighter control; often switch to glargine or detemir for basal and aspart/lispro for meals. Avoid sulfonylureas (glibenclamide) in pregnancy. If on statins/ACEi preconception, stop in early pregnancy and substitute (e.g. labetalol for HTN, pravastatin unlicensed in pregnancy, usually stop statin). - *Targets:* Aim for HbA1c ~ ≤48 mmol/mol preconception; in pregnancy some targets are slightly relaxed (≤53 mmol/mol) to reduce hypoglycaemia risk. - *Emergency:* Avoid hypoglycaemia (carry glucose tabs). In DKA (rare but lethal to fetus), immediate admission: IV insulin and fluids (specialist care). See RCOG 2015 guideline. - **Referral:** All diagnosed diabetics must be under joint endocrinology/maternal-fetal medicine care. GDM referrals: <1 week to joint clinic. Insulin requiring or uncontrolled GDM escalates to daily/weekly review. In labour: specialist diabetic intrapartum management (insulin infusion plus dextrose to keep glucose ~5–7 mmol/L). - **Red Flags:** DKA: vomiting + dehydration + tachycardia + metabolic acidosis (immediate A&E). Fetal hyperinsulinemia risk: large baby (>4kg or >90th centile); shoulder dystocia preparation. Neonatal hypoglycaemia (feed early, check cord/baby sugar). - **Postnatal:** Check maternal glucose tolerance at 6–12 weeks postpartum: type 2 DM by OGTT. GDM: 50% risk future type 2. Encourage breastfeeding (improves glycaemic control) and contraception (avoid unplanned pregnancy; if on oral agents, plan switch to insulin if pregnancy desired). - **Sources:** NICE NG3 (2020); RCOG Green-top on pregnancy and diabetes; NICE CKS *“Diabetes in pregnancy”*; BNF for metformin and insulins.

## Maternal Infections - **Core:** Certain infections can harm mother or fetus. Routine antenatal screening is offered for *asymptomatic* HIV, syphilis and hepatitis B (Booking). Varicella and rubella susceptibility are checked if history unclear; offer immunization postpartum if non-immune. Seasonal influenza vaccination is recommended for all pregnant women (with any trimester). Pertussis (Tdap) vaccine offered at 16–32 weeks (UK policy). - **Common infections:** - *Urinary Tract Infection:* Screen via dipstick/culture at booking and if symptoms. Asymptomatic bacteriuria (≥10^5 CFU/ml) is treated (nitrofurantoin or cephalexin). UTIs can trigger preterm labour; treat promptly. Avoid trimethoprim in 1st tri (folate antagonist) and nitrofurantoin at term (risk neonatal haemolysis). - *Group B Streptococcus (GBS):* UK does **not** perform universal GBS screening by culture (unlike USA). Instead, intrapartum IV benzylpenicillin prophylaxis is given if risk factors (previous baby with GBS disease, GBS bacteriuria this pregnancy, fever in labour, or unknown GBS with <37 wks/membrane rupture >18 h). - *Sexually Transmitted Infections:* Screen for chlamydia and gonorrhoea at booking if <25 or high risk; treat with appropriate antibiotics (azithro or amoxicillin for chlamydia, ceftriaxone for gonorrhea). Syphilis serology is universal; treat positive cases (benzathine penicillin by IDU team). - *Respiratory:* Pneumonia or influenza in pregnancy is more severe; low threshold for admission and antivirals for influenza (oseltamivir) if suspected. - *Skin:* Chickenpox in a susceptible pregnant woman is an emergency (risk fetal varicella); give varicella-zoster immunoglobulin (VZIG) if <20 weeks and aciclovir treatment. Zika (travel) – advise against travel to endemic areas. - **Viral infections:** - *HIV/Hepatitis B:* Identified by screening. Give antiretroviral therapy for HIV and neonatal prophylaxis. Hep B positive: specialist care, baby given immunoglobulin and vaccine at birth. - *Rubella:* If non-immune at booking and exposed, give immunoglobulin. Immunize postpartum. - **Referral:** Any significant infection requires specialist input. For example, confirm chorioamnionitis (fever, tender uterus) -> manage as preterm labour. GBS suspects in labour: give IV benzylpenicillin immediately. - **Red Flags:** Sepsis in pregnancy (fever, tachycardia, hypotension) must trigger maternal sepsis protocol (blood cultures, IV antibiotics). Pyelonephritis (fever+flank pain) – IV antibiotics. - **Patient Info:** Encourage vaccines (flu, pertussis). Advise hygiene (handwashing for listeria prevention, safe sexual practices).

## Fetal Growth: SGA and LGA - **Definitions:** *Small for gestational age (SGA):* <10th percentile or estimated fetal weight (EFW) <10th centile for gestation; *Large (macrosomia):* >90th centile or EFW >4kg at term. - **Risk factors:** SGA: maternal smoking, hypertension, pre-eclampsia, thrombophilia, poor weight gain. LGA: maternal diabetes (especially GDM poorly controlled), obesity, multiparity. - **Presentation/Differential:** SGA often asymptomatic, detected via fundal height lag (measured <expected). LGA may present late by palpation of big baby. Differentiate true SGA from constitutionally small baby (e.g. small parents) – Doppler and growth charts help. Exclude anomalies or infection as cause of growth restriction (TORCH screen in IUGR). - **Assessment:** Routine fundal height measurement each visit (UK–WHO chart); if <2 cm below expected on two occasions, do ultrasound. Ultrasound (serial 2–4 weekly): measure EFW, liquor volume, umbilical artery Doppler (SGA). Middle cerebral artery Doppler if brain-sparing suspected. - **Diagnosis:** Confirm SGA/LGA by ultrasound centiles. For SGA: check placental function (Dopplers) and investigate causes (blood pressure, urine protein). - **Management:** - *SGA:* If EFW <10th centile **with normal Dopplers** and no other concerns, continue enhanced surveillance (frequent CTG, sonography). If abnormal Doppler (absent/ reversed end-diastolic umbilical flow) or oligohydramnios, admit and consider delivery (often at ~37 wk in 3rd degree IUGR; earlier if severe Doppler abnormalities). If SGA suspected <37 wk, give steroids if expecting preterm birth. - *LGA:* If suspected macrosomia (EFW >4kg), counsel about shoulder dystocia risk. Offer induction at 38–39 wk if no other indications. Caesarean is not routinely recommended for LGA unless >5 kg or other risk. Manage GDM tightly (as above) to limit growth. During labour, prepare for dystocia (McRoberts, episiotomy early). - **Referral:** Any concerning growth finding is referred to obstetrics. SGA usually to fetal medicine/maternal-fetal specialist. - **Red Flags:** SGA with abnormal Doppler is “difficult to safely monitor at home” – hospitalize. LGA risk: shoulder dystocia requires emergency manoeuvres (all staff prepared, neonatal team for shoulder dystocia protocol). - **Sources:** RCOG GT31 (SGA fetus) and NG3 on diabetes/maternal obesity. NICE NG3 mentions fetal macrosomia risks.

## Reduced Fetal Movements (RFM) - **Core:** Normal babies move intermittently but mother should feel ≥10 movements in 2 hours once daily activity noted (usually after 28 wk). RCOG advises women report any *reduction or cessation of fetal movements* immediately. New guidelines (RCOG GT57, 2022) emphasize this as a sign of potential fetal compromise. - **Presentation:** A woman notes fewer kicks than usual (subjective); often after evening meal monitoring. There is no absolute “count” method recommended in UK (NICE removed routine kick counting charts). Any perceived reduction warrants assessment. - **Differential:** Not feeling movements can be due to factors like maternal obesity, anterior placenta, quiet baby (normal variation), or true decreased movements (fetal hypoxia/IUGR, oligohydramnios). Pitfall: reassuring mother that occasional inactivity is ok, but NICE says always assess RFM to exclude rare stillbirth risk. - **Assessment/Diagnosis:** Prompt hospital assessment: 1. **Cardiotocography (CTG):** Assess fetal heart reactivity and variability. Normal (reactive CTG) – good. Non-reassuring (decelerations, sinusoidal) – emergency. 2. **Ultrasound:** Check fetal biometry (growth), amniotic fluid index (liquor volume), and cord Dopplers (umbilical artery PI). 3. **Subjective/Exam:** Ask about onset, pattern; do a physical exam (blood pressure, maternal hypoglycaemia, fever). - **Management Algorithm:** (See flowchart below) – broadly: - If **CTG reactive and normal US**: Often reassure and consider homecare, but repeat assessment in 24–48h. If ≥38 wk or any other indication (e.g. overdue, hypertensive, diabetic), consider delivery (induction). - If **CTG non-reassuring or abnormal ultrasound (IUGR, oligohydramnios)**: Treat as fetal compromise – admit for monitoring, give steroids if preterm, expedite delivery (often by induction or caesarean depending on circumstances). - If CTG abnormal (suspect late decels, sinusoidal) – immediately consider delivery. - **Referral:** Any persistent RFM or abnormal tests = obstetric ward admission. - **Patient Info:** Advise mothers to be aware of “usual pattern” and to sit/lie quietly when checking movements. Use of smartphone apps or kick charts is optional but not mandated. - **Red Flags:** RFM with any reduced amniotic fluid or abnormal Dopplers is a “don’t miss” – must deliver even if preterm (given risk of stillbirth rises after 38 wk if movements decrease). - **Mermaid Algorithm:** ```mermaid flowchart TB A([Reduced fetal movements reported]) --> B{Do immediate assessment} B --> C[CTG fetal heart monitoring] B --> D[Ultrasound: growth, AFI, Dopplers] C --> |Reactive (normal)| E[Reassure, repeat in 24h; consider induction if ≥38wk or other risk factors] C --> |Non-reassuring (late decels, low variability)| F[Urgent obstetric review, prepare for delivery] D --> |Normal growth & fluid| G[Conservative: home, maternal kick-count advice, follow-up scan] D --> |Growth restriction or oligohydramnios| H[Fetal compromise → admit for steroid, plan delivery] F --> I[Manage as emergency (as below in Pre-eclampsia/PROM algorithm)] ``` *(Citations: RCOG GT57; NICE NG201 antenatal care summary).*

## Antenatally Detected Chromosomal Abnormalities - **Core:** Down (trisomy 21), Edwards (T18) and Patau (T13) are the main conditions screened. Risk increases with maternal age. - **Screening/Diagnosis:** All women are offered screening (combined/quad tests). A *higher-chance* result leads to offer non-invasive prenatal testing (NIPT, cell-free DNA) for reassurance or CVS/amniocentesis for definitive diagnosis. The patient receives genetic counselling before any invasive test. Other chromosomal findings (sex chromosome anomalies, microdeletions) may be incidentally found on microarray if amnio/CVS is done. - **Presentation/Differential:** Some abnormalities are suspected on ultrasound (e.g. increased nuchal translucency, absent nasal bone, certain heart defects). But minor soft markers (echogenic bowel, choroid plexus cysts) are non-specific. - **Management:** Confirmed trisomy 21, 18, 13: refer to fetal medicine/genetic clinic for discussion of options. NICE and NHS support non-directive counselling: continuation (with high surveillance and neonatology involvement) vs termination (up to 24 wk for Down, 32 wk for lethal anomalies). If pregnancy continues, plan delivery at tertiary center; prepare for neonatal issues (e.g. neonatal ward). - **Patient Info:** Provide written and verbal information; refer to support organizations (e.g. ARC, SANDS). - **Follow-up:** Neonatal assessment after birth; consider early childhood interventions. For Down’s, offer parental karyotyping or screening.

## Hypertension in Pregnancy ### Gestational Hypertension vs Pre-eclampsia - **Definitions:** *Gestational hypertension* = new BP ≥140/90 mmHg after 20 wk, no proteinuria. *Pre-eclampsia* = gestational hypertension **plus** evidence of end-organ damage (proteinuria ≥30 mg/mmol creatinine or ≥300 mg/24h, or other signs: thrombocytopenia, elevated ALT/AST, renal insufficiency, pulmonary oedema, new headache/vision changes). Chronic hypertension is BP ≥140/90 before pregnancy or before 20 wk. - **Risk Factors:** RCOG/NICE list: previous pre-eclampsia, chronic HTN, renal disease, diabetes, autoimmune disease (SLE, APLS), >1 moderate risk (first preg, age ≥40, interval >10y, BMI≥35, family history, multiple pregnancy). - **Presentation:** Often asymptomatic mild hypertension detected on routine check. Pre-eclampsia may present with headache, visual changes, epigastric/RUQ pain, severe oedema, or incidental proteinuria. - **Assessment/Diagnosis:** At each visit measure BP, test urine protein. Any suspicion of pre-eclampsia: do full blood count, liver and renal function, coagulation, and ultrasound for growth. Confirm proteinuria with PCR (protein:creatinine ratio >30 mg/mmol). NICE NG133 recommends confirming dipstick 1+ with protein:creatinine ratio. Screen for severe signs: seizures, severe headache. - **Management:** (see algorithm below) - **Mild gestational HTN/pre-eclampsia** (<160/110 and mild/no symptoms) – outpatient management with BP monitoring and weekly antenatal visits. Start low-dose aspirin (75–150 mg) at 12 weeks in women at high risk (previous pre-eclampsia, CKD, APLS, DM, chronic HT) or with ≥1 moderate risk to prevent pre-eclampsia. First-line antihypertensive: *labetalol* (initial 100 mg BD, titrate); if intolerant, *nifedipine XL* (20 mg OD) or *methyldopa* (250 mg TDS). Target BP ~135/85 mmHg. - **Severe hypertension** (systolic ≥160 or diastolic ≥110): treat promptly with oral antihypertensives (labetalol 200 mg stat, or nifedipine 10 mg prn) to lower BP. Admit for monitoring. Intravenous labetalol or hydralazine may be used if urgent. - **Pre-eclampsia surveillance:** Regular outpatient or inpatient monitoring of maternal (BP, labs) and fetal status (growth scans, CTGs). If preterm (<37 wk) with mild features, manage expectantly in hospital; give magnesium sulfate (IV 4g over 20min, then 1g/hr) if delivery <24h or severe features. If 37+ weeks or severe features (e.g. uncontrolled BP, end-organ compromise), deliver (often by induction if cervix favourable, or C-section). - **Magnesium Sulfate:** Indicated for seizure prophylaxis in severe pre-eclampsia. Typically given as above; monitor urine output and reflexes (toxicity signs). (NICE recommends IV MgSO₄ for severe PE e.g. plan birth <24h). - **Aspirin Prophylaxis:** As above (75–150 mg nightly from 12 wk) for high-risk and multiple moderate-risk women. Continue until birth. - **Other:** Bed rest is not routinely recommended. No evidence for salt restriction. Calcium supplementation (1.5–2g/day) considered if diet low (<600 mg/day). - **Algorithm (Mermaid):** ```mermaid flowchart LR X[Pregnant woman with suspected hypertensive disorder] --> Y{Assess BP and proteinuria} Y --> |BP ≥140/90 or proteinuria| Z[Confirm diagnosis: repeat readings, lab tests] Z --> |Gestational HTN (no proteinuria)| A[Monthly antenatal checks; start aspirin if risk factors] Z --> |Pre-eclampsia (± proteinuria or end-organ signs)| B[Admit or close surveillance] A --> C{BP <150/100?} C --> |Yes| D[Conservative mgmt: labetalol or nifedipine if needed, weekly checks] C --> |No (≥150/100)| F[Start antihypertensives (e.g. labetalol 100–200 mg BD)] F --> D B --> G{Severity of PE} G --> |Mild PE (≥37 wk)| H[Plan delivery (induction)] G --> |Preterm (<37 wk)| I[Hospitalize; give steroids, MgSO4 (if <34–36 wk); control BP] H --> J[Monitor postnatally; BP often peaks days 3–6 postpartum, continue antihypertensive if needed] I --> J ``` *(Citations: NICE NG133, 2019.)* - **Referral:** Urgent (same-day) obstetric review for any severe features (BP≥160/110, severe headache, visual symptoms, epigastric pain, oliguria, thrombocytopenia) or abnormal fetal monitoring. Early referral to specialist is needed for chronic HTN or pre-eclampsia history. - **Red Flags:** Pre-eclampsia can deteriorate rapidly. **Don’t miss**: eclampsia (seizures) – immediate airway/breathing, IV MgSO₄, ICU. Posterior reversible encephalopathy (headache, vision loss). HELLP syndrome (Hemolysis, Elevated LFTs, Low Platelets). Emergency C-section may be needed. - **Postnatal:** Blood pressure often rises postpartum; continue medications. Reassess antihypertensive needs and taper if normotensive. Ensure VTE prophylaxis given ante and postpartum. If pre-eclampsia or HELLP, order an anti-phospholipid screen postpartum (NICE). Inform patient of long-term risk of hypertension and CVD; advise yearly BP checks and healthy lifestyle.

## Hyperemesis Gravidarum (HG) - **Core:** Severe nausea and vomiting (NVP) occurring usually at 6–12 weeks, but HG is the extreme form (affecting ~1–3%) with dehydration, ketonuria, and >5% weight loss. It may last beyond first trimester. Risk factors: primigravida, multiple pregnancy, previous HG, hyperthyroidism. Must exclude other causes (e.g. GI pathology). - **Presentation:** Persistent vomiting leading to dehydration, tachycardia, hypotension, ketonuria. Often poor oral intake, acid-base disturbance. Weight loss is a red flag. - **Assessment/Diagnosis:** NICE CKS defines HG as severe persistent vomiting with signs of dehydration (≥5% weight loss, ketones in urine) after excluding other causes. Check electrolytes (may see hypokalaemia, alkalosis). Rule out UTI, hypercalcemia, hyperthyroidism. Distinguish from normal NVP: HG has metabolic disturbance. The presence of ketones alone is **not required** for diagnosis (new RCOG guidelines discourage reliance on ketones). - **Differential:** Gastroenteritis (fever, diarrhoea), hyperthyroidism (tachycardia, tremor), bile reflux, medication-induced vomiting (metformin, theophylline). - **Management:** 1. **Outpatient**: Initial advice: small frequent bland meals, ginger, acupressure, rest (NICE NG201 notes lifestyle first). Pyridoxine (vitamin B6) 10–25 mg TDS is often recommended first. Cyclizine 50 mg TDS (antihistamine) or prochlorperazine 5–10 mg TDS (phenothiazine) can be first-line antiemetics. Registered drug: Xonvea® (doxylamine+ pyridoxine) is FDA-approved, but cyclizine is commonly used in UK. Reassess in 1–2 days. 2. **If no improvement**: Escalate to second-line antiemetics: oral metoclopramide 10 mg TDS, or domperidone 10 mg TDS, or ondansetron 4–8 mg TDS (caution: avoid ondansetron >5 days due to QT-prolongation; first-trimester use has small cleft risk). Treat reflux if present with ranitidine (Zantac) or omeprazole. 3. **Failure of oral meds or dehydration**: Admit for IV fluids (0.9% saline + KCl) and IV antiemetics (e.g. cyclizine 50 mg IV QDS, metoclopramide 10 mg QDS). Give IV thiamine (Pabrinex) before dextrose-containing fluids to prevent Wernicke’s encephalopathy. If still refractory, consider corticosteroids (oral prednisolone 10–20 mg for 1 week, taper), as RCOG suggests in extreme cases. - **Medications:** BNF safety: Cyclizine is pregnancy category A (antihistamine), prochlorperazine (A, but warns sedation), metoclopramide (A, dystonic risk), ondansetron (B1, avoid long-term first-trimester), pyridoxine (A). Avoid sodium valproate/dextropropoxyphene. - **Referral:** Obstetric admission for severe HG (dehydration, ketonuria, >5% weight loss). Involvement of dietitian, obstetrician, and possibly psychiatric support (HG can trigger depression). If in community and not improved on first-line, same-day referral to hospital. - **Red Flags:** Inability to keep ANY fluids (risk AKI), altered mental state (electrolyte imbalance), jaundice (consider cholestasis or viral hepatitis). If no improvement on IV fluids/antiemetics, consider PICU (parenteral nutrition rare). - **Patient Info:** Reassure that worst often passes by 16–20 weeks but some need care longer. Arrange supportive care (PSS charity info). Advise ginger candies, acupressure wristbands. Offer early referral to dietitian. *(Source: RCOG GT69 updated 2024; NICE CKS).*

## Intrahepatic Cholestasis of Pregnancy (ICP) – Pruritus of Pregnancy - **Core:** ICP (formerly obstetric cholestasis) causes unexplained itching (usually palms/soles) in late pregnancy, with elevated serum bile acids (due to reduced excretion). Incidence ~1%. It increases fetal risk (preterm labour, meconium, stillbirth especially after 37 wk). - **Presentation:** Intense pruritus without rash, often worse at night; may have mild jaundice. Usually appears in 3rd trimester. - **Diagnosis:** Check liver function and serum bile acids. ICP is defined by fasting bile acids ≥10 μmol/L (UK threshold) or as RCOG: *mild*: 19–39 μmol/L, *moderate*: 40–99, *severe*: ≥100 μmol/L. (These RCOG cut-offs are higher than some sources; always correlate with symptoms.) ALT/AST are often mildly raised; GGT usually normal. Rule out other liver diseases. - **Differential:** PUPPP (pruritic urticarial papules), urticaria, atopic eruption, hep C, acute fatty liver of pregnancy (AFPP) – but AFPP has malaise, severe RUQ pain, liver failure. - **Management:** - *Symptomatic relief:* Emollients, antihistamines (chlorphenamine, A), oatmeal baths. Ensure high-vitamin K diet (or supplement) due to malabsorption of fat-soluble vitamins; consider vitamin K injection if coagulopathy. - *Ursodeoxycholic acid (UDCA):* RCOG advises UDCA 10–15 mg/kg/day (often ~1 g/day) to reduce bile acids and itching. Evidence suggests improvement in symptoms and liver tests, though fetal benefit is uncertain. Continue until delivery. - *Monitoring:* Weekly fetal monitoring (CTG, amniotic fluid) if bile acids high. Twice-weekly or more LFTs/bile acids. - *Timing of birth:* RCOG (2022) suggests offering induction by 37–38 weeks for women with ICP (earlier if severe) because stillbirth risk rises late. (Many units induce at 37 wk if bile acids >40). - **Referral:** Any signs of ICP (especially severe itch) should be evaluated by obstetrician. If cholestasis confirmed, obstetrician will manage in conjunction with medicine. - **Red Flags:** Bile acids ≥100 μmol/L (severe) – fetal risk; consider birth by 36–37 wk. Jaundice (bilirubin >100 μmol/L) suggests severe disease. Any bleeding diathesis (prolonged INR) – urgent care. - **Postnatal:** Symptoms typically resolve postpartum. Check LFTs to confirm normalization. Advise high recurrence risk in future pregnancy (>70%). - **Patient Info:** Explain fetal risk. Provide antipruritic advice (cool environment, loose clothing). Refer to RCOG patient leaflet on ICP. *(Sources: RCOG GT43 (2022); NICE NG201 notes pruritus as risk factor).*

## Venous Thromboembolism (VTE) in Pregnancy - **Core:** Pregnancy is a hypercoagulable state; absolute VTE risk ~1-2/1000 (10× non-pregnant). VTE is a leading indirect cause of maternal death. Risk is highest in the postpartum period. - **Risk Factors:** Previous unprovoked VTE or known thrombophilia is highest risk. Others: Obesity (BMI>30), age >35, immobilization, dehydration/hyperemesis, anaemia, stillbirth, varicose veins, smoking, multiple pregnancy, pre-eclampsia, and inherited thrombophilias (e.g. Factor V Leiden). The RCOG risk assessment tool scores these factors (unavailable here). - **Presentation:** DVT: unilateral leg swelling/pain (usually left leg), warmth. PE: sudden dyspnoea, pleuritic chest pain, tachycardia, hypotension (massive PE). Women may attribute symptoms to pregnancy; always assess. - **Diagnosis:** DVT: doppler ultrasound of leg veins. Do not delay because of radiation (US is safe). PE: CTPA (as in non-pregnant) is preferred over V/Q scan (both acceptable; apply shielding). Always consider D-dimer – levels rise normally in pregnancy, so not very useful. - **Management:** - *Prophylaxis:* All pregnant women should have a VTE risk assessment at booking and following any ante/postpartum events (per NICE CG144/CVCG). Those with history of VTE or high-risk thrombophilia (or scoring tool > threshold) are started on prophylactic LMWH (e.g. enoxaparin 40 mg SC daily for BMI <40; 80 mg if BMI >40). Other moderate risks (BMI 30–40 + other factors) may warrant prophylaxis from 28 wk or in labour/postnatal (consult guidelines). All admitted patients get LMWH and TEDS stockings. - *Treatment of confirmed VTE:* LMWH at treatment dose (e.g. enoxaparin 1.5 mg/kg daily or 1.0 mg/kg BD). Continue through pregnancy and 6 weeks postpartum (minimum 3 months total). Warfarin is teratogenic (except during lactation it’s safe). Fondaparinux or heparin if LMWH intolerance. - *Delivery planning:* Stop LMWH 24h before planned induction/C-section. For emergency birth on anticoagulation, use protamine if on heparin. Postpartum: restart LMWH/warfarin (warfarin safe in breastfeeding) with overlap if warfarin used. If patient on aspirin for other reasons, this does not replace heparin prophylaxis. - **Referral:** Thrombosis specialist (often haematology or thrombosis midwife) in high-risk cases. Women with prior VTE should have consultant-led antenatal care and early postpartum prophylaxis. - **Red Flags:** Any suspicion of PE (collapse, severe dyspnoea) – call emergency team; give 100% O2, IV heparin (titrate, or bolus enoxaparin), prepare to scan. DVT with phlegmasia cerulea dolens (massive swelling/ischemia) – emergent vascular input. - **Source:** RCOG GT37a (2015) summary; NICE CG144 (2018 update on general VTE; pregnancy-specific recs from RCOG tool).

## Epilepsy in Pregnancy - **Core:** ~0.4% of pregnant women have epilepsy. The goal is *seizure freedom with minimal fetal risk*. Key principle: avoid valproate due to high teratogenicity (neural tube defects, cognitive impairment) – UK action notes prohibit valproate in women of childbearing age without a Pregnancy Prevention Programme. Use monotherapy at lowest effective dose. Lamotrigine and levetiracetam are now most commonly used (lamotrigine requires dose increase in pregnancy as metabolism speeds up). - **Preconception/Booking:** High-dose folic acid (5 mg) is advised at least 3 months pre-pregnancy. Discuss risks with women planning pregnancy; neurology review to optimize regimen (switch off valproate preconception if possible). Establish baseline seizure control. Check ASM blood levels (esp lamotrigine) and monitor monthly in pregnancy (lamotrigine levels can fall by 50%). - **Presentation:** Seizures (complex/tonic-clonic) are the main risk to mother and fetus (hypoxia, trauma). Status epilepticus is rare but emergency. Auras or focal aware seizures are less risky but still need control. Non-epileptic events (conversion) need different management (psychiatric). - **Differential:** Syncope or migraine aura vs seizure. - **Monitoring:** Check serum drug levels each trimester. If on enzyme inducers (e.g. carbamazepine) or ethosuximide, consider supplementing folate further. - **Management:** Continue regular ASMs. If breakthrough seizures, first ensure compliance; if needed, increase dose gradually. Always use best-tolerated agent at lowest dose. Avoid polytherapy if possible. **Acute seizures/status:** Follow standard protocol (midazolam/diazepam, support airway). Eclampsia must be ruled out if in late pregnancy. Use magnesium sulfate if eclamptic. - **Medication details:** - *Lamotrigine:* Dose increases of 25–50% often needed by 3rd trimester (due to ↑ clearance) – monitor levels. Side effects: rash (SJS), ataxia. Category C (teratogenic risk low). - *Levetiracetam:* Generally well-tolerated; dose may need slight ↑. Side effects: fatigue. - *Carbamazepine/Oxcarbazepine:* Lower spina bifida risk than valproate; teratogenic risk present. - *Phenobarbitone:* Risk of neonatal sedation and withdrawal; rarely first-line now. - *Valproate:* Contraindicated in pregnancy unless absolutely no alternative (very rare, only if mother’s life at stake). - *All:* Safe in breastfeeding (except caution with lamotrigine). - **Referral/Escalation:** Any seizure in pregnancy above baseline or prolonged should prompt hospital review. If status epilepticus, manage aggressively (stop labour if needed, IV benzos, phenytoin). - **Red Flags:** First-onset seizure in pregnancy – consider eclampsia if >20wks (treat as eclampsia with MgSO₄). Non-epileptic seizures (psychogenic) require mental health referral. Monitor neonate for withdrawal if mother had high-dose barbiturates/bzds. - **Sources:** RCOG GT68 (2016) summary; NICE CG137 epilepsy guideline (2012, updated 2021) especially section on women (see surveillance).

## Substance Use in Pregnancy - **Core:** Ask all women about smoking, alcohol and illicit drug use (NICE guidelines on pregnancy care). Smoking causes placental insufficiency, preterm birth, and fetal growth restriction. Alcohol in any amount is not known safe; UK advises abstinence. Illicit drugs (e.g. cocaine, opioids, cannabis) can cause miscarriage, placental abruption (cocaine), IUGR, neurodevelopmental issues, and neonatal abstinence syndrome (opioids). - **Management:** - *Smoking:* Strongly advise cessation. Refer to specialist stop-smoking services and consider NRT (nicotine patches/gum are less harmful than continuing smoking). - *Alcohol:* Advise complete abstinence. If dependence: refer to addiction services; inpatient detox in severe cases (social work involvement). - *Opioids:* Do NOT abruptly cease. Switch heroin users to methadone or buprenorphine under specialist advice. Provide supervised consumption and psychosocial support. Baby will likely need NAS (neonatal abstinence) management. - *Other drugs:* Discuss risks empathetically. Encourage stopping; refer to drug services. For cannabis, counsel on fetal neuro effects (evidence mixed). - **Referral:** Often requires multidisciplinary (obstetric, addiction specialists, social services). - **Red Flags:** Withdrawal seizures (alcohol in late pregnancy), overdose (naloxone in opioid overdose should not be withheld in pregnancy). - **Patient Info:** Emphasize harm reduction and support available.

## Mental Health in Pregnancy - **Core:** Pregnancy can exacerbate existing conditions or precipitate new disorders (e.g. depression, anxiety, psychosis). NICE CG192 (2014) recommends asking about mental health at booking and routinely: previous severe depression, suicidal ideation, domestic violence are all risk factors. - **Common issues:** - *Depression/Anxiety:* Screen (Whooley questions); watch for sleep/appetite changes. First-line is psychological therapy (CBT), but SSRIs (especially sertraline or citalopram) can be used if moderate/severe. Venlafaxine or TCAs (e.g. amitriptyline) are options. Paroxetine is avoided (pulmonary HTN risk). Cognitive behavioral therapy (CBT) recommended as per NICE. - *Severe Mental Illness:* Bipolar or schizophrenia – continue usual medications (though some adjustment: avoid valproate [psychiatric or seizures] in pregnancy). If mania or psychosis, hospitalize with obstetric liaison psychiatry. ECT is safe in pregnancy if needed. - *Perinatal Psychosis:* Very rare emergency (hallucinations/delusions postpartum); treat as psychosis (antipsychotics, ECT). - *Suicidality/Self-harm:* Immediate safety evaluation. High risk warrants admission. - *Substance-related Mood:* Alcohol/drug withdrawal or dependency can cause mood swings, treat through addiction services. - **Referral:** Any severe or risky mental health condition requires liaison with psychiatry. Use Mental Health Act if patient lacks capacity or is a danger to self/others. Consider mother and baby units (MBUs) if postpartum. - **Medication Safety:** Most SSRIs are pregnancy category C but generally low teratogenic risk (except paroxetine). Lithium (for bipolar) has small cardiac malformation risk (Ebstein’s anomaly ~1%), but stopping may be worse; discuss with specialists. Always balance maternal vs fetal risk. - **Patient Info:** Normalize common fears, encourage social support. Screen for domestic violence. Involve GPs/health visitors in follow-up. **References:** Current UK guidelines (NICE, RCOG) as cited in text. Key sources include NICE NG201 (Antenatal Care, 2021), NG3 Diabetes in Pregnancy (2020), NG133 Hypertension in Pregnancy (2019), CG192 Antenatal Mental Health (2014), and RCOG Green-top Guidelines (obesity #72, hyperemesis #69, cholestasis #43, epilepsy #68, RFM #57, VTE #37a, plus NICE CKS topics). All medications mentioned align with BNF recommendations.