thromboembolism

Alcohol-induced dilated cardiomyopathy

Note the enlarged ventricular chambers - the increased size causes the appearance of thinned ventricular walls. Assumption that there is decreased musculature in heart walls can cause incorrect diagnosis of cause-of-death.

Dilated cardiomyopathy can cause systolic dysfunction and atrial fibrilation, as well as being a source of thromboembolism.

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Pulmonary emboli usually arise from thrombi that originate in the deep venous system of the lower extremities; however, they rarely also originate in the pelvic, renal, upper extremity veins, or the right heart chambers. After traveling to the lung, large thrombi can lodge at the bifurcation of the main pulmonary artery or the lobar branches and cause hemodynamic compromise.

Pulmonary thromboembolism is not a disease in and of itself. Rather, it is a complication of underlying venous thrombosis. Under normal conditions, microthrombi (tiny aggregates of red cells, platelets, and fibrin) are formed and lysed continually within the venous circulatory system.

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My Uworld notes- 6
  • serum sickness is a type 3 HSR characterized by deposition of circulation complement fixing immune complexes and resulting vasculitis. Associated findings include fever, urticaria, arthralgias, glomerulonephritis, lymphadenopathy and a low serum c3 level 5-10 days after intravascular exposure to antigen. type 3 HSR typically activate complement at local site where immune complexes containing IgG and or IgM complement fixing antibodies have been deposited. This often results in hypocomplementemia including decreased C3 level

  • liver dz-a/w AFP

  • carcinoembryonic antigen (CEA) a/w colorectal cancer

  • CA125 -ovarian cancer. Both CEA and ca125 are fr monitoring purposes

  • PSA prostate specific antigen is most useful in establishing extent of prostate cancer and evaluating response to prostate cancer tx.

  • Iced water think cold – cold think cold agglutinins – cold agglutinin associated with infection with mycoplasma pneumonia

  • another cold agglutinin is EBV

  • free air in peritoneal cavity= bowel perforation

  • pancreatic calcification= chronic pancreatitis

  • heavily calcified vessels = atherosclerosis and vascular dz

  • distended bladder= urinary retention

  • air in billiary tract a/w gallstone ileus

  • fluoxetine a/w anorgasmia and decreased libido and increase latency to orgasm. They can however be used to tx premature ejaculation

  • phenelzine= MAO-I used in tx of depression monoamine oxidase is a mitochondrial enzyme that deaminates primary and secondary aromatic amines

  • tricyclic antidepressants can cause orthostatic hypotension example imipramine

  • trazadone- priapism

  • paroxysmal breathlessness and wheezing in young patient unrelated to ingestion of aspirin, pulmonary infection inhaled irritant stress and or exercise should raise a strong suspicion for extrinsic allergic asthma. The granule containing cells in sputum are most likely eosinophils and the crystalloid bodies are most likely Charcot Leyden crystals (contain eosinophil membrane protein)

  • chronic eosinophilic bronchitis in asthmatics involves bronchial wall infiltration by numerous activated eosinophils largely in response to IL5 released by TH2 cells

  • digestion and absorption of nutrients primarily occurs in small intestine. SI cells produce enzymes responsible for nutrient absorption. Proteins in ingested food exist primarily as polypeptides and require hydrolysis to dipeptides tripeptides and amino acid for absorption. Hydrolysis of these polypeptides is accomplished by proteolytic enzymes such as pepsin and trypsin

  • these enzymes are secreted inactive proenzymes trypsinogen and pepsinogen from stomach and pancreas

  • trypsin activates other proteolytics enzymes including chymotrypsin carboxypeptidase and elastase. Activation of trypsinogen to trypsin is achieved by enteropeptidase (or enterokinase)an enzyme produced in duodenum

  • enteropeptidase deficiency results in defective conversion of trypsinogen to active trypsin

  • lipase secreted from exocrine pancreas is the most important enzyme of digestion of triglycerides. Chronc pancreatitis is a painful condition that causes lipase deficiency. This leads to poor fat absorption and steatorrhea

  • secretin is a peptide hormone secreted by S cells of duodenum un response to low duodenal pH. Secretins timulates secretion of bicarbonate from the pancreas and gall bladder and reduces acid secretion in the stomach by reducing production of gastrin. Neutralizing the acidic pH of food entering the duodenum from the stomachis necessary for proper function of pancreatic enzymes (amylase, lipase)

  • trisomy 18 (47XX: Edwards syndrome

    • face: micrognathia, microstomia, eye defects (microphthalmis, cataracts) low set ears and malformed ears prominent occiput

    • CNS: microcephaly, neural tube defects (meningocele, anencephaly), holoprosencephaly, arnold chiri malformation, severe MR delayed psychomotor development

    • musculoskeletal: clenched hands with overlapping fingers (index finger overrides the middle fingerand fifth finger overrides the fourth finger) rocker bottom feet short sternum and hypertonia

    • cardiac: VSD, PDA

    • distinguishing features: clenched hands and or overlapping finger

    • GI: Meckel diverticulum, malrotation

    • ultrasound: intrauterine growth restriction and polyhydramnios especially ina fetus with abnormal hand arrangement

  • unlike patients with Edward’s syndrome neonates with Patau syndrome (trisomy 13) have cleft lip and palate, polydactyly and omphalocele. Patau syndrome is not a/w low set ears and overlapping fingers but do present with rocker bottom feet also

  • 47XXX karyotype is clinically silent however, some affected women have slightly decreased IQ scores. Female newborns with this karyotype are phenotypically normal with no obvious dysmorphism

  • 47XXY Kleinfelter’s syndrome: may be a/w mild mental retardation or normal intelligence. The typical patient is tall mall adult with gynecomastia small testes and infertility. Male newborns with this karyotype are phenotypically normal with no obvious dysmorphism. The clinical findings do not become apparent until adulthood.

  • Sudden onset of abdominal or flank pain hematuria and left sided varicocele together suggests renal vein thrombosis a well known complication of nephrotic syndrome. Nephrotic syndrome is a hypercoagulable state d/t increased loss of anticoagulant factors especially anti thrombinIII (responsible for the thrombotic and thromboembolic complications of nephrotic syndrome)

  • venous drainage from left testes travels throught the left testicular vein into the left renal vein and from there the IVC. In contrast to the right testicular vein which empties directly into the IVC. This difference in venous drinage gives diagnostic significance to left sided varicocele in that it often indicates an occlusion of the left renal vein by a malignant tumour or thrombus

  • malaise low grade fever followed by a facial rash. Feels better now but still has the rash- red flushed cheeks with – clinical presentation of erythema infectiosum aka fifth dz. As the facial rash fades an erythematous rash in reticular lace like pattern often appears on trunk and extremities. The rash of erythema infectiosum is thought to result at lest partly from local immune complex deposition once serum levels of virus specific IgM and IgG have attained high enough levels.

  • Erythema infectiosum= non enveloped DNA virus called parvo B19. The blood group P antigen globoside is a parvovirus B19 is highly tropic for erythrocyte precursors particularly erythrocytes and erythroid progenitor cells

  • Parvo B19 replicates predominantly in the bone marrow

  • anthracyclines daunorubicin doxorubicin epirubicin and idarubicin are chemotherapeutic agents a/w severe cardiotoxicity because of their unique ability to generate free radicals.. Dilated cardiomyopathy is dose dependent and may present months after discontinuation of the drug . Swelling of sarcoplasmic reticulum is the morphologic sign of early stage doxorubicin associated cardiomyopathy. Followed by loss of cardiomyocytes and its symptoms are those of biventricular CHF including dyspnea on exertion orthopnea and peripheral edema

  • dexrazoxane prevents Doxorubicin associated cardiomyopathy because dex is a iron chelating agent that decreases formation of free radicals by anthracyclines.

  • Restrictive cardiomyopathy a/w hemochromatosis amyloidosis sarcoidosis and radiation theraapy : remember -osis

  • hypertrophic cardiomyopathy caused by mutation of beta myosin heavy chain

  • focal cardiomyopathyscarring commonly results in MI

  • pericardial fibrosis usually follows cardiac surgery radiation therapy or viral infections of the pericardium

  • PCP aka angel dust aka phencyclidine commonly associated with violent behaviour

  • LSD can also cause aggressive behaviour but it is more typically characterized by affective liability thought disruption )delusion) and visual hallucination whereas PCP produces more psychomotor agitation including clonic jerking of extremities

  • angel dust can be put on marijuana and smoked LD is ingested orally

  • secobarbital is a street barbiturate a CNS depressant which leads to drowsy drunken state of consciousness without the violent behaviour

  • heroin (opioid) produces CNS psychomotor depression and respiratory depression miosis and bradycardia are common

  • dry tap with no splenomegaly or lymphadenopathy – think aplastic anemia which causes pancytopenia

  • aplastic anemia= hypo cellular bone marrow with fat cells and fibrotic stroma

  • hyper cellular marrow with increased blasts found in myeloproliferative d/o and certain leukemias

  • most common side effect of streptokinase= hemorrhage . Streptokinase is a thrombolytic agent that acts by converting plasminogen to plasmin which subsequently degrades fibrin. It is a foreign protein derived from streptococci and induce HSR.

  • Dissection of ascending aorta manifests as tearing chest pain that radiates to the inter-scapular area commonly occurs in hypertension marfans and ehlers danlos

  • hyperactive jaw jerk reflex when lightly tapped= chvostek’s sign- Hypocalcemic – facial m contraction elicited by tapping facial nerve just anterior to ear. The most common cause of outpatient hypocalcemia is primary hypoparathyroidism which is often d/t prior loss of parathyroid tissue during thyroidectomy

  • scotoma is visual defect that occurs d/t pathologic processes that involve parts of retina or optic nerve resulting in discrete area of altered vision surrounded by zones of normal vision. Lesions of macula cause central scotomas.. examples would include MS, diabetic retinopathy and retinitis pigmentosa

  • verapamil is a calcium channel blocker that slows SA and AV node phase 0 depolarization (in nodal cells, the phase of depolarization is mediated by calcium influx)

  • phase 0 depolarization of cardiac conduction system occurs during diastole thus verapamil slows diastolic depolarization

anonymous asked:

So I get that it's like a common misconception that people in a hospital get their hearts restarted with a defibrillator, that's only for hearts that have an irregular rhythm. But then what do hospitals actually use to restart a heart that's stopped? I'm having a weirdly hard time finding this information online. Thanks so much!

That’s a really good question!

Treating asystole comes down to this: Maintain life for as long as possible with CPR, figure out what’s wrong, and, if at all possible, fix it before the person dies for real.

There are 10 “reversible” causes for cardiac arrest:

  • Hypoxia: Too little oxygen in the blood (due to inability to get air into lungs (asthma, COPD), injury to lung tissue, or too little oxygen in the environment.).
    Reverse by getting oxygen into the blood by either CPR/ventilation or ECMO (heart-lung machine) if it can be set up fast enough.
  • Hypovolemia: Too little blood volume, due to dehydration or blood loss.
    Reverse
    by getting IV fluids/blood into the person.
  • Hyper or Hypokalemia- Too high or low potassium levels, which cause irregular heart beats and can eventually cause ineffective heart rhythms.
    Reverse
    by adding IV potassium if too low, or filtering potassium with a dialysis machine if too high.
  • Hyper or Hypothermia- Extreme high or low body temperature, where the body can no longer carry out normal functioning, due to extremely hot or cold environment, fever, or brain damage.
    Reverse
    by returning the person’s body temperature to normal with temperature controlled IV fluids, heating/cooling blankets.
  • Hydrogen Ions- body becomes too acidic either due to respiratory changes (carbon dioxide is acidic) or metabolic changes.
    Reverse
    by giving drugs that change body pH.
  • Tension Pneumothorax- Air in the chest cavity puts pressure on the lungs to they can’t effectively expand. Leads to hypoxia.
    Reverse
    by relieving pressure in the chest with a chest tube/thoracostomy.
  • Tamponade (cardiac)- blood or other fluid builds up around the heart and puts pressure on it.
    Relieve by pericardiocentesis (sticking a needle into the sac around the heart to relieve the pressure).
  • Thrombosis- a blood clot to vessels supplying the heart with blood, killing heart muscle (heart attack).
    Reverse by getting blood to the dying portion of the heart with either a stent or by dissolving the clot with a drug called TPA.
  • Thromboembolism- Same as thrombosis, but in the lung, killing lung tissue.
    Reverse
    same as above, but more likely with the TPA.
  • Toxins- drug overdose or poisoning.
    Reverse
    by figuring out what drug it was, and if available, giving the antidote.

During the time it takes to do any of this, someone would be doing CPR and giving epinephrine every 3-5 minutes. You’re really just hoping a pulse comes back on its own before there’s too much brain damage, TBH.

But unfortunately, that’s the nice version of the answer. Because in real life, it is exceedingly rare to survive asystole, even in a hospital setting with a code team and a crash cart. But hey, you’re writing a story, and anything you want can happen.

Side note: I have personally seen asystole shocked in real life. It was actually more of a demonstration for all the residents and med students participating than an attempt to save the guy, because he’d been an unwitnessed arrest and they’d been coding him for about 25 minutes at that point. Obviously it didn’t work, but that would be a situation where you might see it done.

anonymous asked:

You've probably asked this before so feel free to link me if you want haha. Okay so I want to start T. I know it's something I need to do in order to live my life. BUT, im terrified of medicine. To the point where I live with crippling anxiety because i'm afraid of side effects of pills. I mean, when it's my time of month (ew) I don't even want to take midol because I hate being medicated. Do you have any advice for me? I know there's tons of long term side effects of T and i'm terrified of them

The long term “side effects” of testosterone are aspects of puberty that every male experiences. Beyond that, testosterone is completely safe. In a study done earlier this year of nearly 1,600 trans people (both trans men and trans women) it was noted that cross-sex hormone therapy is associated with low health risks, the worst of which being venous thromboembolism, occurring in just 1% of MTF patients. Testosterone is not associated with any health risks that cis men don’t experience. It doesn’t increase the rate of cancer, it doesn’t destroy your body, it’s not a steroid that damages you. It’s just a hormone and you’re only taking it in a dose that allows your body to masculinize and be healthy. The “long term effects” of testosterone are facial/body hair growth, a deep voice, genital growth, the cessation of menses, increased musculature, etc - all aspects of having a masculine body. You’ll also have an increased red blood cell count and higher cholesterol. But look, cis men have higher rates of cardiovascular issues purely for the same reason. It’s just considered an increase in us because we’re going from an estrogen-dominant system, which has lower rates of these illnesses, to a testosterone-dominant system. Our rates are no higher than a cis male.

Just as well, while testosterone is manufactured in clinic, it might help for you to realize that it’s made to be bio-identical to the testosterone already present within our bodies, meaning that on a chemical level the medication you are giving yourself has the exact same chemical structure (C19H28O2)  as the hormones already in your body. The only difference is injectable testosterone has an added chain on the chemical structure to make it last longer in your body (otherwise you’d be injecting every day) but this is broken down by the body and in no way compromises your health. Therefore all you’re doing it giving yourself what your body can’t create, not giving it some unknown substance. From an anecdotal standpoint, it might calm you to know that awhile back I posted about a man who had been on testosterone for 40 years who reported that he was completely healthy, aside from the typical health issues that everyone experiences as they age.

Warfarin  is an anticoagulant normally used in the prevention of thrombosis and thromboembolism, the formation of blood clots in the blood vessels and their migration elsewhere in the body respectively. It was initially introduced in 1948 as a pesticide against rats and mice and is still used for this purpos.  In the early 1950s, warfarin was found to be effective and relatively safe for preventing thrombosis and thromboembolism in many disorders. It was approved for use as a medication in 1954 and has remained popular ever since; warfarin is the most widely prescribed oral anticoagulant drug in North America.

Planning a Place of Birth

This is all according to one resource, the National Institute for Health and Care Excellence. If anyone (especially midwives) have any other information and good resources on home births and birthing facilities please let me know. I’ll post what the website has as well as what I’ve seen on other resources.

Everyone should be offered the choice of planning birth at home, in a midwife-led unit or in an obstetric unit. Everyone should be informed:

  • That giving birth is generally very safe for both the pregnant person and their baby. (650 people die from pregnancy related issues every year, about half of those giving birth each year have some sort of complication)
  • That the available information on planning place of birth is not of good quality, but suggests that among those who plan to give birth at home or in a midwife-led unit there is a higher likelihood of a natural birth, with less intervention. We do not have enough information about the possible risks relating to planned place of birth.
  • That the obstetric unit provides direct access to obstetricians, anaesthetists, neonatologists and other specialist care including epidural analgesia.
  • Depending on locally available services, the likelihood of being transferred into the obstetric unit and the time this may take. Take this into consideration.
  • That if something does go unexpectedly seriously wrong during labour at home or in a midwife-led unit, the outcome for could be worse than if they were in the obstetric unit with access to specialised care.
  • That if they have a pre-existing medical condition or has had a previous complicated birth that makes them at higher risk of developing complications during their next birth, they should be advised to give birth in an obstetric unit.

I know that a lot of birthing centers do make sure that you are as safe as possible and that if things do go wrong you are transferred to emergency care quickly.

Factors to consider when planning the place of birth

1. Medical conditions that may indicate a need for obstetric care.

These conditions include:

  • Confirmed cardiac disease
  • Hypertensive disorders 
  • Asthma requiring an increase in treatment or hospital treatment
  • Cystic fibrosis
  • Haemoglobinopathies – sickle-cell disease, beta-thalassaemia major
  • History of thromboembolic disorders
  • Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100,000
  • Von Willebrand’s disease
  • Bleeding disorder in the adult or unborn baby
  • Atypical antibodies which carry a risk of haemolytic disease of the newborn
  • Risk factors associated with group B streptococcus whereby antibiotics in labour would be recommended
  • Hepatitis B/C with abnormal liver function tests
  • Carrier of/infected with HIV
  • Toxoplasmosis – receiving treatment
  • Current active infection of chicken pox/rubella/genital herpes in the adult or baby
  • Tuberculosis under treatment
  • Systemic lupus erythematosus
  • Scleroderma
  • Hyperthyroidism
  • Diabetes
  • Abnormal renal function
  • Renal disease requiring supervision by a renal specialist
  • Epilepsy
  • Myasthenia gravis
  • Previous cerebrovascular accident
  • Liver disease associated with current abnormal liver function tests
  • Psychiatric disorder requiring current inpatient care

2. Other factors that may suggest needing obstetric care

Situations where there is an increased risk for parent or child:

  • Unexplained stillbirth/neonatal death or previous death related to intrapartum difficulty
  • Previous baby with neonatal encephalopathy
  • Pre-eclampsia requiring preterm birth
  • Placental abruption with adverse outcome
  • Eclampsia
  • Uterine rupture
  • Primary postpartum haemorrhage requiring additional treatment or blood transfusion
  • Retained placenta requiring manual removal in theatre
  • Caesarean section 
  • Shoulder dystocia
  • Multiple birth 
  • Placenta praevia
  • Pre-eclampsia or pregnancy-induced hypertension
  • Preterm labour or preterm prelabour rupture of membranes 
  • Placental abruption
  • Anaemia –- haemoglobin less than 8.5 g/dl at onset of labour
  • Confirmed intrauterine death
  • Induction of labour 
  • Substance misuse
  • Alcohol dependency requiring assessment or treatment
  • Onset of gestational diabetes 
  • Malpresentation – breech or transverse lie
  • Body mass index at booking of greater than 35 kg/m2
  • Recurrent antepartum haemorrhage
  • Small for gestational age in this pregnancy (less than fifth centile or reduced growth velocity on ultrasound)
  • Abnormal fetal heart rate (FHR)/Doppler studies
  • Ultrasound diagnosis of oligo-/polyhydramnios
  • Myomectomy
  • Hysterotomy

Now many health organizations, like the World Health Organization, say not to focus too much on high risk pregnancies as this causes many supposed “low risk” pregnancies to not get the level of care they need and also limits choices for “high risk” pregnancies that may be totally fine and not need obstetric care.

3. Medical Conditions that aren’t necessarily reasons to have obstetric care but may indicate further consideration

  • Cardiac disease without intrapartum implications
  • Atypical antibodies not putting the baby at risk of haemolytic disease
  • Sickle-cell trait
  • Thalassaemia trait
  • Anaemia – haemoglobin 8.5–10.5 g/dl at onset of labour
  • Hepatitis B/C with normal liver function tests
  • Non-specific connective tissue disorders
  • Unstable hypothyroidism such that a change in treatment is required
  • Spinal abnormalities
  • Previous fractured pelvis
  • Neurological deficits
  • Liver disease without current abnormal liver function
  • Crohn’s disease
  • Ulcerative colitis

4. Other factors that aren’t necessarily reasons to have obstetric care but may indicate further consideration

  • Stillbirth/neonatal death with a known non-recurrent cause
  • Pre-eclampsia developing at term
  • Placental abruption with good outcome
  • History of previous baby more than 4.5 kg
  • Extensive vaginal, cervical, or third- or fourth-degree perineal trauma
  • Previous term baby with jaundice requiring exchange transfusion
  • Antepartum bleeding of unknown origin (single episode after 24 weeks of gestation)
  • Body mass index at booking of 30–34 kg/m2
  • Blood pressure of 140 mmHg systolic or 90 mmHg diastolic on two occasions
  • Clinical or ultrasound suspicion of macrosomia
  • Para 6 or more
  • Recreational drug use
  • Under current outpatient psychiatric care
  • Age over 40 at booking
  • Fetal abnormality
  • Major gynaecological surgery
  • Cone biopsy or large loop excision of the transformation zone (LLETZ)
  • Fibroids

For more information on planning your place of birth, visit this post!

 got this mnemonic online and found it very helpful.

I added some more information to it, my theory being, if I forget one manifestation; I have another one for backup.

A PIE SAC

Arthritis, Ankylosing spondylitis

Pyoderma gangrenosum, Pyoderma vegetans, Perianal skin tags, Psoriasis, Pleuritis, Pericarditis, Pancreatitis

I for eye signs: Iritis, uveitis, episcleritis, conjunctivitis

Erythema nodosum

Sclerosing cholangitis, Sacroilitis

Aphthous ulcers

Clubbing of fingers, Cholelithiasis, renal Calculi

Other manifestations include thromboembolism, vitamin and calcium deficiency due to involvement of the ileum and myocarditis. 

How I remember pANCA is associated with ulcerative colitis: nUCLEAR is an anagram for ULCER so ulcerative colitis is associated with pANCA. 

Is it too much? xD

-IkaN

Routine Antenatal Care

According to Antenatal Care Guidelines developed by the National Institute for Health and care Excellence, here are the minimum set of tests for routine antenatal care:

First contact with health professional

  • Give specific information on folic acid supplements, food hygiene, healthy lifestyle, and all antenatal screening
  • offer information about screening for sickle cell diseases and thalassaemias.
  • Give information about the anomaly scan and let them know that this gives them a chance to terminate pregnancy, prepare for treatment or care of disability, manage the birth in a specialist center, and have intrauterine therapy. Inform them of the limitations of ultrasound screening and that the detection rates vary by the type of anomaly, pregnant person’s BMI, and the position of the fetus at the time of the scan.

At booking

  • Explain the development of pregnancy, nutrition and diet (including vitamin D supplements), exercising (including pelvic floor exercises)
  • start planning the place of birth
  • information about breastfeeding and workshops in the area
  • information on participant-led classes
  • information on maternity benefits.
  • Identify people who may need additional care and plan pattern of care for the pregnancy.
  • Measure blood pressure and test urine for proteinuria (pre-eclampsia)
  • Inform those under 25 of the high prevalence of chlamydia in their age group and give details about STI screening.
  • Offer early ultrasound scan for gestational age assessment and structural anomalies.
  • Ask about mental health, ask about mood to identify possible depression.
  • Ask about occupation to identify potential risks.
  • Haemoglobinopathies screen
  • Blood group and rhesus D status
  • Hepatitis B virus screen
  • HIV screen
  • Rubella susceptibility
  • Syphilis screen
  • MSU for asymptomatic bacteriuria
  • risk of venous thromboembolism evaluated (previous VTE, thrombophilia, medical comorbidities, surgical procedures such as appendicectomy, age about 35, BMI above 30kg/m, 3 or more children, smoker, varicose veins, systemic infection, immobility, pre-eclampsia, dehydration, etc.)
  • test for gestational diabetes if there is an identified risk (height, weight, family history, ethnic group, previous pregnancies, etc)
  • measure Height, weight, and body mass index and give health advice.

After 10 weeks 0 days

  • Before 13 weeks 6 days: ultrasound scan to determine gestational age
  • Before 14 weeks 1 day: Combined test for Down Syndrome

16 weeks

  • Review, discuss, and record the results of any screenings.
  • Measure blood pressure and test urine for proteinuria (pre-eclampsia)
  • investigate if haemoglobin level is below 11g/100ml and consider iron supplements.
  • Give information on the routine anomaly scan to take place at 18 weeks.
  • offer those with significantly atypical red-cell alloantibodies a referral to a specialist.

After 14 weeks 2 days

  • Before 20 weeks 0 days: Serum quadruple test for Down Syndrome

All appointments

  • blood pressure
  • urine test for proteinuria

At booking and 28 weeks

  • Haemoglobin
  • Red-cell alloantibodies

18 weeks

Before 20 weeks 6 days: ultrasound screen for structural anomalies including

  • fetal echocardiography of fetal heart
  • detection of neural tube defects

25 weeks

only needed if you’ve never been pregnant before to measure blood pressure/test urine and measure and plot symphysis-fundal height

28 weeks

  • measure blood pressure/test urine
  • offer a second screening for anaemia and atypical red-cell alloantibodies.
  • investigate a haemoglobin level below 10.5g/100ml and consider iron supplements
  • offer anti-D prophylaxis to people who are rhesus D-negative
  • measure and plot symphysis-fundal height.

31 weeks

Only needed if you’ve never been pregnant; review, discuss, and record the results of screening taken at 28 weeks, measure blood pressure/test urine, measure and plot symphysis-fundal height

34 weeks

  • Review, discuss, and record results of screening taken at 28 weeks
  • measure blood pressure/test urine
  • offer second dose of anti-D prophylaxis to those who are D-negative
  • measure and plot symphysis-fundal height
  • give specific information on preparation for labor and birth including the birth plan, recognizing labor, and coping with pain.
  • Give information about cesarean section including indications of a need for c-section, what the procedure involves, risks and benefits, and implications for future pregnancies after c-section.

36 weeks

Fetus is approximately full term.

38 weeks

  • measure blood pressure/test urine
  • measure and plot symphysis-fundal height
  • give options for management of prolonged pregnancy.

40 weeks

only necessary if this is your first pregnancy; measure blood pressure/test urine, measure and plot symphysis-fundal height, and further discussion of management of prolonged pregnancy.

41 weeks

  • offer membrane sweep
  • offer induction of labor
  • measure blood pressure/test urine
  • measure and plot symphysis-fundal height

42 weeks

  • from this point on offer those who decline induction of labor increased monitoring (at least twice-weekly)

People should be able to make an informed choice about whether to accept or decline each tests, and notes should include a record of any tests offered and declined as well as the results of tests accepted