Antenatal red flags: the ones the paper builds questions around

Antenatal questions in the DRCOG are rarely about what happens on the labour ward. They are about a pregnant woman in general practice with a symptom — and whether you recognise that this symptom, at this gestation, needs the maternity unit today. The single best answer is usually the right action at the right speed.

Bleeding

• Early pregnancy: pain and bleeding with a positive pregnancy test is an ectopic pregnancy until a scan says otherwise. Refer to the early pregnancy assessment service; shoulder-tip pain, collapse or peritonism is an emergency.
• Later pregnancy: painless bright red bleeding suggests placenta praevia; pain, a tense or tender uterus and fetal distress suggest abruption — and the visible bleeding can underestimate the loss. Both mean hospital now. No digital vaginal examination until a scan has excluded praevia.
• Rhesus-negative women need anti-D after potentially sensitising events, according to gestation.

Headache, visual symptoms, epigastric pain

After 20 weeks, a new headache, visual disturbance, epigastric or right upper quadrant pain, vomiting or sudden swelling is pre-eclampsia until proved otherwise. Check the blood pressure and the urine for protein, and arrange same-day assessment in the maternity unit. Severe hypertension is a blood pressure of 160/110 mmHg or higher. Pre-eclampsia can also present after the birth: a postnatal headache with a raised blood pressure is the same emergency.

Prevention is a GP question too. Women at high risk — for example, hypertensive disease in a previous pregnancy, chronic kidney disease, autoimmune disease such as lupus or antiphospholipid syndrome, diabetes or chronic hypertension — or with more than one moderate risk factor are advised by NICE NG133 to take aspirin 75–150 mg daily from 12 weeks until the birth.

Reduced fetal movements

A woman who reports reduced or changed fetal movements later in pregnancy should contact the maternity unit straight away and be assessed the same day — not at her next routine appointment, and never with advice to “wait and see if they pick up”. Recurrent episodes need further investigation.

Itching

Itching without a rash, often worst on the palms and soles, usually in the third trimester, is intrahepatic cholestasis of pregnancy until tests say otherwise. Check bile acids and liver function, and refer for obstetric review: the bile acid level guides the plan and the timing of birth. Current RCOG guidance no longer offers ursodeoxycholic acid to improve outcomes for the baby, though it may still be considered for troublesome itch.

Breathlessness, chest pain or a swollen leg

Pregnancy raises the risk of venous thromboembolism, and thrombosis and thromboembolism have for years been among the leading direct causes of maternal death in the UK. Keep the threshold for same-day assessment low. D-dimer is not used to diagnose VTE in pregnancy, and when VTE is suspected, low-molecular-weight heparin is started while it is being excluded.

Fever, infection and contacts

• Sepsis in pregnancy can progress quickly and present atypically. Use a maternity early warning score and a low threshold for same-day review.
• Pyelonephritis in pregnancy is usually managed in hospital.
• Chickenpox contact in a woman who is not immune: current UK guidance is oral antiviral prophylaxis — aciclovir or valaciclovir — from day 7 to day 14 after the exposure, rather than routine immunoglobulin. If her history of chickenpox is uncertain, check her immunity first.
• A rash illness, or contact with rubella, parvovirus B19 or measles, needs discussion and testing, because the risks depend on the gestation.

Results and findings that change the plan

• Gestational diabetes: women with risk factors are offered a glucose tolerance test at 24–28 weeks, and earlier testing or monitoring if they have had gestational diabetes before. Diagnose on a fasting glucose of 5.6 mmol/L or more, or a two-hour value of 7.8 mmol/L or more.
• Growth: symphysis–fundal height is measured and plotted from 24 weeks. A measurement below the expected range, or slow or static growth, goes for an ultrasound scan.
• Presentation: a breech presentation at 36 weeks means a discussion of external cephalic version.

The trap

Treating antenatal questions as obstetrics. The DRCOG is testing the GP’s part: recognition, the first action and the right referral — the same day, when it matters. “Reassure and review at the next antenatal appointment” is right far less often than it looks. The hypertension-in-pregnancy and early-pregnancy bleeding aids in DRCOG Core Tools drill the same decisions.

The one-line version

Gestation first, then the red flag, then the speed. Most antenatal answers are a same-day referral you must not talk yourself out of.

More DRCOG Core Wisdom →