Routine antenatal care and risk assessment — structured SAQ (15 marks)

(a) Schedule of contacts (2 marks)

One mark for the correct schedule, one for naming the guideline. ^[5]

• As a parous woman she should be offered seven antenatal contacts (NICE NG201): booking, 16, 28, 31, 34, 36 and 40 weeks. (Nulliparous women get ten.)^[5]
• Booking should have occurred by 10 weeks; at 11 weeks she is only just in window, which limits first-trimester combined screening timing.^[5]

(b) Preventive and prophylactic package (5 marks)

One mark per correctly dosed intervention. Marks are lost for "give aspirin" with no dose or timing. ^[1][2]

• Low-dose aspirin 75 to 150 mg daily — she has two high-risk factors (previous pre-eclampsia, BMI over 30); start now (before 16 weeks is ideal; she is 11 weeks). Aspirin at least 100 mg started at or before 16 weeks reduces preterm pre-eclampsia (relative risk 0.62).^[2]
• Folic acid — 400 micrograms daily is standard; given her risk factors there is an argument for 5 mg if there were a previous neural tube defect (there is not), so 400 micrograms to at least 12 weeks, ideally started preconception.^[1]
• Iodine 150 micrograms daily through pregnancy, where intake is inadequate.^[5]
• Pertussis (dTpa) between 20 and 32 weeks in this pregnancy, to protect the infant.^[3]
• Influenza vaccine at any gestation during flu season.^[5]
• Antenatal anti-D prophylaxis — RhD-negative, no antibodies, so offer routine prophylaxis at 28 and 34 weeks (or a single larger dose), plus additional doses for sensitising events.^[5]
• Smoking cessation support — behavioural intervention and, where appropriate, nicotine replacement therapy; smoking is a modifiable risk factor for fetal growth restriction and stillbirth.^[5]

(c) The 31-week contact (4 marks)

One mark for recognising the two abnormalities, one for the assessment plan, one for the action, one for naming the principle. ^[5]

• Two abnormalities: a new blood pressure of 142/92 mmHg with proteinuria (possible pre-eclampsia) and a fundal height below the 10th centile (possible fetal growth restriction).^[5]
• Immediate assessment: repeat the blood pressure, send a midstream urine for protein-to-creatinine ratio or 24-hour protein, bloods (FBC, U&E, LFTs), and arrange a growth ultrasound with umbilical artery Doppler.^[5]
• Action: assess for pre-eclampsia formally and arrange fetal surveillance; she has moved off the low-risk pathway and now needs a management plan and senior review.^[5]
• Principle: every routine contact is a fresh risk assessment — risk status expires between visits, and the woman leaving the low-risk pathway is one contact is designed to catch. This contact is the safety-net working as intended.^[5]

(d) Reduced fetal movements (4 marks)

One mark for taking it seriously, one for the assessment, one for the action, one for the evidence. ^[4]

• Take it seriously. Reduced fetal movements are never dismissed; a woman reporting change is assessed the same day.^[4]
• Assessment: focused history (onset, perception, any trauma or bleeding), auscultation and a cardiotocograph, and a growth scan with Doppler given her other findings.^[4]
• Action: if the CTG and Doppler are normal, reassure and give a clear safety-net for when to return; if abnormal, escalate to delivery planning. Document the discussion.^[4]
• Evidence: the AFFIRM stepped-wedge cluster trial tested a package of fetal-movement awareness plus a standardised care bundle and did not significantly reduce stillbirth overall — but it reaffirmed the principle that reduced fetal movements must always be acted upon, because the cost of dismissal is the stillbirth you can never undo.^[4]