Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) Antenatal Care and Maternal Medicine Syllabus

Antenatal Care and Maternal Medicine syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Antenatal Care and Maternal Medicine in Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG), not a summary of it.

1. 1

   Pre-pregnancy and Routine Antenatal Care

   5 topics

   • Preconception counselling and optimisation
   • Booking assessment and risk stratification
   • Schedule of antenatal visits and investigations
   • Lifestyle, nutrition and supplementation in pregnancy
   • Immunisation and infection screening in pregnancy
2. 2

   Prenatal Screening and Diagnosis

   4 topics

   • Aneuploidy screening
     • Combined and quadruple tests
     • Non-invasive prenatal testing (cffDNA)
   • Invasive diagnostic procedures
     • Chorionic villus sampling and amniocentesis
   • Fetal anomaly ultrasound screening
   • Counselling for abnormal results and termination for fetal anomaly
3. 3

   Medical Disorders in Pregnancy

   6 topics

   • Hypertensive disorders
     • Chronic and gestational hypertension
     • Pre-eclampsia, eclampsia and HELLP syndrome
   • Diabetes in pregnancy
     • Pre-existing diabetes management
     • Gestational diabetes screening and treatment
   • Cardiac, respiratory and renal disease
   • Thyroid and other endocrine disorders
   • Haematological disorders
     • Anaemia and haemoglobinopathies
     • Venous thromboembolism and thrombophilia
   • Neurological, autoimmune and connective tissue disease
4. 4

   Infections in Pregnancy

   4 topics

   • Viral infections
     • Rubella, CMV, parvovirus and varicella
     • HIV, hepatitis B and C
   • Bacterial and parasitic infections
     • Group B streptococcus and syphilis
     • Toxoplasmosis and listeriosis
   • Genital tract and urinary infections
   • Sepsis recognition and management in pregnancy
5. 5

   Fetal Wellbeing and Complications

   5 topics

   • Fetal growth restriction and surveillance
     • Growth charts and customised growth assessment
     • Doppler velocimetry interpretation
   • Rhesus isoimmunisation and fetal anaemia
   • Multiple pregnancy and its complications
     • Chorionicity and twin-twin transfusion syndrome
   • Reduced fetal movements and stillbirth
   • Amniotic fluid abnormalities

Antenatal Care and Maternal Medicine flashcards for Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG)

23 of 75 cards from the Antenatal Care and Maternal Medicine deck — real questions with worked answers.

1. What dose of folic acid is recommended preconceptionally and until 12 weeks for low-risk women, and what dose for high-risk women (e.g. previous NTD, diabetes, BMI >30, antiepileptics)?

   Low-risk: $400\ \mu g$ daily. High-risk: $5\ mg$ daily, started ideally before conception and continued to the end of the first trimester.

2. In preconception counselling of a woman with type 1 or type 2 diabetes, what HbA1c target should be achieved before pregnancy, and above what level is pregnancy strongly advised against?

   Aim for HbA1c $<48\ mmol/mol$ ($6.5\%$) if safely achievable. Advise against pregnancy if HbA1c $>86\ mmol/mol$ ($10\%$) due to high risk of congenital malformation and miscarriage.

3. Name the key antiepileptic drug most teratogenic in pregnancy and the malformation risk, and the preferred safer alternatives.

   Sodium valproate carries the highest risk (neural tube defects, ~$10\%$ major malformation, neurodevelopmental harm) and is contraindicated. Lamotrigine and levetiracetam are preferred lower-risk alternatives.

4. At the antenatal booking visit, by what gestation should it ideally be completed and what are the core blood tests offered?

   Ideally by 10 weeks. Core bloods: FBC, blood group and antibody screen (Rhesus status), haemoglobinopathy screen, HIV, hepatitis B, syphilis serology, plus MSU and rubella susceptibility historically (rubella no longer routinely offered in UK).

5. How many routine antenatal appointments are recommended for a nulliparous woman with an uncomplicated pregnancy versus a parous woman, per NICE?

   Nulliparous: 10 appointments. Parous (multiparous) with uncomplicated pregnancy: 7 appointments.

6. At which gestations are the two routine ultrasound scans offered in UK antenatal care, and what is each for?

   Dating/combined screening scan at $11^{+2}$ to $14^{+1}$ weeks (crown-rump length dating + nuchal translucency). Fetal anomaly scan at $18^{+0}$ to $20^{+6}$ weeks.

7. When is the oral glucose tolerance test offered to women with risk factors for gestational diabetes, and earlier if previous GDM?

   OGTT at 24–28 weeks for women with risk factors. If previous GDM, offer early self-monitoring or OGTT soon after booking, and a further OGTT at 24–28 weeks if the first is normal.

8. State the daily vitamin D supplementation recommended in pregnancy and the higher dose for women at increased deficiency risk.

   All pregnant women: $10\ \mu g$ ($400\ IU$) daily. Women at high risk (e.g. darker skin, limited sun exposure, BMI $>30$): consider higher dose, often $1000\ IU$ daily.

9. Which vitamin should pregnant women specifically avoid in high doses and why?

   Vitamin A (retinol) in high doses is teratogenic; avoid supplements containing it and liver/liver products. Limit to $<700\ \mu g/day$.

10. What is the recommended weekly limit and approach to alcohol and caffeine in pregnancy per UK guidance?

    Alcohol: safest to avoid entirely, especially in the first trimester. Caffeine: limit to $<200\ mg/day$ (about two mugs of instant coffee).

11. Which two vaccines are routinely recommended to all pregnant women in the UK, and at what gestation is each given?

    Pertussis (whooping cough)-containing vaccine from 16 weeks (optimally 16–32). Inactivated influenza vaccine at any stage during flu season. (RSV vaccine now also offered from 28 weeks.)

12. Why are live attenuated vaccines (e.g. MMR, varicella, yellow fever) contraindicated in pregnancy, and when should rubella-susceptible women be vaccinated?

    Live vaccines pose a theoretical risk of fetal infection. Rubella-susceptible women should be vaccinated postpartum (and avoid pregnancy for 1 month after MMR).

13. In combined first-trimester aneuploidy screening, which markers are combined, and what is the screen-positive threshold for Down syndrome?

    Maternal age + nuchal translucency + serum free $\beta$-hCG + PAPP-A. Screen-positive (higher-chance) result is a risk $\geq 1\ in\ 150$.

14. In trisomy 21 (Down syndrome), how do serum PAPP-A, free $\beta$-hCG and nuchal translucency typically change?

    PAPP-A decreased (low), free $\beta$-hCG increased (high), nuchal translucency increased (thickened).

15. What is the quadruple test, when is it used, and which analytes are measured?

    Second-trimester serum screen offered at 14–20 weeks when first-trimester combined screening is missed. Measures AFP, unconjugated estriol (uE3), total hCG and inhibin A.

16. What does cell-free DNA (NIPT) analyse, what is its approximate detection rate for trisomy 21, and what is a key limitation?

    Analyses cell-free fetal (placental) DNA in maternal blood; detection rate for trisomy 21 ~$99\%$ with low false-positive rate. Limitation: it is a screening, not diagnostic test, so positives require confirmatory invasive testing; can fail with low fetal fraction.

17. Compare chorionic villus sampling and amniocentesis regarding timing and procedure-related miscarriage risk.

    CVS: from 11 weeks (placental tissue, transabdominal/transcervical). Amniocentesis: from 15 weeks (amniotic fluid). Procedure-related miscarriage risk is approximately $0.5\%$ (roughly $1\ in\ 200$) for each, similar in current data.

18. What anti-D prophylaxis is required after an invasive procedure such as amniocentesis or CVS in a Rhesus-negative woman?

    Give anti-D immunoglobulin (at least $250\ IU$ before 20 weeks, $500\ IU$ after) to all non-sensitised RhD-negative women following any invasive procedure, as it is a potentially sensitising event.

19. List the 11 conditions screened for in the UK Fetal Anomaly Screening Programme 20-week scan.

    Anencephaly, open spina bifida, cleft lip, diaphragmatic hernia, gastroschisis, exomphalos, serious cardiac anomalies, bilateral renal agenesis, lethal skeletal dysplasia, Edwards syndrome (T18) and Patau syndrome (T13).

20. Up to what gestation can a termination be performed under Ground E of the UK Abortion Act, and what does Ground E specify?

    Ground E has no upper gestational limit. It permits termination where there is substantial risk that the child would be seriously physically or mentally handicapped.

21. What method of feticide is used before late termination for fetal anomaly (after ~22 weeks) and why?

    Intracardiac or intrafunic potassium chloride (KCl) injection to ensure the fetus is not born alive, recommended for terminations performed at or beyond 21–22 weeks gestation.

22. Define gestational hypertension, chronic hypertension and pre-eclampsia.

    Gestational hypertension: new hypertension ($\geq 140/90$) after 20 weeks without proteinuria/features. Chronic hypertension: hypertension before 20 weeks or pre-pregnancy. Pre-eclampsia: new hypertension after 20 weeks PLUS proteinuria or maternal organ/uteroplacental dysfunction.

23. State the blood pressure threshold defining severe hypertension in pregnancy and the BP treatment targets in pregnancy.

    Severe hypertension: $\geq 160/110\ mmHg$. Target with treatment: aim for BP $\leq 135/85\ mmHg$.

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