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Reproductive Health (Y4) > 8- Complicated pregnancy (abnormal development) > Flashcards

8- Complicated pregnancy (abnormal development) Flashcards

1
Q

define small for gestational age

A

Small for gestational age is defined as a fetus that measures below the 10th centile for their gestational age.

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2
Q

Severe SGA is when the fetus is below the …….. for their gestational age

A

3rd centile

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3
Q

Low birth weight is defined as a birth weight of less than

A

2500g

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4
Q

causes of SGA is divided into 2 categories

A
  • Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart
  • Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR)
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5
Q

what is fetal growth restriction (also known as intrauterine growth restriction)

A

there is a small fetus (or a fetus that is not growing as expected) due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta.

A growth restricted fetus is one that has failed to reach its genetic growth potential
***

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6
Q

The causes of fetal growth restriction can be divided into two categories:

A
  • Placenta mediated growth restriction
  • Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality
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7
Q

placenta mediated growth restriction

A

refers to conditions that affect the transfer of nutrients across the placenta:

  • Idiopathic
  • Pre-eclampsia
  • Maternal smoking
  • Maternal alcohol
  • Anaemia
  • Malnutrition
  • Infection
  • Maternal health conditions
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8
Q

Non-placenta medicated growth restriction refers to pathology of the fetus, such as:

A
  • Genetic abnormalities
  • Structural abnormalities
  • Fetal infection
  • Errors of metabolism
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9
Q

There may be other signs that would indicate FGR other than the fetus being SGA, such as:

A
  • Reduced amniotic fluid volume
  • Abnormal Doppler studies
  • Reduced fetal movements
  • Abnormal CTGs

Reduced amniotic fluid volume
Abnormal Doppler studies
Reduced fetal mov

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10
Q

short term complications of fetal growth restriction

A
  • Fetal death or stillbirth
  • Birth asphyxia
  • Neonatal hypothermia
  • Neonatal hypoglycaemia
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11
Q

long terms complications of fetal growth restriction

A
  • Cardiovascular disease, particularly hypertension
  • Type 2 diabetes
  • Obesity
  • Mood and behavioural problems
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12
Q

SGA risk factors

A
  • Previous SGA baby
  • Obesity
  • Smoking
  • Diabetes
  • Existing hypertension
  • Pre-eclampsia
  • Older mother (over 35 years)
  • Multiple pregnancy
  • Low pregnancy‑associated plasma protein‑A (PAPPA)
  • Antepartum haemorrhage
  • Antiphospholipid syndrome
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13
Q

monitoring for women at low risk of having SGA

A

1) Maternal monitoring
- Assess for any modifiable factors (smoking)
- Assess for presence of maternal disease
- Continue monitoring for pre-eclampsia, with blood pressure and urine checks, in regular intervals

2) Fetal surveillance
- Serial growth measurements (every 2-4 weeks)
- Fetal wellbeing surveillance
- Maternal perception of fetal movements
- Fetal Doppler (umbilica, MCA and venous)
- Amniotic volume measurements
- Biophysical profile

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14
Q

monitoring for women at risk or with SGA

A

serial USS

  • Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity
  • Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery
  • Amniotic fluid volume
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15
Q

When a fetus is identified as SGA, investigations to identify the underlying cause include:

A
  • Blood pressure and urine dipstick for pre-eclampsia
  • Uterine artery doppler scanning
  • Detailed fetal anatomy scan by fetal medicine
  • Karyotyping for chromosomal abnormalities
  • Testing for infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria)
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16
Q

critical management steps for SGA

A
  • Identifying those at risk of SGA
  • Aspirin is given to those at risk of pre-eclampsia
  • Treating modifiable risk factors (e.g. stop smoking)
  • Serial growth scans to monitor growth
  • Early delivery where growth is static, or there are other concerns
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17
Q

when is early delivery considered in SGA

A

when growth is static on the growth charts, or other problems are identified (e.g. abnormal Doppler results)

  • This reduces the risk of stillbirth.
  • Corticosteroids are given when delivery is planned early, particularly when delivered by caesarean section.
  • Paediatricians should be involved at birth to help with neonatal resuscitation and management if required.
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18
Q

Babies are defined as being large for gestational age (also known as macrosomia) when the weight of the newborn is more than …..kg at birth.

A

4.5kg

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19
Q

During pregnancy, an estimated fetal weight above the …….. centile is considered large for gestational age.

A

90th

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20
Q

Causes of Macrosomia

A
  • Constitutional
  • Maternal diabetes
  • Previous macrosomia
  • Maternal obesity or rapid weight gain
  • Overdue
  • Male baby
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21
Q

risks of macrosomnia to mother

A
  • Shoulder dystocia
  • Failure to progress
  • Perineal tears
  • Instrumental delivery or caesarean
  • Postpartum haemorrhage
  • Uterine rupture (rare)
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22
Q

risks of macrosomnia to baby

A
  • Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
  • Neonatal hypoglycaemia
  • Obesity in childhood and later life
  • Type 2 diabetes in adulthood
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23
Q

Investigations for a large for gestational age baby are:

A
  • Ultrasound to exclude polyhydramnios and estimate the fetal weight
  • US also to ensure the pregnancy has been accurately dated
  • Oral glucose tolerance test for gestational diabetes
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24
Q

The main risk with a large for gestational age baby is

A

shoulder dystocia.

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25
Q

The risks at delivery of a macrosonmic baby can be reduced by:

A
  • Delivery on a consultant lead unit
  • Delivery by an experienced midwife or obstetrician
  • Access to an obstetrician and theatre if required
  • Active management of the third stage (delivery of the placenta)
  • Early decision for caesarean section if required
  • Paediatrician attending the birth
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26
Q

Multiple pregnancy

A

Multiple pregnancy refers to a pregnancy with more than one fetus. The incidence of multiple pregnancies increased with the development of fertility treatment.

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27
Q

types of multiple pregnancies

A
  • Monozygotic: identical twins (from a single zygote)
  • Dizygotic: non-identical (from two different zygotes)
  • Monoamniotic: single amniotic sac
  • Diamniotic: two separate amniotic sacs
  • Monochorionic: share a single placenta
  • Dichorionic: two separate placentas
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28
Q

which type of multiple pregnancy has the best outcomes

A

diazygotic , dichorionic twin pregnancies, as each fetus has their own nutrient supply.

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29
Q

diagnosing mulitple pregnancies

A

usually diagnosed on the booking ultrasound scan. Ultrasound is also used to determine the:

  • Gestational age
  • Number of placentas (chorionicity) and amniotic sacs (amnionicity)
  • Risk of Down’s syndrome (as part of the combined test)
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30
Q

When determining the type of twins using an ultrasound scan:

A
  • Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign
  • Monochorionic diamniotic twins have a membrane between the twins, with a T sign
  • Monochorionic monoamniotic twins have no membrane separating the twins
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31
Q

dichorionic diamniotic twins sign on USS

A

lambda sign

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32
Q

monochorionic diamniotic twins on US

A

T signs

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33
Q

monochorionic monoamniotic twins on US

A

have no membrane separating the twins

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34
Q

The lambda sign

A

or twin peak sign, refers to a triangular appearance where the membrane between the twins meets the chorion, as the chorion blends partially into the membrane. This indicates a dichorionic twin pregnancy (separate placentas).

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35
Q

T sign

A

refers to where the membrane between the twins abruptly meets the chorion, giving a T appearance. This indicates a monochorionic twin pregnancy (single placenta).

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36
Q

complications of multiple pregnancies: risks to mother

A

Risks to the mother:

  • Anaemia
  • Polyhydramnios
  • Hypertension
  • Malpresentation
  • Spontaneous preterm birth
  • Instrumental delivery or caesarean
  • Postpartum haemorrhage
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37
Q

complications of multiple pregnancies: risks to baby

A
  • Miscarriage
  • Stillbirth
  • Fetal growth restriction
  • Prematurity
  • Twin-twin transfusion syndrome
  • Twin anaemia polycythaemia sequence
  • Congenital abnormalities
38
Q

Twin-Twin Transfusion Syndrome

A

Twin-twin transfusion syndrome occurs when the fetuses share a placenta. It is called feto-fetal transfusion syndrome in pregnancies with more than two fetuses.

When there is a connection between the blood supplies of the two fetuses, one fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood. The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. The donor has growth restriction, anaemia and oligohydramnios. There will be a discrepancy between the size of the fetuses.

39
Q

management of twin-twin transfusion syndrome

A

Women with twin-twin transfusion syndrome need to be referred to a tertiary specialist fetal medicine centre. In severe cases, laser treatment may be used to destroy the connection between the two blood supplies.

40
Q

Twin Anaemia Polycythaemia Sequence

A

Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute. One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).

41
Q

antenatal care of multiple pregnancies

A
  • specialist management by multiple pregnancy obstetric team
  • Additional montioring for anaemia (booking, 20 weeks, 28 weeks)
  • Additional US (fetal growth restirction, unequal growth and twin-twin transfusion sydrome
  • Planned birth offered
42
Q

planned birth in multiple pregnnacy offered between

A
  • 32 and 33 + 6 weeks for uncomplicated monochorionic monoamniotic twins
  • 36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins
  • 37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins
  • Before 35 + 6 weeks for triplets
43
Q

why early delivery in multiple pregnancies

A

Increased risk of fetal death.

The timing of birth when there are complications is assessed on an individual basis. Corticosteroids are given before delivery to help mature the lungs.

44
Q

how should monoamniotics twins be delivered

A

elective caesarean section at between 32 and 33 + 6 weeks.

45
Q

how should diamniotic twins be born

A

(aim to deliver between 37 and 37 + 6 weeks):

  • Vaginal delivery is possible when the first baby has a cephalic presentation (head first)
  • Caesarean section may be required for the second baby after successful birth of the first baby
  • Elective caesarean is advised when the presenting twin is not cephalic presentation
46
Q

define stillbirth

A

the birth of a dead fetus after 24 weeks gestation.

47
Q

still birth is the result of

A

intrauterine fetal death (IUFD).

48
Q

causes of intrauterine fetal death

A
  • Unexplained (around 50%)
  • Pre-eclampsia
  • Placental abruption
  • Vasa praevia
  • Cord prolapse or wrapped around the fetal neck
  • Obstetric cholestasis
  • Diabetes
  • Thyroid disease
  • Infections, such as rubella, parvovirus and listeria
  • Genetic abnormalities or congenital malformations
49
Q

risk factors for intrauterine fetal death

A
  • Fetal growth restriction
  • Smoking
  • Alcohol
  • Increased maternal age
  • Maternal obesity
  • Twins
  • Sleeping on the back (as opposed to either side)
50
Q

prevention of intrauterine fetal death

A

Fetal growth restirtion
- risk assessment
- closely monitored with serial growth scan

Pre-eclamosia
- given aspirin

Modifiable risk factors stopped
- smoking
- alcohol
- effective control of diabetes
- sleeping on the side

51
Q

There are three key symptoms to always ask during pregnancy. Women would report these immediately if they occur:

A
  • Reduced fetal movements
  • Abdominal pain
  • Vaginal bleeding
52
Q

how is intrauterine fetal death (IUFD) diagnosed

A

Ultrasound scan used to visualise the fetal heartbeat to confirm the fetus is still alive.

53
Q

what may be experienced by mother after IUFD

A

Passive fetal movements are possible after IUFD, and a repeat scan is offered to confirm the situation.

54
Q

what other precautions should be taken in women with IUFD

A

Rhesus-D negative women require anti-D prophylaxis when IUFD is diagnosed. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.

55
Q

delivery after diagnosis of intrauterine fetal death (IUFD)

A

First line: vaginal
Can choose if want:
- induction
- expectant management (waiting for natural labour)

56
Q

induction of labour due to IUFD

A

involves using a combination of oral mifepristone (anti-progesterone) and vaginal or oral misoprostol (prostaglandin analogue).

57
Q

Dopamine agonists (e.g. cabergoline) can be used to suppress

A

lactation after stillbirth.

58
Q

testing is carried out after stillbirth to determine the cause:

A
  • Genetic testing of the fetus and placenta
  • Postmortem examination of the fetus (including xrays)
  • Testing for maternal and fetal infection
  • Testing the mother for conditions associated with stillbirth, such as diabetes, thyroid disease and thrombophilia
59
Q

oligohydramnios

A

refers to a low level of amniotic fluid during pregnancy

  • amniotic fluid index that is below the 5th centile for the gestational age, and is thought to affect approximately 4.5% of term pregnancies
60
Q

pattern of amniotic fluid volumes

A

1) volume of amniotic fluid increases steadily up untill 33 weeks
2) plateaus from 33-38 weeks
3) then declines
4) volume of amniotic fluid at term approx 500ml

61
Q

what comprises amnitoitc fluid

A

fetal urine output, with small contributions from the placenta and some fetal secretions (e.g. respiratory).

62
Q

pathophysiology behind oligohydramnios

A

The fetus breathes and swallows the amniotic fluid. It gets processed, fills the bladder and is voided, and the cycle repeats. Problems with any of the structures in this pathway can lead to either too much or too little fluid.

Anything that reduces the production of urine, blocks output from the fetus, or a rupture of the membranes (allowing amniotic fluid to leak) can lead to oligohydramnios.

63
Q

causes of oligohydramnios

A
  • Preterm prelabour rupture of membranes
  • Placental insufficiency – resulting in the blood flow being redistributed to the fetal brain rather than the abdomen and kidneys. This causes poor urine output.
  • Renal agenesis (known as Potter’s syndrome)
  • Non-functioning fetal kidneys, e.g. bilateral multicystic dysplastic kidneys
  • Obstructive uropathy
  • Genetic/chromosomal anomalies
  • Viral infections (although may also cause polyhydramnios)
64
Q

diagnosing oligohydramnios

A

made via ultrasound examination. There are two ways of measuring amniotic fluid; amniotic fluid index (AFI) or maximum pool depth (MPD). They have similar diagnostic accuracy, however AFI is more commonly used.

1) Amniotic fluid index is calculated by measuring maximum cord-free vertical pocket of fluid in four quadrants of the uterus and adding them together.
2) Maximum pool depth is the vertical measurement in any area.

65
Q

clinical assessment for patient with oligohyramnios

A

History
- Inquire about symptoms of leaking fluid and feeling damp all the time (often described as new urinary incontinence).
Examination
- Measure the symphysis fundal height.
- Perform a speculum examination (can a ‘pool’ of liquor be seen in the vagina?).
Ultrasound
- Assess for liquor volume, structural abnormalities, renal agenesis and obstructive uropathy.
- Measure fetal size. Small babies can result from placental insufficiency, which also causes oligohydramnios. There may also be a rise in pulsatility index of the umbilical artery Doppler in placental insufficiency.
Karyotyping (if appropriate) – particularly in cases of early and unexplained oligohydramnios.

66
Q

When considering ruptured membranes as a cause for oligohydramnios, a bedside test can be performed to detect the presence of

A

IGFBP-1 (insulin-like growth factor binding protein-1) or PAMG-1 (placental alpha-microglobulin-1) in the vagina. These proteins are found in amniotic fluid, and if detected, strongly suggest membrane rupture.

67
Q

the two most common causes of oligohydramnios

A

are rupture of the membranes and placental insufficiency

68
Q

management of ruptuered membranes

A

If oligohydramnios is due to ruptured membranes, labour is likely to commence within 24-48 hours in most pregnancies.

In cases of preterm rupture of membranes (i.e. before 37 weeks’ gestation), and where labour doesn’t start automatically, induction of labour should be considered around 34-36 weeks (in the absence of infection).

A course of steroids should be given to aid fetal lung development, and antibiotics to reduce the risk of ascending infection.

Magnesium sulfate to protect neural development

69
Q

management of plcaental insufficiency

A

In women where oligohydramnios is caused by placental insufficiency, the timing of delivery depends on a number of factors:

  • Rate of fetal growth
  • Umbilical artery and middle cerebral artery Doppler scans
  • Cardiotocography
    These babies are likely to be delivered before 36-37 weeks.
70
Q

the effect of oligohydramnios on the fetus

A
  • Amniotic fluid also allows the fetus move its limbs in utero (exercise). Without this, the fetus can develop severe muscle contractures – which may lead to disability despite physiotherapy after birth.
  • Premature delivery
  • Early delivery :pulmonary hypoplasia.
70
Q

the effect of oligohydramnios on the fetus

A
  • Amniotic fluid also allows the fetus move its limbs in utero (exercise). Without this, the fetus can develop severe muscle contractures – which may lead to disability despite physiotherapy after birth.
  • Premature delivery
  • Early delivery :pulmonary hypoplasia.
71
Q

Polyhydramnios

A

refers to an abnormally large level of amniotic fluid during pregnancy.

It is defined by an amniotic fluid index that is above the 95th centile for gestational age.

72
Q

Pathophysiology of polyhydramnios

A

The volume of amniotic fluid increases steadily until 33 weeks of gestation. It plateaus from 33-38 weeks, and then declines – with the volume of amniotic fluid at term approximately 500ml.

It is predominantly comprised of the fetal urine output, with small contributions from the placenta and some fetal secretions (e.g. respiratory, oral).

The fetus breathes and swallows the amniotic fluid. It gets processed, fills the bladder and is voided, and the cycle repeats. Problems with any of the structures in this pathway can lead to either too much or too little fluid.

73
Q

causes of polyhydramnios

A
  • idiopathic 50-60%
  • Any condition that prevents the fetus from swallowing – e.g. oesophageal atresia, CNS abnormalities, muscular dystrophies, congenital diaphragmatic hernia obstructing the oesophagus
  • Duodenal atresia – ‘double bubble’ sign on ultrasound scan
  • Anaemia – alloimmune disorders, viral infections
  • Fetal hydrops
  • Twin-to-twin transfusion syndrome
  • Increased lung secretions – cystic adenomatoid malformation of lung
  • Genetic or chromosomal abnormalities
  • Maternal diabetes – especially if poorly controlled
  • Maternal ingestion of lithium – leads to fetal diabetes insipidus
  • Macrosomia – larger babies produce more urine.
74
Q

Diagnosis of Polyhydramnios

A

same as oligohydramnios

75
Q

clinical assessment for polyhydramnios

A

Examination
- Palpate the uterus – does it feel tense?
Ultrasound
- Repeat measurement of liquor volume
- Assess fetal size
- Assess fetal anatomy to detect any structural causes
- Doppler – to detect fetal anaemia
Maternal glucose tolerance test – for maternal diabetes
Karyotyping (if appropriate) – especially if other structural abnormalities are detected, or if the fetus is small.
Viral screens
Some viral infections can cause polyhydramnios. Therefore, a TORCH (Toxoplasmosis, Other (Parvovirus), Rubella, Cytomegalovirus, Hepatitis) screen should be undertaken. Maternal red cell antibodies should also be checked; in the UK this is performed routinely at 28 weeks for all pregnancies.

76
Q

management of polyhydramnios

A
  • majority require no intervention
    -if symptoms of maternal breathlessness -> aminoreduction
  • indomethacin can be used to enhance waster retention
  • if idiopathic- baby must be examined by paediatrician before first feed (NG tube passed to ensure no tracheoesophageal fistual or atresia)
77
Q

management of polyhydramnios

A
  • majority require no intervention
    -if symptoms of maternal breathlessness -> aminoreduction
  • indomethacin can be used to enhance waster retention
  • if idiopathic- baby must be examined by paediatrician before first feed (NG tube passed to ensure no tracheoesophageal fistual or atresia)
78
Q

aminoreduction asscoiated with

A

It is associated with infection and placental abruption (due to a sudden decrease in intrauterine pressure), and is therefore not performed routinely.

79
Q

indomethacin

A

can be used to enhance water retention, and thus reduces fetal urine output. It is associated with premature closure of the ductus arteriosus and therefore should not be used beyond 32 weeks.

80
Q

prognosis of polyhydramnios

A

1) Severe and persistently unexplained polyhydramnios is associated with increased perinatal mortality. This is largely due to two factors:

2) The likely presence of an underlying abnormality or congenital malformation.
The increased incidence of preterm labour (due to over-distension of the uterus).

3) Malpresentation (baby more space to float around)
4) higher incidence of postpartum haemorrhage

81
Q

fetal movements are generally perceived by

A

16-24 weeks of gestation. Multiparous women may notice movements earlier (16 weeks); primiparous women later (20-24 weeks).

82
Q

pattern of movement throughout pregnancy

A

From 16-24 weeks onwards, a pregnant woman should feel the baby move more and more up until 32 weeks, then stay roughly the same until she gives birth. The mother should CONTINUE to feel her baby move right up to the time she goes into labour and fetal movements may continue to be perceived whilst she is in labour too.

83
Q

reduced fetal movement is a marker for

A

fetal compromise, this is thought to represent a fetal response to chronic hypoxia by conserving energy, with the subsequent reduction of fetal movements is an adaptive mechanism to reduce oxygen consumption
- Between 40-55% women with stillbirth experience RFM prior to diagnosis of intrauterine fetal death

84
Q

RFM is defined as

A

maternal perception of reduced or absent fetal movements

84
Q

RFM is defined as

A

maternal perception of reduced or absent fetal movements

85
Q

Multiple factors can decrease perception of movement, including

A

early gestation, a reduced volume of amniotic fluid, fetal sleep state, obesity, anterior placenta (up to 28 weeks gestation), smoking and nulliparity.

86
Q

causes of reduced fetal movement

A
  • baby is asleep
  • after intercourse
  • less room in womb
  • babys head engages in pelvic
  • low or high amniotic fluid
  • fetal distress
87
Q

how is fetal growth assessed in the antenatal period

A

usually after 24 weeks serial measurments are taken and blotted on graph

1) Symphysis-fundal height measurement using a measuring tape

2) Ultrasound assessment

88
Q

syphysis-fundal height measurement

A
89
Q

US assessment: key anthropometric measurements

A
  • Head circumference (and Biparietal diameter)
  • Abdominal Circumference
  • Femur length

Reproductive Health (Y4) (34 decks)

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