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Yr 4 - GOSH > Antenatal Care: Small & Large for Gestational Age, Multiple Pregnancy > Flashcards

Antenatal Care: Small & Large for Gestational Age, Multiple Pregnancy Flashcards

1
Q

Define small for gestational age (SGA)

A

A fetus that measures below the 10th centile for their gestational age

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2
Q

What 2 measurements are used to assess the fetal size?

A

1) Estimated fetal weight (EFW)
2) Fetal abdominal circumference (AC)

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3
Q

Customised growth charts are used to assess the size of the fetus.

These are based on what 4 features of the mother?

A

1) Ethnic group
2) Weight
3) Height
4) Parity

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4
Q

What is severe small for gestational age?

A

Severe SGA is when the foetus is below the 3rd centile for their gestational age.

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5
Q

Define low birth weight

A

Birth weight of less than 2500g

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6
Q

The causes of SGA can be divided into two categories.

What are they?

A

1) Constitutionally small

2) Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR)

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7
Q

What is a constitutionally small cause of SGA?

A

Matching the mother and others in the family, and growing appropriately on the growth chart

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8
Q

What is foetal growth restriction?

A

When 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.

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9
Q

SGA vs fetal growth restriction (FGR)?

A

Small for gestational age simply means that the baby is small for the dates, without stating why. The fetus may be constitutionally small, growing appropriately, and not at increased risk of complications. Alternatively, the fetus may be small for gestational age due to pathology (i.e. FGR), with a higher risk of morbidity and mortality.

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10
Q

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

A

1) Placenta mediated growth restriction

2) Non-placenta mediated growth restriction

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11
Q

What is non-placenta mediated growth restriction?

A

where the baby is small due to a genetic or structural abnormality

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12
Q

What does placenta mediated growth restriction refer to?

A

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

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13
Q

What are some conditions that affect the transfer of nutrients across the placenta?

A

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

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14
Q

Non-placenta medicated growth restriction refers to pathology of the fetus.

Give some examples

A

1) Genetic abnormalities
2) Structural abnormalities
3) Fetal infection
4) Errors of metabolism

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15
Q

Give some signs that may indicate foetal growth restriction

A

1) SGA
2) Reduced amniotic fluid volume
3) Abnormal Doppler studies
4) Reduced fetal movements
5) Abnormal CTGs

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16
Q

Give some complications of foetal growth restriction?

A

1) Fetal death or stillbirth
2) Birth asphyxia
3) Neonatal hypothermia
4) Neonatal hypoglycaemia

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17
Q

Give some risk factors for SGA

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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18
Q

The RCOG green-top guidelines on SGA (2013) lists major and minor risk factors.

When are women assessed for risk factors for SGA?

A

At the booking clinic

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19
Q

How are low-risk women for SGA monitored?

A

Monitoring of the symphysis fundal height (SFH) at every antenatal appointment from 24 weeks onwards to identify potential SGA.

The SFH is plotted on a customised growth chart to assess the appropriate size for the individual woman.

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20
Q

What is the symphysis fundal height (SFH)?

A

the distance from the symphysis pubis (mothers pubic bone) to the top of the uterine fundus

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21
Q

If the symphysis fundal height is less than the 10th centile in women being monitored for SGA, what happens?

A

Women are booked for serial growth scans with umbilical artery doppler.

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22
Q

When are women are booked for serial growth scans with umbilical artery doppler?

A

If they have:

1) Three or more minor risk factors
2) One or more major risk factors
3) Issues with measuring the symphysis fundal height (e.g. large fibroids or BMI > 35)

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23
Q

Women at risk or with SGA are monitored closely with serial ultrasound scans.

What do these scans measure?

A

1) Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity

2) Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery

3) Amniotic fluid volume

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24
Q

Management steps for SGA?

A

1) Identify those at risk

2) Aspirin given to those at risk of pre-eclampsia

3) Treating modifiable risk factors e.g. stop smoking

4) Serial growth scans to monitor growth

5) Early delivery where growth is static, or there are concerns

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25
Q

When a foetus is identified as SGA, what investigations can be done to identify the underlying cause?

A

1) Blood pressue & urine dip for pre-eclampsia

2) Uterine artery doppler scanning

3) Detailed fetal anatomy scan by fetal medicine

4) Karyotyping for chromosomal abnormalities

5) Testing for infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria)

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26
Q

When is early delivery in SGA considered?

A

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

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27
Q

What does early delivery in SGA reduce the risk of?

A

Stillbirth

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28
Q

What is given when delivery is planned early, particularly when delivered by caesarean section?

A

Corticosteroids

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29
Q

Define large for gestational age (macrosomia)?

A

When the weight of the newborn is more than 4.5kg at birth.

During pregnancy, an estimated fetal weight above the 90th centile is considered large for gestational age.

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30
Q

Causes of macrosomia?

A

1) Constitutional
2) Maternal diabetes
3) Previous macrosomia
4) Maternal obesity or rapid weight gain
5) Overdue
6) Male baby

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31
Q

Risks to mother of macrosomia?

A

1) Shoulder dystocia
2) Failure to progress
3) Perineal tears
4) Instrumental delivery or caesarean
5) Postpartum haemorrhage
6) Uterine rupture (rare)

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32
Q

Risks to baby of macrosomia?

A

1) Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
2) Neonatal hypoglycaemia
3) Obesity in childhood and later life
4) Type 2 diabetes in adulthood

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33
Q

Tip about macrosomia:

A

TOM TIP: If you only remember two things about macrosomia, remember that it is caused by gestational diabetes, and there is a significant risk of shoulder dystocia during birth.

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34
Q

What 2 investigations can be done for a LGA baby?

A

1) Ultrasound to exclude polyhydramnios and estimate the fetal weight

2) Oral glucose tolerance test for gestational diabetes

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35
Q

Define polyhydramnios

A

Polyhydramnios is where there is too much amniotic fluid around the baby during pregnancy.

36
Q

Is the induction of labour on the grounds of macrosomia advised?

A

No - most women with large for gestational age pregnancy will have a successful vaginal delivery.

37
Q

What is the main risk with a LGA baby?

A

Shoulder dystocia

38
Q

How can the risks of shoulder dystocia be reduced in macrosomia?

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
39
Q

What is shoulder dystocia?

A

A complication of vaginal delivery (cause of both maternal and fetal morbidity).

Shoulder dystocia is when the baby’s head has been born but one of the shoulders becomes stuck behind the mother’s pubic symphysis, delaying the birth of the baby’s body.

40
Q

Key risk factors for shoulder dystocia?

A

1) fetal macrosomia (hence association with maternal diabetes mellitus)
2) high maternal body mass index
3) diabetes mellitus
4) prolonged labour

41
Q

Management of shoulder dystocia?

A

1) Call for senior help

2) McRoberts’ manoeuvre

42
Q

What does McRoberts’ manoeuvre involve?

A

1) this manoeuvre entails flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen

2) this rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery.

3) can sometimes do an episiotomy: will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres.

43
Q

Maternal & foetal complications of shoulder dystocia?

A

Maternal: postpartum haemorrhage, perineal tears

Foetal: brachial plexus injury, neonatal death

44
Q

What is a multiple pregnancy?

A

Multiple pregnancy refers to a pregnancy with more than one fetus.

45
Q

Why has the incidence of multiple pregnancies increased?

A

Due to the development of fertility treatment

46
Q

Define monozygotic

A

identical twins (from a single zygote)

47
Q

Define dizygotic

A

non-identical (from two different zygotes)

48
Q

Define monoamniotic

A

single amniotic sac

49
Q

Define diamniotic

A

two separate amniotic sacs

50
Q

Define monochorionic

A

share a single placenta

51
Q

Define dichorionic

A

two separate placentas

52
Q

Why are the best outcomes in multiple pregnancy with diamniotic, dichorionic twin pregnancies?

A

as each fetus has their own nutrient supply.

53
Q

When is multiple pregnancy usually diagnosed?

A

On the booking US scan

54
Q

What is US used to determine at booking scan?

A

1) multiple pregnancy
2) Gestational age
3) Number of placentas (chorionicity) and amniotic sacs (amnionicity)
4) Risk of Down’s syndrome (as part of the combined test)

55
Q

Define chorionicity

A

number of placentas

56
Q

Define amnionicity

A

number of amniotic sacs

57
Q

How can an US be used to determine dichorionic diamniotic twins?

A

Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign

58
Q

What US sign is seen in dichorionic diamniotic twins?

A

lambda sign or twin peak sign

59
Q

How can an US be used to determine monochorionic diamniotic twins?

A

Monochorionic diamniotic twins have a membrane between the twins, with a T sign

60
Q

What US sign is seen in monochorionic diamniotic twins?

A

T sign

61
Q

How can an US be used to determine monochorionic monoamniotic twins?

A

Monochorionic monoamniotic twins have no membrane separating the twins

62
Q

What is a lambda sign, or twin peak sign?

A

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).

63
Q

What is the T sign?

A

The T sign refers to where the membrane between the twins abruptly meets the chorion, giving a T appearance.

This indicates a monochorionic twin pregnancy (single placenta).

64
Q

Risks to mother of multiple pregnancy?

A
  • Anaemia
  • Polyhydramnios
  • Hypertension
  • Malpresentation
  • Spontaneous preterm birth
  • Instrumental delivery or caesarean
  • Postpartum haemorrhage
65
Q

Risks to foetus and neonates in multiple preganancy?

A
  • Miscarriage
  • Stillbirth
  • Fetal growth restriction
  • Prematurity
  • Twin-twin transfusion syndrome
  • Twin anaemia polycythaemia sequence
  • Congenital abnormalities
66
Q

What is twin-twin transfusion syndrome?

A

Twin-twin transfusion syndrome occurs when the fetuses share a placenta.

67
Q

Twin-twin transfusion syndrome vs feto-fetal transfusion syndrome?

A

It is called feto-fetal transfusion syndrome in pregnancies with more than two fetuses.

68
Q

What happens in twin-twin transfusion syndrome?

A

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.

69
Q

How can the recipient who gets the majority of the blood in twin-twin transfusion syndrome be affected?

A

Can become fluid overloaded: HF, polyhydramnios

70
Q

How can the donor in twin-twin transfusion syndrome be affected?

A

Growth restriction, anaemia, oligohydramnios

71
Q

Management of twin-twin transfusion syndrome?

A

Refer to a tertiary specialist fetal medicine centre. In severe cases, laser treatment may be used to destroy the connection between the two blood supplies.

72
Q

What is twin anaemia polycythaemia?

A

Is similar to twin-twin transfusion syndrome, but less acute.

One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).

73
Q

What do women with multiple pregnancies require additional monitoring for?

A

Anaemia

74
Q

Women with multiple pregnancies require additional monitoring for anaemia.

When is a FBC done?

A

Three time:

1) booking clinic

2) 20 weeks gestation

3) 28 weeks gestation

75
Q

What investigation is required in multiple pregnancy to monitor for fetal growth restriction, unequal growth and twin-twin transfusion syndrome?

A

Additional US scans:

1) 2 weekly scans from 16 weeks for monochorionic twins
2) 4 weekly scans from 20 weeks for dichorionic twins

76
Q

Frequency of US scans for monochorionic twins?

A

2 weekly scans from 16 weeks

77
Q

Frequency of US scans for dichorionic twins?

A

4 weekly scans from 20 weeks

78
Q

When is planned birth offered for uncomplicated monochorionic monoamniotic twins?

A

32 and 33 + 6 weeks

79
Q

When is planned birth offered for uncomplicated monochorionic diamniotic twins?

A

36 and 36 + 6 weeks

80
Q

When is planned birth offered for uncomplicated dichorionic diamniotic twins?

A

37 and 37 + 6 weeks

81
Q

When is planned birth offered for triplets?

A

Before 35 + 6 weeks

82
Q

What is waiting beyond planned birth dates associated with in multiple pregnancy?

A

Increased risk of fetal death.

83
Q

What is given before delivery in planned births in multiple pregnancy?

A

Corticosteroids are given before delivery to help mature the lungs.

84
Q

Planned birth of monoamniotic twins?

A

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

85
Q

Delivery options for diamniotic twins?

A

Aim to deliver between 37 and 37 + 6 weeks:

1) Vaginal delivery is possible when the first baby has a cephalic presentation (head first)

2) Caesarean section may be required for the second baby after successful birth of the first baby

3) Elective caesarean is advised when the presenting twin is not cephalic presentation

86
Q

What is a cephalic presentation at birth?

A

Head first

87
Q
A

Yr 4 - GOSH (45 decks)

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