Complicated pregnancy - pre-labour Flashcards
where should the fundus of the uterus be at 12 weeks?
just above pubic bone
where should the fundus be 36-38w after?
upto sternum
where should the uterine fundus be upto at the age of 40w?
fundus drops below 38w level as presenting part drops down into pelvis
what is defines as small of gestational age?
anthropometric variables below 10th population centile
*severe if below 3rd
low birth weight of <2500g
why might a foetus be small?
constitutionally small
abnormal small - congenital, chromosomal, syndromic
infected - CMV
starved - placental insufficiency, smoking, maternal disease, multiple pregnancies
wrong dates etc
what are some risk factors for SGA?
previous FGR, SGA
stillbirths
smoking, alcohol, substance misuse
pre-eclampsia
age
HTN, renal disease etc
what is FGR?
small foetus (or a foetus 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
how might you investigate FGR or SGA?
centile position, symmetry, amniotic fluid volume, doppler
karyotyping, BP, infections etc
what may cause FGR?
placental mediated: idiopathic, pre-eclampsia, anaemia, malnutrition
non-placental: genetic, structural, foetal infection, metabolism errors
what signs may suggest FGR > SGA?
- reduced amniotic fluid volume
- abnormal doppler studies
- reduced foetal movements
- abnormal CTG
what are some short term complications of a small baby?
- foetal death or stillbirth
- birth asphyxia
- neonatal hypothermia or hypoglycaemia
what are some long term complications of a small baby?
- CVS risk eg: HTN
- T2DM
- obesity
- mood and behavioural problems
what defines large for gestational age?
- anthropometric variables above 90th population centile for gestational age
- newborn 4.5kg at birth
what could cause LGA?
foetal: constitutional, male, overdue, genetics
maternal: DM, age, multiparity, previous macrosomia, obesity
what are some maternal risks with LGA?
- prolonged labour and failure to progress
- perineal tears
- instrumental delivery or caesarean
- postpartum haemorrhage
- uterine rupture (rare)
what are some foetal risks with LGA?
- shoulder dystocia
- birth injury - Erb’s, clavicular #, foetal distress, hypoxia
- neonatal hypoglycaemia
- obesity in childhood and later life
- T2DM in adulthood
what are some important differentials to rule out in LGA?
uterine fibroids
pelvic mass pushing up uterus
polyhydramnios
maternal obesity
how would you manage LGA?
- induction of labour advised against
- aim to reduce risk of shoulder dystocia
- delivery in consultant led unit, experienced midwife or obstetrician
- access to obstetrician and theatre if required
- active management of third stage (delivery of placenta)
- early decision for C-section
- paeds attending birth
- monitor for hypoglycaemia
how is SGA managed?
- is foetus really small?
- confirm dates, USS scan and review measurements (previous scans?)
- why is foetus small?
- monitor pregnancy with small foetus (mx plan)
- timing and mode of delivery
what is the physiology and the importance of amniotic fluid production?
- increases steadily upto 33w, plateaus until 38w at 500ml
- foetal urine output, with small contributions from from placenta and some foetal secretions
- foetus swallows some and bladder voids
what counts as oligohydramnios and polyhydramnios?
oligo - below 5th centile
poly - above 95th
what causes oligohydramnios?
- ROM
- placental insufficiency
- renal agenesis
- non-functioning kidneys
- obstructive nephropathy
how would you diagnose abnormal amniotic fluid levels?
- USS
- amniotic fluid index
how would you investigate oligohydramnios?
- history
- exam: fundal height, speculum
- USS
- karyotyping
- IGFBP-1 or PAMG-1 for membrane rupture
how is oligohydramnios managed?
- ruptured membranes: steroids if PPROM, abx
- placental insufficiency: CTG, consider delivery etc
what is a consequence to the foetus as a result of oligohydramnios?
pulmonary hypoplasia, meconium aspiration syndrome, fetal compression, infections and contractures as unable to move around
what could cause polyhydramnios?
duodenal atresia
oesophageal atresia
anaemia
fetal hydrops
twin-twin transfusion syndrome
increased lung secretions
genetic
DM
ingestion of lithium
macrosomia
how do you manage polyhydramnios?
*if mother symptomatic
- amnioreduction
- indomethacin to enhance water retention and reduce foetal urine output
- examine baby before feed for causes
what are some complications of polyhydramnios?
malpresentation as a lot of room to move around
PPH as uterus needs to contract more to reach haemostasis
what does reduced foetal movement suggest?
foetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero
- risk of stillbirth and foetal growth restriction
what is the physiology of foetal movements?
first recognised at 18-20w and increases and then plateaus
multiparous may notice at 16-18w
movements unlikely to reduce through pregnancy
when is it a red flag and should prompt referral for not feeling foetal movements?
less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation)
not felt by 24w maternal foetal medicine referral
what are some risk factors for reduced foetal movements?
posture - prominent when lying down
distraction
placental position
medication like sedatives
foetal position
body habitus
amniotic fluid
foetal size
how is reduced foetal movements assessed?
28w+ doppler first, then CTG if present, USS if unsure
24-28w handheld doppler
below 24w handheld doppler first
what are some causes for intrauterine death?
maternal: SLE, DM, HTN, antiphospholipid, thrombotic
foetal: anomalies, umbilical cord complications
placental: insufficiency, abruption, chorioamnionitis
what are some risk factors for intrauterine death?
- advanced maternal age
- young maternal age
- substance use
- prior IUFD
- fetal growth restriction
- placental abnormalities
- multiple gestation
- infection
- congenital/genetic anomalies
what are some differentials for intrauterine death?
foetal sleep state - <40 min duration of RFM
foetal sedation from maternal sedatives
how might you investigate foetal intrauterine death?
USS for RFM transvaginal view
*findings foetus, absence of heart beat, no movement
B-HCG, antibodies, urine labs
amniocentesis
karyotyping
how is intrauterine death managed?
- labour and induction
- <28w with misoprostol or IV oxytocin for induction
- > 28w induction
- dopamine agonists
- counselling
- surgical D&E if <24w
what are some complications of multiple pregnancy for the mother?
- Anaemia
- Polyhydramnios
- Hypertension
- Malpresentation
- Spontaneous preterm birth
- Instrumental delivery or caesarean
- Postpartum haemorrhage
what are some complications of multiple pregnancy for the foetus?
- Miscarriage
- Stillbirth
- Fetal growth restriction
- Prematurity
- Twin-twin transfusion syndrome
- Twin anaemia polycythaemia sequence
- Congenital abnormalities
what is twin-twin transfusion syndrome?
- one fetus (therecipient) may receive the majority of the blood from the placenta, while the other fetus (thedonor) is starved of blood
- Therecipient gets the majority of the blood, and can become fluid overloaded, withheart failureandpolyhydramnios
- The donor hasgrowth restriction,anaemia andoligohydramnios
what is twin-twin polycythaemia sequence?
- similar to twin-twin transfusion syndrome, but less acute
- One twin becomesanaemicwhilst the other developspolycythaemia(raised haemoglobin)
what additional antenatal care is given in multibirths?
- anaemia monitoring additionally
- additional USS
- planned birth earlier
- waiting beyond 37w may increase risk of foetal death
how might multiple births be delivered?
- monoamniotic twins - ECS between 32 and 33+6 weeks
- diamniotic
- vaginal possible when first baby cephalic
- CS for second after successful delivery of first
- ECS when presenting twin is not cephalic
