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Y4 Obs & Gyn > Complicated pregnancy - pre-labour > Flashcards

Complicated pregnancy - pre-labour Flashcards

1
Q

where should the fundus of the uterus be at 12 weeks?

A

just above pubic bone

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2
Q

where should the fundus be 36-38w after?

A

upto sternum

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3
Q

where should the uterine fundus be upto at the age of 40w?

A

fundus drops below 38w level as presenting part drops down into pelvis

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4
Q

what is defines as small of gestational age?

A

anthropometric variables below 10th population centile
*severe if below 3rd
low birth weight of <2500g

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5
Q

why might a foetus be small?

A

constitutionally small
abnormal small - congenital, chromosomal, syndromic
infected - CMV
starved - placental insufficiency, smoking, maternal disease, multiple pregnancies
wrong dates etc

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6
Q

what are some risk factors for SGA?

A

previous FGR, SGA
stillbirths
smoking, alcohol, substance misuse
pre-eclampsia
age
HTN, renal disease etc

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7
Q

what is FGR?

A

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

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8
Q

how might you investigate FGR or SGA?

A

centile position, symmetry, amniotic fluid volume, doppler

karyotyping, BP, infections etc

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9
Q

what may cause FGR?

A

placental mediated: idiopathic, pre-eclampsia, anaemia, malnutrition

non-placental: genetic, structural, foetal infection, metabolism errors

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10
Q

what signs may suggest FGR > SGA?

A
  • reduced amniotic fluid volume
  • abnormal doppler studies
  • reduced foetal movements
  • abnormal CTG
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11
Q

what are some short term complications of a small baby?

A
  • foetal death or stillbirth
  • birth asphyxia
  • neonatal hypothermia or hypoglycaemia
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12
Q

what are some long term complications of a small baby?

A
  • CVS risk eg: HTN
  • T2DM
  • obesity
  • mood and behavioural problems
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13
Q

what defines large for gestational age?

A
  • anthropometric variables above 90th population centile for gestational age
  • newborn 4.5kg at birth
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14
Q

what could cause LGA?

A

foetal: constitutional, male, overdue, genetics

maternal: DM, age, multiparity, previous macrosomia, obesity

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15
Q

what are some maternal risks with LGA?

A
  • prolonged labour and failure to progress
  • perineal tears
  • instrumental delivery or caesarean
  • postpartum haemorrhage
  • uterine rupture (rare)
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16
Q

what are some foetal risks with LGA?

A
  • shoulder dystocia
  • birth injury - Erb’s, clavicular #, foetal distress, hypoxia
  • neonatal hypoglycaemia
  • obesity in childhood and later life
  • T2DM in adulthood
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17
Q

what are some important differentials to rule out in LGA?

A

uterine fibroids
pelvic mass pushing up uterus
polyhydramnios
maternal obesity

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18
Q

how would you manage LGA?

A
  • 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
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19
Q

how is SGA managed?

A
  • 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
20
Q

what is the physiology and the importance of amniotic fluid production?

A
  • 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
21
Q

what counts as oligohydramnios and polyhydramnios?

A

oligo - below 5th centile
poly - above 95th

21
Q

what causes oligohydramnios?

A
  • ROM
  • placental insufficiency
  • renal agenesis
  • non-functioning kidneys
  • obstructive nephropathy
22
Q

how would you diagnose abnormal amniotic fluid levels?

A
  • USS
  • amniotic fluid index
23
Q

how would you investigate oligohydramnios?

A
  • history
  • exam: fundal height, speculum
  • USS
  • karyotyping
  • IGFBP-1 or PAMG-1 for membrane rupture
24
Q

how is oligohydramnios managed?

A
  • ruptured membranes: steroids if PPROM, abx
  • placental insufficiency: CTG, consider delivery etc
25
Q

what is a consequence to the foetus as a result of oligohydramnios?

A

pulmonary hypoplasia, meconium aspiration syndrome, fetal compression, infections and contractures as unable to move around

26
Q

what could cause polyhydramnios?

A

duodenal atresia
oesophageal atresia
anaemia
fetal hydrops
twin-twin transfusion syndrome
increased lung secretions
genetic
DM
ingestion of lithium
macrosomia

27
Q

how do you manage polyhydramnios?

A

*if mother symptomatic

  • amnioreduction
  • indomethacin to enhance water retention and reduce foetal urine output
  • examine baby before feed for causes
28
Q

what are some complications of polyhydramnios?

A

malpresentation as a lot of room to move around
PPH as uterus needs to contract more to reach haemostasis

29
Q

what does reduced foetal movement suggest?

A

foetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero

  • risk of stillbirth and foetal growth restriction
30
Q

what is the physiology of foetal movements?

A

first recognised at 18-20w and increases and then plateaus
multiparous may notice at 16-18w

movements unlikely to reduce through pregnancy

31
Q

when is it a red flag and should prompt referral for not feeling foetal movements?

A

less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation)

not felt by 24w maternal foetal medicine referral

32
Q

what are some risk factors for reduced foetal movements?

A

posture - prominent when lying down
distraction
placental position
medication like sedatives
foetal position
body habitus
amniotic fluid
foetal size

33
Q

how is reduced foetal movements assessed?

A

28w+ doppler first, then CTG if present, USS if unsure

24-28w handheld doppler

below 24w handheld doppler first

34
Q

what are some causes for intrauterine death?

A

maternal: SLE, DM, HTN, antiphospholipid, thrombotic

foetal: anomalies, umbilical cord complications

placental: insufficiency, abruption, chorioamnionitis

35
Q

what are some risk factors for intrauterine death?

A
  • advanced maternal age
  • young maternal age
  • substance use
  • prior IUFD
  • fetal growth restriction
  • placental abnormalities
  • multiple gestation
  • infection
  • congenital/genetic anomalies
36
Q

what are some differentials for intrauterine death?

A

foetal sleep state - <40 min duration of RFM

foetal sedation from maternal sedatives

37
Q

how might you investigate foetal intrauterine death?

A

USS for RFM transvaginal view
*findings foetus, absence of heart beat, no movement

B-HCG, antibodies, urine labs
amniocentesis
karyotyping

38
Q

how is intrauterine death managed?

A
  • labour and induction
  • <28w with misoprostol or IV oxytocin for induction
  • > 28w induction
  • dopamine agonists
  • counselling
  • surgical D&E if <24w
39
Q

what are some complications of multiple pregnancy for the mother?

A
  • Anaemia
  • Polyhydramnios
  • Hypertension
  • Malpresentation
  • Spontaneous preterm birth
  • Instrumental delivery or caesarean
  • Postpartum haemorrhage
40
Q

what are some complications of multiple pregnancy for the foetus?

A
  • Miscarriage
  • Stillbirth
  • Fetal growth restriction
  • Prematurity
  • Twin-twin transfusion syndrome
  • Twin anaemia polycythaemia sequence
  • Congenital abnormalities
41
Q

what is twin-twin transfusion syndrome?

A
  • 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
42
Q

what is twin-twin polycythaemia sequence?

A
  • similar to twin-twin transfusion syndrome, but less acute
  • One twin becomesanaemicwhilst the other developspolycythaemia(raised haemoglobin)
43
Q

what additional antenatal care is given in multibirths?

A
  • anaemia monitoring additionally
  • additional USS
  • planned birth earlier
  • waiting beyond 37w may increase risk of foetal death
44
Q

how might multiple births be delivered?

A
  • 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

Y4 Obs & Gyn (16 decks)

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