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Obs & Gynae > Foetus and monitoring > Flashcards

Foetus and monitoring Flashcards

1
Q

Monozygotic twin means?

A

Identical twins from a single zygote

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2
Q

Dizygotic twin means?

A

Non-identical twins from two different zygotes

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3
Q

Monoamniotic means?

A

Single amniotic sac

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4
Q

Diamniotic means?

A

Two separate amniotic sacs

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5
Q

Monochorionic means?

A

Share single placenta

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6
Q

Dichorionic means?

A

Two separate placentas

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7
Q

Best outcomes for twins are with ______, ______ pregnancies as each fetus has their own nutrient supply.

A

Diamniotic

Dichorionic

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8
Q

Dichoronic, diamniotic twins are differentiated how using USS?

A

Dichoronic, diamniotic twins have membrane between them.

Lambda sign/ twin peak sign

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9
Q

What is the lambda sign/twin peak sign?

A

Occurs in USS with dichorionic, diamniotic twins.

Triangular appearance where membrane between the twins meets the chorion (as the chorion blends partially in the membrane).

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10
Q

Monochoronic, diamniotic twins are differentiated how using USS?

A

Monochoronic, diamniotic twins have a membrane between them.

T sign

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11
Q

What is the T sign?

A

Occurs in USS with monochoronic, diamniotic twins.

Membrane between the twins abruptly meets the chorion, giving a T appearance.

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12
Q

What are maternal risks associated with multiple pregnancies?

A 
Anaemia
Polyhydramnios
HTN
Malpresentation
Spontaneous preterm birth
Instrument/C-section delivery
PPH
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13
Q

What are foetal/neonatal risks associated with multiple pregnancies?

A 
Miscarriage
Stillbirth
Fetal growth restriction
Prematurity
Twin-twin transfusion syndrome
Twin anaemia polycythaemia seqeuence
Congenital abnormalities
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14
Q

What is twin-twin tranfusion syndrome?

A

Occurs when foetuses share a placenta.

One twin gets more of the blood (recipient) than the other (donor).

Recipient - fluid overloaded, heart failure, polyhydramnios

Donar - FGR, anaemia, oligohydramnios

Size difference between the fetuses!

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15
Q

How is twin-twin transfusion syndrome managed?

A

Referral to tertiary specialist fetal medicine centre

(If severe) - laser treatment to destroy connection between the 2 blood supplies

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16
Q

What is twin anaemia polycythaemia sequence?

A

Similar to twin-twin transfusion syndrome, happens with twins sharing 1 placenta.

Difference is it’s less acute.

One twin becomes anaemia while other gets polycythaemia.

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17
Q

When women with multiple pregnancies are monitored for anaemia, their FBC is taken at which 3 time points?

A

Booking clinic
20 weeks
28 weeks

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18
Q

USS is used in multiple pregnancy women to monitor for which 3 issues?

A

FGR
Unequal growth
Twin-twin transfusion syndrome

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19
Q

USS scans of multiple pregnancy women are done at which time periods?

A

2 weekly scans from 16 weeks + for monochorionic twins

4 weekly scans from 20 weeks for dichorionic twins

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20
Q

Why is planned birth offered to women with multiple pregnancies?

A

Decrease risk of fetal death.

Allows timing of birth to reduce complications.

Allow corticosteroids to be administered before delivery to help lungs mature.

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21
Q

Monoamniotic twins require what form of delivery between 32 - 34 weeks?

A

Elective C-section

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22
Q

Diamniotic twins can be delivered how?

A

Vaginal delivery (if cephalic)

C-section (for 2nd baby after 1st successfully born)

Elective caesarean when presenting twin is not cephalic

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23
Q

Prematurity is defined as birth before __ weeks gestation

A

37 weeks

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24
Q

Babies are considered non-viable below __ weeks gestation.

A

23 weeks

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25
Q

Prematurity is classed as:

Extreme preterm -> 1.
Very preterm -> 2
Moderate to late preterm -> 3

A
  1. Under 28 weeks
  2. 28-32 weeks
  3. 32-37 weeks
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26
Q

What 2 methods can be used as prophylaxis against preterm labour?

A

Vaginal progesterone

Cervical cerclage

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27
Q

Progesterone is given as a vaginal pessary/gel why?

How does it work?

A

Prophylaxis against preterm labour.

Maintains pregnancy, prevents labour by decreasing myometrium activity and prevents cervix remodelling in preparation for delivery.

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28
Q

What is the criteria for offering vaginal progesterone to women?

A

Risk of preterm labour

Cervical length less than 25mm on vaginal USS between 16-24 weeks gestation

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29
Q

What is cervical cerclage and why is it used?

A

Put stitch in cervix to add support and keep it closed.

Stitch removed when woman goes into labour or reaches term.

Used prophylactically against preterm labour

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30
Q

When is “rescue” cervical cerclage used?

A

Between 16 and 27+6 weeks when there is cervical dilatation without rupture of membranes

To prevent progression and premature delivery

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31
Q

What is PPROM?

A

Amniotic sac ruptures, releasing amniotic fluid before onset of labour and in a preterm pregnancy (under 37 weeks gestation)

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32
Q

How is PPROM diagnosed?

A

Speculum examination revealing pooling of amniotic fluid in the vagina

If there is doubt:

  • IGFBP-1 protein test (high in amniotic fluid) - test vaginal fluid for this
  • PAMG-1 protein test is an alternative
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33
Q

How is PPROM managed?

A

Prophylactic antibiotics to prevent chorioamnionitis (erythromycin)

Induction of labour (from 34 weeks)

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34
Q

What is preterm labour with intact membranes?

A

Regular painful contractions and cervical dilatation without rupture of amniotic sac

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35
Q

How is cervical length measured?

A

Transvaginal USS

36
Q

What is the relevance of cervical length <15mm in 30+ weeks gestation?

A

Preterm labour more likely

37
Q

Fetal ______ is alternative test to vaginal USS. It is the glue between chorion and uterus and is found in vagina during labour.

Can be used to determine preterm labour

A

Fibronectin

38
Q

How can preterm labour be managed?

A

Fetal monitoring (CTG)

Tocolysis with nifedipine

Maternal corticosteroids

IV magnesium sulphate

Delayed cord clamping/milking

39
Q

What is tocolysis?

What medication is used 1st line for this?

A

Medicines used to stop uterine contractions. SHORT TERM MEASURE - buys time for further fetal development.

Nifedipine (or Atosiban as an alternative)

40
Q

During which gestational age can tocolysis be used?

A

24 and 33+6 weeks gestation in preterm labour

41
Q

Giving mother ______ helps develop fetal lungs and reduce ______ syndrome

A

Corticosteroids

Respiratory distress

42
Q

______ helps protect fetal brain during premature delivery

It reduces the risk of cerebral palsy

A

IV magnesium sulfate

43
Q

Why must magnesium sulphate be monitored post-administration?

A

Magnesium toxicity

Check obs, tendon reflexes (patella).

Signs:

Reduced RR
Reduced BP
Absent reflexes

44
Q

How is intermittent foetal monitoring performed?

A

Pinard stethoscope

Handheld doppler

Using either of these, listen to foetal heartbeat

45
Q

How is continuous foetal monitoring performed?

A

CTG +/- Foetal scalp electrode (more accurate)

46
Q

Which 2 measurements are used to assess fetal size on USS?

A

Estimated fetal weight (EFW)

Fetal abdominal circumference (AC)

47
Q

Which 4 factors are taken into account on customised growth charts used to assess the size of a foetus?

A

Ethnicity
Weight
Height
Parity

48
Q

Severe SGA is when the fetus is below the ___ centile for gestational age

A

3rd

49
Q

Low birth weight is defined as a birth weight of _______

A

<2500g

50
Q

What are the 2 main categories of causes of SGA?

A

Constituionally small (match mother and others in family, growing appropriately on growth chart)

Foetal growth restriction (FGr) - when small fetus due to pathology reducing amount of nutrients anx oxygen being delivered to foetus via placenta

51
Q

What are the 2 categories of causes of Foetal growth restriction (FGR)?

A

Placenta-mediated growth restriction (conditions affecting nutrient transfer via placenta)

Non-placenta mediated growth restriction (pathology of foetus itself)

52
Q

What are causes of placenta mediated growth restriction?

A 
Idiopathic
Pre-eclampsia
Maternal smoking/alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions
53
Q

What are causes of non-placenta mediated growth restriction?

A

Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism

54
Q

Other than being SGA, what other signs would indicated foetal growth restriction?

A

Oligohydramnios
Abnormal Doppler studies
Reduced foetal movements
Abnormal CTG

55
Q

What are short-term complications of foetal growth restriction?

A

Foetal death/stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia

56
Q

What are long-term complications of foetal growth restriction?

A

Cardiovascular disease (HTN)
T2DM
Obesity
Mood/behaviour problems

57
Q

What are risk factors for SGA?

List 5

A 
Previous SGA baby
Obesity
Smoking
Diabetes
Existing HTN
Pre-eclampsia
Older mother (35 yo+)
Multiple pregnancy
Low PAPPA protein
Antepartum haemorrhage
Antiphospholipid syndrome
58
Q

What measurement is taken routinely to identify SGA in low-risk women?

A

SFH (symphysial-fundal height)

Done at every antenatal appointment from 24 weeks+

59
Q

If symphysis fundal height is less than 10th centile, woman are booked for what investigation for SGA?

A

Serial growth scans with umbilical artery Doppler

60
Q

What issues can make measuring the symphysis fundal height harder?

A

Large fibroids

BMI >35

61
Q

____ , ____ and ____measurements determine growth velocity in serial USS

A

Estimated foetal weight (EFW)

Abdominal circumference (AC)

Amniotic fluid volume

62
Q

What are the important management steps for SGA?

A

Identify those at risk

Aspirin -> risk of pre-eclampsia

Treating modifiable risk factors (stop smoking)

Serial growth scans (monitor growth)

Early delivery if growth static (or other concerns)

63
Q

If a fetus is identified as SGA, what investigations are carried out to find the underlying cause?

A

BP/urine dip for pre-eclampsia

Uterine artery Doppler scanning

Detailed foetal anatomy scan

Karyotyping for chromosomal abnormalities

Testing for infections (TORCH, malaria, syphillis)

64
Q

Why is early delivery performed if growth becomes static on growth charts?

A

Reduces risk of stillbirth

Corticosteroids given when delivery planned early

Allows pediatricians to be present at birth to help with neonatal resuscitation/management if required.

65
Q

What are 2 important things to remember about macrosomia?

Hint: 1. pathology that could cause it
2. complication during birth

A
  1. gestational diabetes can cause macrosomia

2. shoulder dystocia can occur during birth

66
Q

LGA (macrosomia) is defined as when the weight of the newborn being ____ kg at birth

During pregnancy, an estimated fetal weight (EFW) above ____ centile is considered LGA.

A

> 4.5kg

90th centile

67
Q

What are possible causes of LGA/macrosomia?

A 
Constitutional (normal for mother/family)
GDM
Previous macrosomia
Maternal obesity/rapid weight gain
Overdue
Male baby
68
Q

What are risks to the mother having LGA/macrosomic baby?

A 
Failure to progress
Perineal tears
Delivery - instrument/C-section
PPH
Uterine rupture (rare)
69
Q

What are the risks to the baby of LGA/macrosomia?

A

Shoulder dystocia

Birth injury (Erb’s palsy, clavicular fracture, fetal distress, hypoxia)

Neonatal hypoglycaemia

Obesity in childhood/later life

T2DM in adulthood

70
Q

What investigations are carried out for LGA fetuses?

A

USS (exclude polyhydramnios + estimate fetal weight)

OGTT (test for GDM)

71
Q

Most women with LGA pregnancy will have a successful vaginal delivery. True or False?

A

True.

NICE guidelines advise against labour induction only on grounds of macrosomia

72
Q

How can the risk of shoulder dystocia in LGA babies be reduced?

A

Delivery on consultant-lead unit

Delivery by experienced midwife/obstetrician

Access to obstetrician/theatre if required

Active management of thrid stage (delivery of placenta)

Early decision for C-section if required

Pediatrician attending the birth

73
Q

What is fetal hydrops?

A

When extra fluid accumulates in 2+ areas in the fetus.

E.g. pleural effusion, skin oedema, pericardial effusions, ascites

74
Q

What are causes of “immune” fetal hydrops?

A

Anaemia

Haemolysis (result of Rhesus disease)

75
Q

What are causes of “non-immune” fetal hydrops

A

Chromosome abnormalities (Trisomy-21)

Structural abnormalities (pleural effusions)

Cardiac abnormalities/arrhythmias

Anaemia causing cardiac failure (infection, fetomaternal haemorrhage, thalassemia)

Twin-twin transfusion syndrome in severe cases.

76
Q

What are investigations for fetal hydrops?

A

USS

Echo

Assessment of middle cerebral artery

Bloods: Kleihauer, viral PCR

FBS if anaemia suspected

Amniocentesis for karyotyping

77
Q

What is the treatment for fetal hydrops?

A

Depends on cause

Anaemia - transfusion

Pleural effusions - vesicoamniotic shunting of fetus

Twin-twin transfusion syndrome - laser ablation

78
Q

Where are rhesus antigens found?

A

On surface of RBCs

Not always (i.e. when Rhesus negative)

79
Q

Women who are rhesus-D ______ve do not need any additional treatment during pregnancy.

A

Positive

80
Q

When does sensitisation to foetal Rhesus-D become a problem?

Why?

A

During 2nd + subsequent pregnancies

During subsequent pregnancies, the anti-D antibodies can cross placenta into foetus. Attach themselves to RBCs of foetus and causes auto-immune response from mother to attach foetal RBCs, causing haemolytic disease of the newborn.

81
Q

How is Rhesus disease managed?

How does this intervention work?

A

Preventing senitisation by giving IM anti-D injections to Rhesus negative women.

Anti-D medication works by attaching to the rhesus-D antigens on the fetal RBCs in the mother’s circulation, causing them to be destroyed. This prevents mother’s own immune system recognising the antigen and creating its own antibodies. “Kill the foetal RBCs in maternal blood before they get recognised and antibodies start being made!”

82
Q

When are anti-D injections given ROUTINELY?

A

28 weeks gestation

Birth (if baby blood group is Rh +ve)

83
Q

Aside from routine, when might anti-D injections be given against Rhesus disease?

A 
Antepartum hemorrhage (APH)
Amniocentesis procedures
Abdominal trauma

This is because these procedures may involve maternal blood mixing with foetal blood.

84
Q

At which gestational age can the Kleihauer test be used onwards from?

A

Any sensitising event from 20 weeks gestation onwards

85
Q

What is the purpose of the Kleihauer test in Rhesus disease?

A

Determine amount of foetal blood mixing with maternal blood to determine dose of anti-D required for prophylaxis.

86
Q

What does the Kleihauer test involve in terms of method?

A

Acid added to mother’s blood sample.

Foetal Hb is naturally more resistant to acid.

Foetal Hb persists in response to added acid, mother’s Hb destroyed.

Number of cells still containing Hb (aka remaining foetal cells) can then be calculated.

Obs & Gynae (13 decks)

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