growth in pregnancy + twins Flashcards
which antibiotic given during pregnancy or in early childhood can cause this appearance?
tetracycline - staining of bones + teeth
avoid in kids <12yrs
which antiepileptic drug is assoc with cleft lip + palate?
phenytoin
which drug taken during pregnancy can cause bvaginal adenocarcinoma in female offspring?
stilbestrol
- prevent miscarriage or early delivery in pregnant women who are at risk
- menopausal wome
which antiepileptic drug is assoc with neural tube defects + anencephaly
sodium valporate
listeriosis in pregnancy
can cause in utero infection
- cause miscarriages, still births + preterm labour
reducing risk of listeriosis in pregnancy
drinking only pasturised or UHT milk
avoid ripened or soft cheese
avoid pate
avoid eating undercooked food
sources of infections
- (as risk factors^)
- someone else who has it - kissing, eating food theyve touched
- close contact with farm animals - sheep/cows giving birth
foods to avoid in pregnancy
soft cheese
undercooked meat, cured meats, game
tuna
raw/partially cooked eggs
pate
liver - high vit A neurotoxic to fetus
fish oil supplements
healthy start scheme UK
available to pregnant women
- on benefits
- under 18
vit supplements
- 70mg vit C
- 10ug vit D
- 400ug folic acid
money given to help buy healthy food from 10wks to 4yrs old
management of underweight pregnancies
exclude eating disorders - manage appropriately
USS for growth 28, 32, 36wks
labour mx
- beware of “normal blood loss”
- drug adjustments - fragmin
post partum mx of obese women
monitor if sleep apnoea
thromboprophylaxis
- fragmin dose weight dependent *
- usually for 6wks postnatal
- stocking dont fit
wound problems
investigating small for gestational age
measurement of -
- abdominal circumference
- head circumference
- femur length
liquor volume
- deepest vertical pool (DVP) most accurate
- normal >2cm + <10cm
- poor sign in fetal growth restriction
–>(would be reduction in DVP as marker of reduced renal perfusion +urine output
doopler studies - middle cerebral artery, ductus venosus
complications of small for gestational age
antenatal/in labout - hypoxia, still birth
postnatal
- hypoglycaemia, hypothermia
- polycythaemia
- hyperbilirubinaemia
- abnormal neuro development
- prematurity complications
prevention of small for gestational age
aspirin for those at risk of preeclampsia
smoking cessation - stop before 15wks, reduces risk to same as non-smoker
drug problem service input
LMWH for those with antiphospholipid syndrome
monitoring of high risk of fetal growth restriction (FGR)
-> growth scans every 4wks from 28wks (sometimes 24wks)
Women are booked for serial growth scans with umbilical artery doppler if –
o 3 or more minor risk factors
o One or more major risk factors
o Issues with measuring the symphysis fundal height – large fibroids, BMI >35
Women at risk / with SGA monitored with serial US measuring –
o Estimated fetal weight (EFW) + abdominal circumference (AC) to determine growth velocity
o Umbilical arterial pulsatility index (UA-PI) to measure flow through umbilical artery
o Amniotic fluid volume
management of small for gestational age
<10th but >3rd centil
o Fortnightly scans
o Offer IOL at 39wks
<3rd
o One weekly monitoring
o Education
o Delivery at 37wks if no other concerns
Offer IOL + aim for vaginal birth unless
o Abnormal fetal dopplers
o Other obstetric indication for birth by C-section
- Consultant led unit
- Continuous fetal monitoring from onset of contractions
risk factors for fetal growth restriction
previous severe SGA
previous stillbirth
chronic hypertension on treatment
diabetes
renal disease - nephropathy
antiphospholipid syndrome
abnormal uterine dopple
who gets a growth scan at 32 + 36wks to check for FGR
IVF pregnancy
>=40 age
fibroids >6cm
smoker
low PAPP-A
BmI >=35
BMI <19
echogenic bowel
previous SGA baby
causes of fetal growth restriction
placenta mediated growth restriction
non-placenta mediated growth restriction - where baby small due to genetic or structural abnormality
(see risk factors)
presentation of fetal grwoth restriction
reduced amniotic fluid volume
abnormal doppler studies reduced fetal movements
abnormal CTGs
define a low birth weight
< 2.5kg at gestation
complications of a large for gestational age baby
maternal
- anxiety
- perineal tears
- C-section
- PPH
- uterine rupture
fetal
- shoulder dystocia
- birth injury - erbs palsy, fetal distress, hypoxia
- neonatal hypoglycamia **
- obesity later i life
- T2DM later in life
investigation large for gestational age
US to exclude polyhydramnios + estimate fetal weight
- OGTT for gestational diabetes
most have successful vaginal deliveries
polyhydramniosis
excessive amniotic fluid
- amniotic fluid index (AFI) >25cm
- deepest pool >8cm
- subjective
causes of polyhydramnios
maternal
- diabetes - getus has polyuria, pees in sac
- red cell antibodies
fetal
- anomaly - GI atresia, cardiac tumours
- fetal renal disorders
- monochorionic twins
- hydrops fetalis - Rh isoimmunisation
- viral infection - CMV
idiopathic
polyhydramnios presentation
abdominal discomfort
preterm labour
cord prolapse
pre-labour rupture of membranes
large for dates
malpresentation
tense shiny abdomen
inability to feel fetal parts
diagnosis of polyhydramnios
USS confirmation
- DVP >8cm
- AFI >25
polyhydramnios investigations
OGTT
viral serology - TORCH
antibody screen
USS fetal survey - lips, stomach bubble
mangement of polyhydramnios
educate
serial USS - monitor growth
IOL by 40wks
if symptoms severe (breathlessness) an amnioreduction can be considered
labour risks with polyhydramnios
malpresentation
cord prolapse
preterm labour
PPH
monozygotic twins
identical twins
from a single zygote
1 sperm, 1 egg - splitting of a single fertilised egg
depending when egg has split produces variable pairs of dichorionic + diamniotic/monoamniotic
dizygotic
non identical
from 2 different zygotes
fetilisation of 2 ova by 2 sperm
ALL are dichorionic + diamniotic (2 separate outer + inner sacs) + have separate placentas
monoamniotic vs diamniotics
mono = single amniotic sac
di = 2 separate amniotic sacs
monochorionic vs dichorionic
mono = share a placenta
di = 2 separate placenta (always DCDA)
- best outcomes - own space + nutrient supply
what type of twins are at greatest risk of complications, what are these complications?
monochorionic-monoamniotic twins
- identical that share same amniotic sac + share placenta (2 separate cords)
complications
- cord entanglement
- cord compression
- twin to twin transfusion syndrome
- pre-term birth
risk factors for multiple pregnancies
assited conception
race - afican, nigerian
FH
increased maternal age
increased parity
tall >short women
progression of chorionicity
after fertilisation
day 0-1 - DCDA
day 4-7 - MCDA
day 8-14 - MCMA
day 15 onwards - conjoined twins
determining chorionicity
determining chorionicity - US
- twin peak at 11-13+6wks
- lambda (twin peak) - triangular appearance where membrane btween twins meets chorion indicates DIchorionic twins
- T sign - membrane meets chorrrion abruptly, indicates MONO chorionic twin
(both diamniotic)
presentation + diagnosis of high order pregnancies
exaggerated pregnancy symptoms - excessive sickness/hypermesis gravidarum
high AFP
large for date uterus
multiple fetal poles
diagnosis = USS confirmation at 12 weeks
how frequently are twin pregnancies seen in antental clinic?
monochorionic - every 2weeks from 16wks
dichorionic - every 4wks from 20wks
(give Fe, low dose aspirin, folic acid)
delivery of high order pregnancies
MCMA - c-section at 32-33+6wks
diamniotic
- if one twin cephalic (head first) aim for vaginal delivery)
- syntocinon after twin 1
- DCDA -> 37-38wks
- MCDA -> after 36+0wks with steroids
triplets or more -> C-section
twin anaemia polycythaemia sequence
one twin anaemic + other develops polycythaemia (raised Hb)
twin to twin transfusion syndrome
when foetuses share a placenta, syndrome with artery-vein anastomoses, donor twin perfuses the recipient twin
- recipient receive majority of blood from placenta, donor is starved
recipient = fluid overload, heart failure, polyhydramnios
donot = growth restriction, anaemia, oligohydramnios
diagnosis of twin to twin transfusion syndrome
oligohydramnios-polyhydramnios (oly-poly)
management of twin to twin transfusion syndrome
<26wks - fetoscopic laser ablation
>26wks - amnioreduction/septostomy
deliver 34-36wks
complications
- mortality >90% with no treatment
- neuro morbidity 37% + high in surviving twin if IUD
