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Large for Date Pregnancies Flashcards

1
Q

What would be defined as large for date?

A

Symphyseal-fundal height >2cm for gestational age

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2
Q

What are some causes of large for date babies?

A

Wrong dates, foetal macrosomia, polyhydramnios, diabetes, multiple pregnancy

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3
Q

Why may someone end up with the wrong due date?

A

Late booker = concealed pregnancy, vulnerable women, transfer of care (e.g booked abroad)

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4
Q

How is foetal macrosomia diagnosed?

A

USS = EFW >90th centile, AC >97th centile

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5
Q

What are the risks associated with foetal macrosomia?

A

Clinician and maternal anxiety, labour dystocia, shoulder dystocia, PPH

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6
Q

How accurate is US at diagnosing foetal macrosomia?

A

Commonly overestimates EFW in comparison to actual weight = margin of error up to 10%
Gestation more accurate if <38 weeks

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7
Q

How is foetal macrosomia managed?

A

Exclude diabetes and reassure mother

Conservative, induction of labour or C-section

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8
Q

What are the conditions of induction of labour for foetal macrosomia?

A

Shouldn’t be done in absence of other indications

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9
Q

What is polyhydramnios?

A

Excess amniotic fluid = AFI >25cm and DVP >8cm

May be idiopathic

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10
Q

What is a maternal cause of polyhydramnios?

A

Diabetes

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11
Q

What are some foetal causes of polyhydramnios?

A

GI atresia, cardiac anomaly, tumour, monochorionic twin, hydrops foetalis, viral infection (CMV, erythrovirus B19)

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12
Q

What are the symptoms of polyhydramnios?

A

Abdominal discomfort, pre-labour membrane rupture, preterm labour, cord prolapse

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13
Q

What are the signs of polyhydramnios?

A

Large for date pregnancy, malpresentation, tense shiny abdomen, inability to feel foetal parts

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14
Q

What investigations are done for polyhydramnios?

A

OGTT, serology, antibody screen, US foetal survey

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15
Q

What is the management for polyhydramnios?

A

Serial USS = growth, LV, presentation

Induction of labour by 40 weeks

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16
Q

Wat are the risks in labour associated with polyhydramnios?

A

Malpresentation, cord prolapse, preterm labour, PPH

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17
Q

What are the risk factors for multiple pregnancy?

A

Assisted conception, African race, family history, increased maternal age, increased parity, taller height

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18
Q

What does zygosity refer to in twins?

A 
Monozygotic = splitting of single fertilised egg (30%)
Dizygotic = fertilisation of two ova by two sperm (70%)
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19
Q

How does zygosity influence chorionicity?

A 
Dizygous = always dichorionic/diamniotic
Monozygous = monochorionic/monoamniotic, monochorionic/diamniotic, dichorionic/diamniotic
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20
Q

What does chorionicity depend on?

A

On the time the fertilised ovum split

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21
Q

How does timing influence chorionicity?

A 
DCDA = days 0-3 after fertilisation (morula)
MCDA = days 4-7 after fertilisation (blastocyst)
MCMA = days 8-14 after fertilisation (implanted blastocyst)
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22
Q

What causes conjoined twins?

A

Splitting of the formed embryonic disc 15+ days after fertilisation

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23
Q

How is chorionicity determined using US?

A

Shape/thickness of membrane = twin peak at 11-13+6 weeks (CRL 45-84mm), Lambda sign (triangular appearance of chorion)

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24
Q

What are monochorionic/monozygotic twins at higher risk of?

A

Complications during pregnancy = risk of cord entanglement, higher risk of foetal death

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25
Q

What are the symptoms and signs of multiple pregnancies?

A 
Symptoms = exaggerated pregnancy symptoms 
Signs = high AFP, large for date uterus, multiple foetal poles
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26
Q

When would a US confirm the presence of a multiple pregnancy?

A

At 12 weeks gestation

27
Q

Do multiple pregnancies carry higher risk during labour than singleton pregnancies?

A

Yes = 6x higher perinatal mortality

28
Q

What are the foetal complications associated with multiple births?

A

Congenital abnormalities, intrauterine death, preterm birth, growth restriction, cerebra palsy, twin-to-twin transfusion syndrome

29
Q

What are the maternal complications associated with multiple births?

A

Hyperemesis gravidarum, anaemia, pre-eclampsia, antepartum haemorrhage (abruption, placenta praevia), preterm labour, C-section

30
Q

What is the antenatal management for multiple pregnancies?

A

Consultant-led care in twin/multiple pregnancy clinic

See MC twins every 2 weeks and DC twins every 4 weeks

31
Q

What medications are given antenatally to women with multiple pregnancies?

A

Iron supplements, folic acid, low dose aspirin

32
Q

How often are USS done for multiple pregnancies?

A

MC twins done weekly from 16 weeks gestation
DC twins done 4 weekly
Anomaly US done at 18-20 weeks gestation

33
Q

What are the complications associated with monochorionic twins?

A

Single foetal death, selective growth restriction, twin anaemia-polycythaemia sequence, absent/reversed EDV, twin-to-twin transfusion syndrome

34
Q

What are the features of single foetal death?

A

Risk to survivor of intra-uterine death (15%) or neurological abnormality
Do MRI of foetal brain 4 weeks post-IUD of co-twin
MCA PSV for foetal anaemia

35
Q

What are the features of selective growth restriction?

A

May effect one twin or both
>20% associated with increased perinatal risks
Consider selective reduction if early onset with abnormal dopplers

36
Q

What may twin anaemia-polycythaemia sequence follow?

A

Foetoscopic laser ablation for twin-to-twin transfusion syndrome = do MCA PSV

37
Q

What is twin-to-twin transfusion syndrome?

A

Syndrome with AV anastomoses = donor twin perfuses recipient twin, rare after 26 weeks gestation

38
Q

What would confirm the diagnosis of twin-to-twin transfusion syndrome?

A

Oligohydramnios-polyhydramnios

39
Q

What is the treatment of twin-to-twin transfusion syndrome?

A

<26 weeks = foetoscopic laser ablation
>26 weeks = amnioreduction/septostomy
34-36 weeks = delivery

40
Q

What is the prognosis of twin-to-twin transfusion syndrome?

A

Mortality of >90% if untreated

41
Q

When should multiple births be delivered?

A 
MCMA = 32-34+0 weeks 
DCDA = 37-38 weeks
MCDA = 36+0 weeks with steroids
42
Q

How should multiple births be delivered?

A

Triplets and MCMA twins = C-section

If one twin is cephalic then aim for vaginal delivery

43
Q

What are the features of labour for a multiple birth?

A

Epidural analgesia
Foetal monitoring with USS and FSE
Syntocinon after first twin
USS to confirm presentation

44
Q

What is the intertwin interval aimed for during a multiple birth?

A

Delivery time <30 mins inbetween twins

45
Q

What are the complications of diabetes seen in pregnancy?

A

Congenital abnormalities, miscarriage, intra-uterine death, worsening of diabetic complications, pre-eclampsia, macrosomia, shoulder dystocia, neonatal hypoglycaemia

46
Q

How should type 1 and 2 diabetics be counselled before pregnancy?

A

Avoid pregnancy is HbA1c >86 mmol/mol
Stop any embryopathic medications
High dose folic acid = 5mg

47
Q

When should women with diabetes take folic acid supplement?

A

5mg/day from 3 months before conception to 12 weeks gestation

48
Q

How are type 1 and 2 diabetics managed during pregnancy?

A

Low dose aspirin from 12 weeks gestation
Regular eye checks for retinopathy
Consider continuous glucose monitoring

49
Q

What scans are done for type 1 and 2 diabetics during pregnancy?

A

Growth scans 4 weekly from 28 weeks gestation

Foetal anomaly scan at 18-20 weeks

50
Q

When would you consider delivery in a woman with type 1 or 2 diabetes?

A

From 38 weeks onwards = may do so earlier if complications present

51
Q

What are the risk factors for gestational diabetes?

A

Previous gestational diabetes, BMI >30, affected first degree relative, previous macrosomia, polyhydramnios, South Asian/Black Caribbean, big baby, glycosuria (+1 on >1 occasion or >= 2+ on 1 occasion)

52
Q

Why can pregnancy cause diabetes?

A

It is diabetogenic state = placental hormones cause relative insulin resistance

53
Q

What are some of the consequences of gestational diabetes?

A

Overgrowth of insulin sensitive tissues and macrosomia, short term metabolic complications, hypoxaemic state in utero, increased foetal risk of obesity and diabetes

54
Q

How are women with previous gestational diabetes managed?

A

Recurrence is >50% so blood glucose monitoring or OGTT in firs trimester = repeat at 24-28 weeks if normal

55
Q

When would you screen for gestational diabetes?

A

Do OGTT at 24-28 weeks = diagnostic if fasting glucose >= 5.1 mmol/l and 2hr glucose >= 8.5 mmol/l

56
Q

Does gestational diabetes increase the risk of the mother developing type 2 diabetes?

A

Yes = increases risk by up to 70%

57
Q

What are the glycaemic targets during pregnancy?

A

Do measurements at least 4 times a day
Fasting glucose = 3.5-5.5 mmol/l
1 hour glucose = <7.8 mmol/l

58
Q

What are the benefits of oral hypoglycaemic agents?

A

Avoidance of insulin-associated hypoglycaemia

Less weight gain

59
Q

Does insulin cross the placenta?

A

No

60
Q

When would you consider delivery in a woman with gestational diabetes?

A

Insulin treatment = 38-39 weeks
Metformin treatment = 39-40 weeks
Managed by diet alone = 40-41 weeks
Deliver earlier if IUGR, pre-eclampsia or macrosomia

61
Q

When would you do a C-section for a woman with diabetes during pregnancy?

A

If EFW is greater than 4.5kg

62
Q

What are the risk factors for developing type 2 diabetes following gestational diabetes?

A

Obesity, insulin use during pregnancy, ethnic group

63
Q

How are women with diabetes during pregnancy managed post-natally?

A

Measure fasting blood glucose 6-8 weeks postnatally

If picture of type 2 diabetes then do OGTT 6 weeks postnatally

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