Large for Dates Flashcards
What are the possible causes for a ‘LFD’ pregnancy?
Wrong dates
Multiple pregnancy
DM
Polyhydramnios
What is polyhydramnios?
Excess amniotic fluid
What are some causes of polyhydramnios?
Monochorionic twin pregnancy Fetal anomaly Maternal diabetes Hydrops fetalis – Rh isoimmunisation, infection (erythrovirus B19) Ideopathic
What are some symptoms/complications of polyhydramnios?
Discomfort
Labour
Membrane rupture
Cord prolapse
How is polyhydramnios diagnosed?
US
Clinical
What are the incidences of spontaneous multiple pregnancies?
Twins 1:80
Triplets 1:10000
What is zygosity?
The number of eggs fertilised to produce twins
What is chorionicity?
The membrane pattern of the twins
What types of twins are at a higher risk of pregnancy complications?
Monochorionic/monozygous
What chorionicities can occur in monozygotic twins?
Monochorionic diamnotic ~2/3
Dichorionic diamnotic ~1/3
Monochorionic monoamniotic ~1%
What chorionicity occurs in dizygotic twins?
Dichorionic diamniotic
How can the chroionicity be discovered before birth?
US- shape of membrane and thickness of membrane: twin peak at 12 weeks
When is multiple pregnancy usually diagnosed?
12 weeks at US
What clinical features can indicate multiple pregnancy?
Exaggerated pregnancy symptoms e.g. excessive sickness
High AFP
Large for dates uterus
Feeling more than two fetal poles
Why does a multiple pregnancy have a much higher perinatal mortality?
Congenital anomalies Pre term labour Growth restriction Pre eclampsia Antepartum haemorrhage Twin to twin transfusion
How is a multiple pregnancy managed?
More frequent antenatal visits Detailed anomaly scan at 18wks Regular scans from 28wks for growth Routine iron supplementation Warning to mother re risk and signs of pre term labour
How is a multiple pregnancy delivered?
Twins- if twin one cephalic aim for SVD, possibly with epidural. Much greater risk for C-section (50%)
Triplets or more- C section
What is the definition of GDM?
Carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy
What is the incidence and ethnic variation of GDM?
2-18%
South Asia, Middle Eastern
Black Caribbean
What is the pathophysiology of GDM?
Placental hormones lead to relative insulin deficiency or resistance
Aberrant fuel mixture> glucose, aa’s and lipids
Enter placenta
Leads to hyperinsulinaemia
What are the consequences of GDM?
Overgrowth of insulin sensitive tissues and macrosomia
Hypoxaemic state in utero
Short term metabolic complications
Fetal metabolic reprogramming leading to increase long term risk of obesity, insulin resistance and diabetes
What screening is carried out for GDM?
Women screened for GTT based on RF’s or random blood glucose at booking and 28wks
How is GDM diagnosed?
Based on GTT at 28wks
Fasting >5.1mmol/l
2 hour>=8.5mmol/l
What are the risk factors for GDM?
FHx of DM Previous big baby Previous unexplained still birth Recurrently glycosuria Maternal obesity Previous GDM
What complications occur in pregnancy due to pre-existing DM?
Congenital anomalies
Miscarriage
Intra uterine death
What complications in pregnancy are common to pre-existing and GDM?
Pre eclampsia Polyhydramnios Macrosomia Shoulder dystocia Neonatal hypoglycaemia
What do all complications in pregnancy due to diabetes relate to?
Poor control
What should target levels of glucose be in pregnancy?
Fasting 3.5-5.9mmol/l
1hr post prandial <7.8mmol/l
What should initially be done in prevention of hyperglycaemia in pregnancy?
Diet
Wt control
Exercise
When should hypoglycaemic therapy be used in pregnancy?
Diet and exercise fail to maintain targets
Macrosomia on US
How is the choice of hypoglycaemic agent decided in pregnancy?
Tailored to glycaemic profile
Individual woman
What are the advantages of oral hypoglycaemics in pregnancy?
Avoidance of hypoglycaemia associated with insulin
Less wt gain
Less education required to ensure safe/effective administration
What specific obstetric care should be carried out in diabetes-related pregnancies?
Regular monitoring for PET
Growth: 2-4weekly FAC from 28wks or diagnosis
Fetal wellbeing: benefits of umbilical Doppler in high risk pregnancies and compared to CTG/BPP
Offer delivery from 38wks
What has a 38wk delivery shown to improve in insulin dependent pregnancies?
Reduction in Macrosomia
No cases of shoulder dystocia
No significant difference in C-section rates
What mode of delivery should be carried out in diabetes-related pregnancies?
Pregnant women with DM who have US diagnosed macrosomia should be informed of risks of vaginal birth and C-section
(Diabetes should not be a contraindication to attempting vaginal birth)
What risk of developing T2DM do GDM mothers have?
Up to 70%
What are the main risk factors for GDM mothers to develop T2DM?
Obesity Use of insulin during pregnancy Fasting glucose levels from OGTT in pregnancy IGT post partum Ethnic group
What lifestyle advice should women be offered post pregnancy who have IGT?
Diet, weight, exercise
Also have annual fasting blood glucose
What general management should occur with pregnant mothers who have T1/T2DM?
Pre pregnancy counselling
Fetal anomaly scan at 18 wks
Regular eye checks for retinopathy
