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Reproduction and Sexual Health > Large for Dates > Flashcards

Large for Dates Flashcards

1
Q

Give 5 potential reasons why a baby may be LFD.

A
  • Wrong dates.
  • Fetal macrosomia.
  • Polyhydramnios.
  • Diabetes.
  • Multiple pregnancy.
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2
Q

What may cause a woman to be a ‘late booker’?

A
  • Concealed pregnancy.
  • Vulnerable woman.
  • Booked abroad.
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3
Q

What does foetal macrosomnia essentially mean?

A

‘Big baby.’

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4
Q

How is foetal macrosomnia diagnosed?

A

Using USS – if EFW (estimated fetal weight) is >90th centile.
+
Generic population-based and customised growth charts (ethnicity, BMI, parity).

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5
Q

What risks are associated with foetal macrosomnia?

A
  • Clinician and maternal anxiety.
  • Labour dystocia.
  • Shoulder dystocia.
  • PPH.
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6
Q

What is shoulder dystocia more common with?

A

Diabetes

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7
Q

How is shoulder dystocia managed?

A
  • Exclude diabetes.
  • Reassure.
  • Conservative vs IOL vs C/S delivery.
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8
Q

What is Polyhydramnios?

A

Excess amniotic fluid

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9
Q

What are the potential causes of polyhydramnios?

A
  • Maternal diabetes.
  • Fetal anomaly.
  • Monochorionic twin pregnancy.
  • Hydrops fetalis – Rh isoimmunisation, infection (erythrovirus B19).
  • Idiopathic.
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10
Q

List clincal features of polyhydramnios.

A
  • Abdominal discomfort.
  • Pre-labour rupture of membranes.
  • Preterm labour.
  • Cord prolapse.
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11
Q

Outline components of polyhydramnios seen clinically.

A
  • Abdominal discomfort.
  • Pre-labour rupture of membranes.
  • Preterm labour.
  • Cord prolapse. * Malpresentation.
  • Tense shiny abdomen.
  • Inability to feel fetal parts.
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12
Q

Outline what is seen on US in polyhydramnios.

A
  • AFI (amniotic fluid index) >25.

* DVP (deepest vertical pocket) >8cm.

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13
Q

How is polyhydramnios diagnosed?

A

Clinical + US

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14
Q

Once polyhydramnios has been diagnosed, what further investigations should be carried out?

A
  • OGTT.
  • Serology – toxoplasmosis, CMV, parovirus.
  • Antibody screen.
  • USS – fetal survey – lips, stomach.
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15
Q

Outline the management of polyhydramnios.

A
  • Patient information re complications.
  • Serial USS to monitor growth, LV, presentation.
  • IOL (induction of labour) by 40 weeks.
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16
Q

What is there a risk of in labour of someone with polyhydramnios?

A
  1. Cord prolapse.
  2. Preterm labour.
  3. PPH.
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17
Q

What type of exam must be done thoroughly in someone with polyhydramnios?

A

Neonatal exam

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18
Q

What is multiple pregnancy defined as?

A

The presence of more than 1 foetus e.g. twins, triplets etc.

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19
Q

What factors increase the risk of multiple pregnancy?

A
  • Assisted conception- clomid, IVF (UK limits to 2 embryos)
  • Race- African
  • Geography
  • Europe 6-9/1000 deliveries
  • Nigeria 40-50/1000 (1 in 25) deliveries
  • Japan & China 2/1000 (1 in 500) deliveries
  • Family History
  • Increased maternal age
  • Increased Parity
  • Tall women> short women
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20
Q

What is meant by ‘monozygotic’?

A

The splitting of a single fertilised egg

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21
Q

What % of twin pregnancies are monozygotic?

A

30%

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22
Q

What is mean by dizygotic?

A

The fertilization of 2 ova by 2 spermatozoa

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23
Q

What % of twin pregnancies are dizygotic?

A

70%

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24
Q

What does ‘Chorionicity’ refer to?

A

Whether there is 1 or 2 placentas

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25
Q

Dizygous pregnancies are always what?

A

DCDA

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26
Q

Monozygous pregnancies can be what?

A

MCMA, MCDA, DCDA, conjoined

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27
Q

What does Chorionicity depend on?

A

The time of splitting of the fertilised ovum

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28
Q

What features – seen on ULTRASOUND – can help determine chorionicity?

A
  • Shape of membrane and thickness of membrane – twin peak at 12 weeks.
  • Foetal sex.
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29
Q

If splitting of the fertilized ovum occurs at each of the following days after fertilisation, what type of twin pregnancy results?

i) Day 0-3
ii) Day 4-7
iii) Day 8-14
iv) Day 15 onwards

A
  • DCDA
  • MCDA
  • MCMA
  • Conjoined twins
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30
Q

Why is it important to determine chorionicity?

A

Monochorionic/monozygous twins are at higher risk of pregnancy complications.

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31
Q

What sign is suggestive of dichorionic diamniotic twins?

A

Lambda

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32
Q

What sign is suggestive of monochorionic diamniotic twins?

A

T sign

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33
Q

Outline the symptoms of multiple pregnancy.

A

Exaggerated pregnancy sx e.g. excessive sickness/hyperemesis gravidarum.

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34
Q

What are the signs of multiple pregnancy (on ix)?

A
  • High AFP.
  • Large for dates uterus.
  • Multiple foetal poles.
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35
Q

When and how is a multiple pregnancy confirmed?

A

USS at 12 weeks

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36
Q

Multiple pregnancies are associated with higher perinatal mortality. How much higher is this?

A

6 x’s higher than a single pregnancy

37
Q

What foetal complications are associated with multiple pregnancy?

A
  • Congenital anomalies
  • IUD (single/both)
  • Pre-term birth
  • Growth restriction- both /discordant
  • Cerebral Palsy-(twins 8X higher, triplets 47X higher)
  • Twin to twin transfusion- oligohydramnios& polyhydramnios
38
Q

What maternal complications are associated with multiple pregnancy?

A
  • Hyperemesis Gravidarum
  • Anaemia
  • Pre-eclampsia
  • Antepartum haemorrhage- abruption, placenta praevia
  • Preterm Labour
  • Caesarean section
39
Q

What health professional leads a multiple pregnancy antenatal management?

A

Consultant

40
Q

How often do monochorionic twins get a clinical appointment?

A

Every 2 weeks

41
Q

How often do dichorionic twins have an antenatal appointment?

A

Every 4 weeks

42
Q

What medications should women who are pregnant with twins be taking?

A
  • Fe supplementation.
  • Low dose aspirin.
  • Folic acid.
43
Q

How often do monochorionic twins get an US scan?

A

Every 2 weeks

44
Q

How often do dichorionic twins get an US scan?

A

Every 4 weeks

45
Q

When is the anomaly US scan done for twins?

A

18-20 weeks.

46
Q

When do DCDA tend to deliver?

A

At 37-38 weeks

47
Q

When do MCDA twins deliver?

A

At 36 weeks

48
Q

What is the mode of delivery for triplets or more?

A

C section

49
Q

In twins, if one is cephalic, what kind of delivery should you aim for?

A

Vaginal

50
Q

Syntocinon (oxytocin) should be given when (in a multiple pregnancy birth)?

A

After twin 1

51
Q

How long should intertwin delivery time be?

A

<30 mins

52
Q

What are the 3 types of pre-gestational diabetes to consider?

A
  1. Type 1.
  2. Type 2.
  3. MODY.
53
Q

What does the WHO define gestational diabetes as?

A

Carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy.

54
Q

What do complications of diabetes in pregnancy all relate to?

A

Poor control

55
Q

What complication are specific to pre-existing diabetes?

A
  • Congenital anomalies – related to high HBA1C at booking.
  • Miscarriage.
  • Intra-uterine death.
56
Q

What complications are specific to pre-existing and gestational diabetes?

A
  • Pre-eclampsia.
  • Polyhydramnios.
  • Macrosomia.
  • Shoulder dystocia.
  • Neonatal hypoglycaemia.
57
Q

Ideally, what should pre-pregnancy counselling in type 1 and type 2 diabetes cover(5)?

A
  • HBA1C Monitoring- avoid pregnancy if HBA1C very high
  • Stop any embryopathic medication eg ACE inhibitors, cholesterol lowering agents
  • High Dose Folic Acid 5mg (3 months before conception to 12 weeks of pregnancy)
  • Advice about diabetes
  • Contraception
58
Q

What 2 things should a woman with diabetes be prescribed in a diabetic antenatal clinic?

A
  • Folic acid - 5mg

* Low dose Aspirin

59
Q

When is the foetal anomaly scan done in diabetes?

A

18 weeks

60
Q

Why should women with diabetes have regular eye scans?

A

To screen for retinopathy

61
Q

How often should pregnancy diabetic women get growth scans?

A

Growth scans 4 weekly from 28 weeks

62
Q

There is an __________ incidence of gestational DM

A

INCREASING

63
Q

Outline the risk factors for gestational DM.

A
  • Previous GDM
  • Obesity BMI 30 or more
  • FH: 1st degree relative
  • Ethnic variation: South Asia (India / Pakistan/ Bangladesh), Middle Eastern, Black Caribbean
  • Previous big baby
  • Polyhydramnios
  • Big baby – AC / EFW on USS
  • Glycosuria (1+ on >1 occasion or >= 2+ on one occasion)
64
Q

Pregnancy is diabetogenic

A

TRUE

65
Q

What is the effect of placental hormones in gestational DM?

A

They can contribute to a relative insulin deficiency/insulin resistance.

66
Q

What are the potential consequences of placenta hormones in GDM?

A
  • 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.
67
Q

If a woman has had previous GDM, what should be done?

A
  • BG monitoring.
    or
  • OGTT 1st trimester – repeat at 24-28weeks if normal.
68
Q

When should an OGTT be done in someone with previous GDM?

A

24-28 weeks

69
Q

How is the OGTT carried out during pregnancy?

A

Venous FBS - 75g glucose - 2hr venous glucose.

70
Q

What are the diagnostic results of the OGTT for GDM?

A

Fasting >=5.1mmol/l.

2 hour >=8.5mmol/l.

71
Q

What fasting BG should be aimed for in GDM?

A

3.5-5.9mmol/l.

72
Q

What 1hr BG should be aimed for in GDM?

A

<7.8mmol/l.

73
Q

How often should blood glucose be taken in someone with GDM?

A

Minimum 4 times a day- premeals (sometimes 1 hr postmeal ) and before bed.

74
Q

When should hypoglycaemic agents be considered in someone with GDM?

A
  • diet and exercise fail to maintain targets

* macrosomia on ultrasoun

75
Q

What are the potential advantages of oral hypoglycaemic agents?

A
  • Avoidance of hypoglycaemia associated with insulin.
  • Less weight gain.
  • Less ‘education’ required to ensure safe/ effective administration.
76
Q

Does insulin cross the placenta?

A

NO

77
Q

What is there a risk of with insulin tx?

A

Hypoglycaemia

78
Q

In a mother with pre-gestational diabetes, when should the baby be delivered?

A

38 weeks onwards, but earlier if there are complications

79
Q

In a mother with GDM, when should the baby be delivered if on insulin?

A

38 weeks

80
Q

In a mother with GDM, when should the baby be delivered if on metformin?

A

39-40 weeks

81
Q

In a mother with GDM, when should the baby be delivered if managed with diet alone?

A

40-41 weeks

82
Q

In a mother with GDM, when should the baby be delivered if fetal macrosomia/IUGR/PET?

A

Earlier delivery

83
Q

If EFW >4.5kg, what should the mode of delivery be?

A

C -section

84
Q

What is the mode of delivery in a diabetic mother?

A

Whatever the mother wants

85
Q

What is the risk of future development of T2DM in someone with GDM?

A

70%

86
Q

What are the main risk factors for the development of T2DM post-natal?

A
  • Obesity
  • Use of insulin during pregnancy
  • Fasting glucose levels from OGTT in pregnancy
  • IGT post-partum
  • Ethnic group
87
Q

When should FBS (fasting blood sugar) be checked post-natal??

A

6-8 weeks

88
Q

If picture of T2DM, what should be done?

A

OGTT at 6 weeks post-natal

Reproduction and Sexual Health (51 decks)

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