Large for Dates Flashcards
What is meant by being large for dates?
- SFH >2cm for the gestational age
- bby at 35 weeks measures at 37 weeks
Reasons for being Large for Dates ?
- wrong dates
- fetal Macrosomia
- Polyhydramnios
- Diabetes
- Multiple pregnancy
Why may wrong dates occur in some cases?
- concealed pregnancy
- socially vulnerable women
- transfer of care
How to diagnose LFD?
- USS EFW >90th centile
- AC>95th Centile
- generic popn and customised growth (ehthnicity, BMI, parity)
Risks of LFD?
- clinican & maternal anxiety
- Labour dystocia (difficulty)
- Shoulder dystocia
(more with diabetes)
-PPH
A 26 week fetus is found to be LFD.
What is the course of action now?
- Exclude diabetes
- Reassure the mom
- Plan pregnancy:
Conservative vs IOL (induction of labour) vs C/S delivery
—-estimate of bby being more than 4.5kg: c-section must be done
What is polyhydramnios?
- Excess amniotic fluid
- —-deepest pool (in cord-free area) >8cm
- —-AFI of >25cm
Maternal causes of polyhydramnios?
- diabetes
Fetal etiology of Polyhydramnios?
- ANOMALY: GI atesia, cardiac, tumors,
- monochorionic TWIN pregnancy
- hydrops fetalis: fluid accumulation in 2 or more compartments (Rh isoimmunisation)
- viral infection (CMV, toxoplasmosis, EBV 19)
What is seen on examination for suspected polyhydramnios?
- LFD
- Malpresentation
- tense shiny abdomen
- inability to feel fetal parts
Management of polyhydramnios?
Patient information- complications
Serial USS- to monitor growth, LV, presentation
IOL by 40 weeks —-associated perinatal mortality
Neonatal examination
How is Polyhydramnios diagnosed?
Ultrasound Confirmation
AFI (amniotic fluid index) >25
DVP(deep vertical pocket) >8cm
What are symptoms of Polyhydramnios?
- Abdominal discomfort
- Pre-labour rupture of membranes
- Preterm labour
- Cord prolapse
Why may multiple pregnancies occur?
- assisted conception (IVF-UK limits to 1 embryo, clomid)
- Race (African)
- geography (1 in 25 births in Nigeria are twins vs 1 in 500 in Japan)
- family hx
- increased maternal AGE
- increased parity
- Tall women> short women
Why is there a geographical discrepancy with twin gestation?
- evolution; nature gives you a better chance to survival
Split in day 1-3?
DCDA
When does the splitting of the embryo occur for conjoined twins to result? Why?
Days 13-15
—-late: time for the embryonic disc form
e
How to determine chorionicity?
Ultrasound
- –Shape of membrane and THICKNESS of membrane (twin peak at 11-13+6 weeks)
- -placental masses
- Lambda sign (membrane thickness, appearance of membrane attachment)
—Fetal Sex
Symptoms of Multiple pregnancy?
Exaggerated pregnancy symptoms e.g. excessive sickness/ hyperemesis gravidarum
SIgns of multiple pregn?
- High AFP
- Large for dates uterus
- Mutiple fetal poles
When can multiple pregnancies be confirmed?
- USS confirmation at 12 weeks
WHat are the complications for the mother from multiple pregnancie?
- Hyperemesis Gravidarum
- Anaemia
- Pre eclampsia
- Antepartum haemorrhage- abruption, placenta praevia
- Preterm Labour
- Caesarean section
Fetal complications of multiple pregnancies?
Perinatal mortality is 6x HIGHER compared to Singleton pregnancy….
- Congenital anomalies (acardiac twin)
- IUD ( single/both)
- Pre term birth
- Growth restriction- both /discordant
- Cerebral Palsy-(twins 8X higher, triplets 47X higher)
Twin to twin transfusion- oligohydramnios & polyhydramnios
Diff. in clinical appointments between MC and DC twins?
MC: every 2 weeks (monochorionic)
DC every 4 weeks
Medications for multiple preg. mom?
Fe supplementation
Low Dose Aspirin
Folic Acid
What is the risk of single intra-uterine death to the survivor?
- 26% risk of neurological abnormality
- 15 % risk of survivor death (IUD)
Twin-twin transfusion syndrome?
- smaller one baby
- arteriovenous anastomosis —–donor twin perfuses the recipient twin
- —-rare after 26 weeks gestation
What is the risk of MCMA?
- Risk for cord entanglement
- Higher Risk of Fetal Death
- Deliver by C/Section 32-34+0 weeks
When should MCDA and DCDA twins be delivered?
- DCDA: deliver at 37-38 weeks
- MCDA: deliver after 36+0 weeks with steroids
Mode of delivery for multiple pregnancy?
- C-section: triplets and MCMA
- do Vaginal delivery if one is in Cephalic
What is the intertwin delivery time?
<30 mins each
Types of Pregestattional diabetes?
- MODY (mature onset of diabetes of the young)
- Type 1, 2
Always tell a sexually active diabetic to ______
- use contraception !
- –high risk pregnancy; should be prepared for it
Complications common to PRE-existing and gestational diabetes in pregnancy?
- Pre eclampsia
- Polyhydramnios
- Macrosomia
- Shoulder dystocia
- Neonatal hypoglycaemia
At what hba1c level should the pregnancy not be done?
HBA1C ABOVE 86mmol/mol
How to manage TYPE 1 AND 2 diabtes in preg.?
- folic acid 5mg
- Low dose aspirin from 12 weeks
- INSULIN AND METFORMIN (type2)
- continous glucose monitoring
- growth scans (4 weekly)
- counsel about SHOULDER dystocia
- deliver at 38 weeks (earlier with complications)
- —-fetal anomaly scan at 18-20 weeks
- eye check ups for retinopathy
- early booking in diabetic ANC
OGTT dx of GDM?
Fasting >=5.6 mmol/l
2 hour >= 7.8 mmol/l
Mainstay rx for GDM?
- mainstay exercise and diet control
RIsks of lack of GDM control?
- Macrosomia
- Neonatal Hypoglycemia
Educating the patient of what risks regarding GDM?
- importance (measure glucose 4 times a week) - premeals——measure POST-PRANDIAL BG
- transient morbidity in baby
- risk of obesity and diabetes
- increased risk of type 2 diabetes
WHy is insulin administration NOT enough for diabetes control?
- insulin without exercise = WEIGHT gain; sugar build up in fat
What is the % risk of shoulder dystocia?
- 9-10% risk
POSTNATAL - management?
= FBS at 6-8wks
DOSE OF FOLIC ACID Administration in diabetic mother ?
- 5mg!!!
What occurs in shoulder dystocia?
- baby’s anterior shoulder gets stuck underneath the mother’s pubic bone==> MAY damage the brachial plexus
How accurate is the USS for predicting the bby’s weight?
- USS EFW is commonly OVERESTIMATED (compared to actual weight)
- margin of error up to 10%
- —more accurate <38 weeks !
What is NICE recommendation on IOL?
- should NOT be carried out simply because a healthcare professional suspects a baby is LFD
What investigations are done for suspected polyhydramnios?
- OGTT (oral glucose tolerance tests)
- serology (CMV, Parvovirus, toxoplasmosis)
- Antibody screen
- USS (fetal survey: lips and stomach)
How is polyhramnios managed?
- make pt aware of complications that MAY arise
- Serial USS (growth, LV, presentation)
- IOL by 40 weeks
- risk of pre-term labour (serial check ups!)
- risk of cord prolapse/ PPH
- risk malpresentation
What are the 2 types of Zygosity?
- Monozygotic: splitting of a SINGLE fertilized egg (30%)
- Dizygotic: fertilization of 2 ova by 2 sperms (70%)
What is meant by chorionicity?
1 placenta/2placentas
- —-DIZYGOUS: DCDA
- —-MONOZYGOUS: MCMA, MCDA, DCDA, conjoined
Cleavage of the blastocyst at day 4-8?
MCDA
Cleavage of implanted blastocyst at days 8-13?
MCMA
When are monochorionic pregnancies likely to occur?
- Days 4-7 and 8-14
What chorionicty is at a higher risk of pregnancy complications?
- Monochorionic/ Monozygous twins
- —-clinical appointments are evry 2 WEEKS
(DC: 4Wks)
How does the Lambda sign appear?
- a triangle appearance of the chorion insinuating layers of the intertwin pregnancies
What is told to the mother during maternal education for multiple pregnancy?
- pre-term labour and risks
- support
- TAMBA
What is the managment of multiple pregnancies?
Meds: Fe supplementation/ Folic Acid/ Low dose aspirin
USS: MC (2x wkly)/ Anomaly USS (18-20 wks)
Why are MC twins asked to come in more frequently for their USS scans?
- Huge risk of complications including:
1. Single fetal death
2. Selective growth restriction
3. Twin-to-twin Transfusion syndrome
(TTTS)
4. Twin anemia-Polycythemia Sequence (TAPS)
5. Absent EDV (AEDV) or Reversed (REDV)
What is EDV?
- indicated through an umbilical artery Doppler assessment
- placental insufficiency (seen in MC) may result in Absent EDV (End diastolic flow) or Reversed EDV (REDV)
What ivx to follow after singleton death?
- MRI of cofetal brain 4 wks post IUD!
- MCA PSV to check for fetal anemia (middle cerebral arterial, peak systolic velocity)
What is meant by EFW discordance?
- growth discordance means a significant wgt differences between the 2 fetuses
> 20% is a.w INCR. PERINATAL risks
When may TAPS (Twin Anemia- Polycythemia Sequence occur)?
What should be checked for?
- after a small surgical procedure to resolve TTTS (twin-transfusion $) –
FETOSCOPIC laser ablation for TTTS - abnormal vessel connections are sealed off
- MCA PSV
- absent/ reversed EDV to be checked for!
How is TTTS dx?
- findings of polyhydramnios in one sac and oligohydramnios in the other sac
What are the complications of TTTS?
- mortality >90% with no rx
- neurological morbidity of 37% and HIGH in surviving twin if IUD
RX for TTTS?
- fetoscopic laser ablation (before 26wks)
- Amnioreduction/septosomy >26wks
- deliver 34-36 wks
Multiple pregnancy labour holds high risk. What are some precautions that should be taken?
- consultant LED unit
- epidural analgesia
- fetal monitoring (USS and FSE)
- Syntocinon after twin 1
- USS to confirm presentation
- intertwin delivery time (<30 min)
- risk of PPH (active 3rd stage)
Define GDM.
- carbohydrate intolerance resulting in HYPERGLYCEMIA of variable severity with onset or first recognition during pregnancy
Complications specific to pre-existing diabetes in pregnancy?
- congenital anomalies (depends on HBA1C levels)
- miscarriage
- IUD
- worsening diabetic complications
What would be expected of a Type 1 diabetic vs a type 2?
- Tpe 1: slimmer/ 5-10% prevalence/insulin def./white
- type 2: overweight/older/ non-caucasian
Why is it important to be well-prepared prior to conceiving a child when diabetic?
- aim for HBA1C of 48 mmol./mol (6.5%)
- to stop embryopathic meds (ACE inhibitors, cholestrol lowering agents)
- determine macrovascular and microvascular complications
- —-start on HIGH dose FOLIC ACID 3 months before conception (5mg)
- —-advise on hypglycemia
- contraception if not wanting to concieve
What are risk factors of GDM?
- previous
- BMI >31
- Family hx
- Asian, Caribbean, Middle eastern
- previous /current BIG baby
- polyhydramnios
- glycosuria (1+ on >1 times)
What is HpL known to do? Its consequence?
- during late pregnancy increases up to 30 fold ; inducing huge insulin release !
> cause insulin resistance
—-overgrowth of insulin sensitive tissues
—-hyopxaemic state in utero ….metabolic changes to baby (obesity, diabetes)
WHat happens if OGTT in 1st trimester is NORMAL?
- repeat in 24-28 weeks
What does OGTT involve?
- venous FBS > given a 75g Glucose solution> 2hr venous glucose reading is obtained (minimal activity to avoid false +)
Advs of oral hypoglycemics agents over insulin?
- less weight gain
- less administration info
What is problem with insuling use for the fetus?
- risk of hypoglycemia
- —does not cross the placenta
How is the delivery timing diff. for timing of delivery for GDM pts on metformin vs diet alone?
- diet alone: 40-41 weeks
- Metformin: 39-40
—-insulin rx: 38-39 weeks
When should the baby be delivered early with diabetic pts?
- if fetus has macrosomia/ IUGR/ PET earlier delivery
What is the % risk of the Type 2 diabetes developing later in the mom ?
- 70%
- —-main risks: obesity/insulin use/ ethnic gr.
Risks during labour in polyhydramnios?
- Risk malpresentation
- Risk of cord prolapse
- Risk of Preterm Labour
- Risk of PPH (postpartum hemorrh.)
