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REPRO > Large for Dates > Flashcards

Large for Dates Flashcards

1
Q

What is meant by being large for dates?

A
  • SFH >2cm for the gestational age

- bby at 35 weeks measures at 37 weeks

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2
Q

Reasons for being Large for Dates ?

A
  • wrong dates
  • fetal Macrosomia
  • Polyhydramnios
  • Diabetes
  • Multiple pregnancy
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3
Q

Why may wrong dates occur in some cases?

A
  • concealed pregnancy
  • socially vulnerable women
  • transfer of care
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4
Q

How to diagnose LFD?

A
  • USS EFW >90th centile
  • AC>95th Centile
  • generic popn and customised growth (ehthnicity, BMI, parity)
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5
Q

Risks of LFD?

A
  • clinican & maternal anxiety
  • Labour dystocia (difficulty)
  • Shoulder dystocia
    (more with diabetes)
    -PPH
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6
Q

A 26 week fetus is found to be LFD.

What is the course of action now?

A
  1. Exclude diabetes
  2. Reassure the mom
  3. 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

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7
Q

What is polyhydramnios?

A
  • Excess amniotic fluid
  • —-deepest pool (in cord-free area) >8cm
  • —-AFI of >25cm
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8
Q

Maternal causes of polyhydramnios?

A
  • diabetes
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9
Q

Fetal etiology of Polyhydramnios?

A
  • 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)
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10
Q

What is seen on examination for suspected polyhydramnios?

A
  • LFD
  • Malpresentation
  • tense shiny abdomen
  • inability to feel fetal parts
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11
Q

Management of polyhydramnios?

A

Patient information- complications
Serial USS- to monitor growth, LV, presentation
IOL by 40 weeks —-associated perinatal mortality

Neonatal examination

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12
Q

How is Polyhydramnios diagnosed?

A

Ultrasound Confirmation
AFI (amniotic fluid index) >25
DVP(deep vertical pocket) >8cm

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13
Q

What are symptoms of Polyhydramnios?

A
  • Abdominal discomfort
  • Pre-labour rupture of membranes
  • Preterm labour
  • Cord prolapse
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14
Q

Why may multiple pregnancies occur?

A
  • 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
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15
Q

Why is there a geographical discrepancy with twin gestation?

A
  • evolution; nature gives you a better chance to survival
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16
Q

Split in day 1-3?

A

DCDA

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17
Q

When does the splitting of the embryo occur for conjoined twins to result? Why?

A

Days 13-15
—-late: time for the embryonic disc form

e

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18
Q

How to determine chorionicity?

A

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

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19
Q

Symptoms of Multiple pregnancy?

A

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

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20
Q

SIgns of multiple pregn?

A
  • High AFP
  • Large for dates uterus
  • Mutiple fetal poles
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21
Q

When can multiple pregnancies be confirmed?

A
  • USS confirmation at 12 weeks
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22
Q

WHat are the complications for the mother from multiple pregnancie?

A
  • Hyperemesis Gravidarum
  • Anaemia
  • Pre eclampsia
  • Antepartum haemorrhage- abruption, placenta praevia
  • Preterm Labour
  • Caesarean section
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23
Q

Fetal complications of multiple pregnancies?

A

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

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24
Q

Diff. in clinical appointments between MC and DC twins?

A

MC: every 2 weeks (monochorionic)

DC every 4 weeks

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25
Q

Medications for multiple preg. mom?

A

Fe supplementation
Low Dose Aspirin
Folic Acid

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26
Q

What is the risk of single intra-uterine death to the survivor?

A
  • 26% risk of neurological abnormality

- 15 % risk of survivor death (IUD)

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27
Q

Twin-twin transfusion syndrome?

A
  • smaller one baby
  • arteriovenous anastomosis —–donor twin perfuses the recipient twin
  • —-rare after 26 weeks gestation
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28
Q

What is the risk of MCMA?

A
  • Risk for cord entanglement
  • Higher Risk of Fetal Death
  • Deliver by C/Section 32-34+0 weeks
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29
Q

When should MCDA and DCDA twins be delivered?

A
  • DCDA: deliver at 37-38 weeks

- MCDA: deliver after 36+0 weeks with steroids

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30
Q

Mode of delivery for multiple pregnancy?

A
  • C-section: triplets and MCMA

- do Vaginal delivery if one is in Cephalic

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31
Q

What is the intertwin delivery time?

A

<30 mins each

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32
Q

Types of Pregestattional diabetes?

A
  • MODY (mature onset of diabetes of the young)

- Type 1, 2

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33
Q

Always tell a sexually active diabetic to ______

A
  • use contraception !

- –high risk pregnancy; should be prepared for it

34
Q

Complications common to PRE-existing and gestational diabetes in pregnancy?

A
  • Pre eclampsia
  • Polyhydramnios
  • Macrosomia
  • Shoulder dystocia
  • Neonatal hypoglycaemia
35
Q

At what hba1c level should the pregnancy not be done?

A

HBA1C ABOVE 86mmol/mol

36
Q

How to manage TYPE 1 AND 2 diabtes in preg.?

A
  • 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
37
Q

OGTT dx of GDM?

A

Fasting >=5.6 mmol/l

2 hour >= 7.8 mmol/l

38
Q

Mainstay rx for GDM?

A
  • mainstay exercise and diet control
39
Q

RIsks of lack of GDM control?

A
  • Macrosomia

- Neonatal Hypoglycemia

40
Q

Educating the patient of what risks regarding GDM?

A
  • 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
41
Q

WHy is insulin administration NOT enough for diabetes control?

A
  • insulin without exercise = WEIGHT gain; sugar build up in fat
42
Q

What is the % risk of shoulder dystocia?

A
  • 9-10% risk
43
Q

POSTNATAL - management?

A

= FBS at 6-8wks

44
Q

DOSE OF FOLIC ACID Administration in diabetic mother ?

A
  • 5mg!!!
45
Q

What occurs in shoulder dystocia?

A
  • baby’s anterior shoulder gets stuck underneath the mother’s pubic bone==> MAY damage the brachial plexus
46
Q

How accurate is the USS for predicting the bby’s weight?

A
  • USS EFW is commonly OVERESTIMATED (compared to actual weight)
  • margin of error up to 10%
  • —more accurate <38 weeks !
47
Q

What is NICE recommendation on IOL?

A
  • should NOT be carried out simply because a healthcare professional suspects a baby is LFD
48
Q

What investigations are done for suspected polyhydramnios?

A
  • OGTT (oral glucose tolerance tests)
  • serology (CMV, Parvovirus, toxoplasmosis)
  • Antibody screen
  • USS (fetal survey: lips and stomach)
49
Q

How is polyhramnios managed?

A
  1. make pt aware of complications that MAY arise
  2. Serial USS (growth, LV, presentation)
  3. IOL by 40 weeks
    - risk of pre-term labour (serial check ups!)
    - risk of cord prolapse/ PPH
    - risk malpresentation
50
Q

What are the 2 types of Zygosity?

A
  • Monozygotic: splitting of a SINGLE fertilized egg (30%)

- Dizygotic: fertilization of 2 ova by 2 sperms (70%)

51
Q

What is meant by chorionicity?

A

1 placenta/2placentas

  • —-DIZYGOUS: DCDA
  • —-MONOZYGOUS: MCMA, MCDA, DCDA, conjoined
52
Q

Cleavage of the blastocyst at day 4-8?

A

MCDA

53
Q

Cleavage of implanted blastocyst at days 8-13?

A

MCMA

54
Q

When are monochorionic pregnancies likely to occur?

A
  • Days 4-7 and 8-14
55
Q

What chorionicty is at a higher risk of pregnancy complications?

A
  • Monochorionic/ Monozygous twins
  • —-clinical appointments are evry 2 WEEKS

(DC: 4Wks)

56
Q

How does the Lambda sign appear?

A
  • a triangle appearance of the chorion insinuating layers of the intertwin pregnancies
57
Q

What is told to the mother during maternal education for multiple pregnancy?

A
  • pre-term labour and risks
  • support
  • TAMBA
58
Q

What is the managment of multiple pregnancies?

A

Meds: Fe supplementation/ Folic Acid/ Low dose aspirin

USS: MC (2x wkly)/ Anomaly USS (18-20 wks)

59
Q

Why are MC twins asked to come in more frequently for their USS scans?

A
  • 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)
60
Q

What is EDV?

A
  • indicated through an umbilical artery Doppler assessment

- placental insufficiency (seen in MC) may result in Absent EDV (End diastolic flow) or Reversed EDV (REDV)

61
Q

What ivx to follow after singleton death?

A
  • MRI of cofetal brain 4 wks post IUD!

- MCA PSV to check for fetal anemia (middle cerebral arterial, peak systolic velocity)

62
Q

What is meant by EFW discordance?

A
  • growth discordance means a significant wgt differences between the 2 fetuses

> 20% is a.w INCR. PERINATAL risks

63
Q

When may TAPS (Twin Anemia- Polycythemia Sequence occur)?

What should be checked for?

A
  • 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!
64
Q

How is TTTS dx?

A
  • findings of polyhydramnios in one sac and oligohydramnios in the other sac
65
Q

What are the complications of TTTS?

A
  • mortality >90% with no rx

- neurological morbidity of 37% and HIGH in surviving twin if IUD

66
Q

RX for TTTS?

A
  • fetoscopic laser ablation (before 26wks)
  • Amnioreduction/septosomy >26wks
  • deliver 34-36 wks
67
Q

Multiple pregnancy labour holds high risk. What are some precautions that should be taken?

A
  • 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)
68
Q

Define GDM.

A
  • carbohydrate intolerance resulting in HYPERGLYCEMIA of variable severity with onset or first recognition during pregnancy
69
Q

Complications specific to pre-existing diabetes in pregnancy?

A
  • congenital anomalies (depends on HBA1C levels)
  • miscarriage
  • IUD
  • worsening diabetic complications
70
Q

What would be expected of a Type 1 diabetic vs a type 2?

A
  • Tpe 1: slimmer/ 5-10% prevalence/insulin def./white

- type 2: overweight/older/ non-caucasian

71
Q

Why is it important to be well-prepared prior to conceiving a child when diabetic?

A
  • 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
72
Q

What are risk factors of GDM?

A
    • previous
  • BMI >31
  • Family hx
  • Asian, Caribbean, Middle eastern
  • previous /current BIG baby
  • polyhydramnios
  • glycosuria (1+ on >1 times)
73
Q

What is HpL known to do? Its consequence?

A
  • 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)
74
Q

WHat happens if OGTT in 1st trimester is NORMAL?

A
  • repeat in 24-28 weeks
75
Q

What does OGTT involve?

A
  • venous FBS > given a 75g Glucose solution> 2hr venous glucose reading is obtained (minimal activity to avoid false +)
76
Q

Advs of oral hypoglycemics agents over insulin?

A
  • less weight gain

- less administration info

77
Q

What is problem with insuling use for the fetus?

A
  • risk of hypoglycemia

- —does not cross the placenta

78
Q

How is the delivery timing diff. for timing of delivery for GDM pts on metformin vs diet alone?

A
  • diet alone: 40-41 weeks
  • Metformin: 39-40

—-insulin rx: 38-39 weeks

79
Q

When should the baby be delivered early with diabetic pts?

A
  • if fetus has macrosomia/ IUGR/ PET earlier delivery
80
Q

What is the % risk of the Type 2 diabetes developing later in the mom ?

A
  • 70%

- —-main risks: obesity/insulin use/ ethnic gr.

81
Q

Risks during labour in polyhydramnios?

A
  • Risk malpresentation
  • Risk of cord prolapse
  • Risk of Preterm Labour
  • Risk of PPH (postpartum hemorrh.)

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