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Repro and Sexual Health > Large For Dates > Flashcards

Large For Dates Flashcards

1
Q

what is large for dates?

A

symphyseal-fundal height >2cm above gestational age

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2
Q

examples of what can cause large for dates?

A 
wrong date
fetal macrosomnia
polyhydramnios
diabetes (can cause macrosomnia, polyhyramnias and multiple pregnancy)
multiple pregnancy
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3
Q

what can lead to wrong dates at pregnancy booking?

A

late booking

  • concealed pregnancy (deliberate or unaware that theyre pregnant - common in very athletic women)
  • vulnerable women
  • transfer of care from abroad
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4
Q

what is fetal macrosomnia?

A

big baby
EFW > 90th centile
AC > 97th centile
(generic charts not used, charts for different ethnicities etc)

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5
Q

risks to mother of macrosomnia?

A

clinical and maternal anxiety
labour dystocia
shoulder dystocia (more with diabetes)
PPH

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6
Q

how is macrosomnia diagnosed?

A

US scan

- but EFW is commonly overestimated (10% margin of error)

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7
Q

how is macrosomnia managed?

A

exclude diabetes in mother
reassure mother
conservative measures

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8
Q

when is a cesarian section delivery advised in macrosomnia?

A

> 4.5kg

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9
Q 
25 y/o
first pregnancy
abdominal discomfort
28 weeks pregnant
35cm symphyseal-fundal height (SFH)
what is main differential?
A

polyhydramnios

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10
Q

what is polyhydramnios?

A

excess amniotic fluid
amniotic fluid index >25cm
deepest pool >8cm
(can be clinical diagnosis in experienced clinician)

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11
Q

maternal causes of polyhydramnios?

A

diabetes

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12
Q

fetal causes of polyhydramnios?

A 
anomaly (GI atresia, cardiac, tumours)
monochorionic twin pregnancy
hydrops fetalis (Rh isoimmunisation)
viral infection (erythrovirus B19, toxoplasmosis, CMV)
idiopathic
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13
Q

symptoms of polyhydramnios?

A

abdominal discomfort
pre-labour rupture of membranes (water breaking)
preterm labour
cord collapse

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14
Q

signs of polyhydramnios?

A

large for dates
malpresentation
tense shiny abdomen
inability to feel fetal parts

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15
Q

diagnosis of polyhydramnios?

A

US
- AFI >25
- DVP >8cm
(can be subjective)

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16
Q

investigations in polyhydramnios?

A

OGTT (exclude diabetes)
serology (toxoplasmosis, CMV, parovirus)
antibodys creen
USS (fetal survey - lips, stomach)

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17
Q

management of polyhydramnios?

A

inform patient of potential complications
serial US (growth, LV, presentation)
induce labour by 40 weeks
neonatal examination

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18
Q

what increases chance of multiple pregnancy?

A 
assisted conception
African race
more common in nigeria
family history
increased maternal age
increased parity
more common in tall women
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19
Q

mono/dizygotic twins?

A 
mono = splitting of a single fertilized egg (30%)
di = fertilization of 2 ova by 2 spermatozoa (70%)
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20
Q

what is chorionicity and why is it important?

A

number of placenta (1 or 2)
dizygous = always dichorionic, diamniotic (2 placenta, 2 sacs)
monozygous = can be MC/MA, MC/DA, DC/DA, or conjoined depending in time of splitting of fertilized ovum

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21
Q

splitting of the fertilized ovum at which points in time create which classification of twins?

A

day 3 after fertilization = dichorionic, diamniotic
day 4-7 = monochorionic, diamniotic
day 8-14 = monochorionic, monoamniotic
day 15+ = conjoined twins

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22
Q

how is chorionicity determined?

A

shape and thickness of membrane on US scan (11-13+6 weeks)

  • T sign = monochorionic diamniotic
  • Lambda sign = dichorionic diamniotic
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23
Q

why is chorionicity important?

A

monochorionic/monozygous twins at higher risk of complications

24
Q

symptoms of multiple pregnancy?

A

exaggerated pregnancy symptoms (e.g excessive sickness/hyperemesis gravidarum)
high AFP
large for dates
multiple fetal poles

25
Q

when can multiple pregnancy be confirmed?

A

US scan at 12 weeks

26
Q

fetal complications of multiple pregnancy?

A 
congenital abnormalities
IUD (single/both)
pre-term birth
growth restriction
cerebral palsy
twin to twin transfusion (oligohydramnios and polyhydramnios)
27
Q

maternal complications of multiple pregnancy?

A 
hyperemesis gravidarum
anaemia
pre-eclampsia
antepartum haemorrhage (abruption, placenta praevia)
preterm labour
caesarean section
28
Q

management of multiple pregnancy?

A 
consultant lead care
twin/multiple pregnancy clinic
clinic appointments
- every 2 weeks if Monochorionic
- every 4 weeks if DC
give maternal education
29
Q

what medication can be used in multiple pregnancy?

A

iron supplement
low dose aspirin
folic acid

30
Q

how are monochorionic twins monitored via US?

A 
every 2 weeks from 16 weeks
look for anomaly at 18-20 weeks
look at deep vertical pool
bladder and umbilical artery doppler
EFW
31
Q

complications in monochorionic twins?

A

single fetal death (also involves risk to surviving twin)
selective growth restriction
twin to twin transfusion syndrome (TTTS)
twin anaemia-polycythaemia sequence (TAPS)
absent EDV (AEDV) or reversed (REDV)

32
Q

what is twin anaemia polycythaemia sequence?

A

unequal blood counts between twins in the womb (form of TTTS)
can follow fetoscopic laser ablation for TTTS?

33
Q

main complications to be aware of?

A

twin to twin transfusion syndrome (TTTS)

34
Q

what is TTTS?

A

syndrome with artery-vein anastamosis
donor twin perfuses the recipient twin
(rare after 26 weeks)

35
Q

how is TTTS diagnosed?

A

oligohydramnios of one amniotic sac (low amniotic fluid) and polyhydramnios of the other (high amniotic fluid)

36
Q

complications of TTTS?

A

mortality >90% without treatment

37% neurological morbidity

37
Q

management of TTTS?

A

if before 26 weeks = fetoscopic laser ablation
if over 26 weeks = amnioreduction/septostomy
deliver at 34-36 weeks

38
Q

risks in monochorionic monoamniotic twins?

A

risk for cord entanglement
higher risk of fetal death
should be delivered by C section at 32-34 weeks

39
Q

types of complex multiple births?

A

monochorionic monoamniotic twins
conjoined twins
higher order births (trichorionic twins, monochorionic dichorionic twins)

40
Q

how are multiple pregnancies delivered?

A 
timing
- DCDA = 37-38 weeks
- MCDA = after 36 weeks with steroids
mode of delivery
- triplets or more = C/section
- MCMA = C/section
- twins = if twin one cephalic, aim for vaginal delivery
41
Q

labour is high risk in multiple pregnancy, how is this managed?

A 
ocnsultant lead
epidural anaesthesia
feal monitoring (US and FSE)
syntocinon after twin 1
US to confirm presentation
intertwin delivery time <30 mins
risks of PPH - active 3rd stage
42
Q

complications of pre-existing diabetes in pregnancy?

A

if pre-existing diabetes

  • congenital anomalies (related to high HBA1C)
  • miscarriage
  • intra-uterine death
  • worsening diabetes complications (retinopathy, nephropathy)
43
Q

complications of gestational and pre-existing diabetes in pregnancy?

A 
pre-eclampsia
polyhydramnios
macrosomnia
shoulder dystocia
neonatal hypoglycaemia
44
Q

pre-pregnancy counselling in diabetes?

A

monitor HBA1C (aim for 48)
avoid pregnancy if HBA1C >86
stop any embryopathic medication (eg ACE inhibitors, cholesterols lowering drugs)
determine macrovascular and microvascular complications
high dose folic acid 5mg 3 months before and after conception
advice about diabetes and hypoglycaemia
contraception

45
Q

management of diabetes in pregnancy?

A

early booking
5mg folic acid
low dose aspirin from 12 weeks
fetal anomaly scan at 18-20 weeks
regular eye checks for retinopathy
refer to renal team if nephropathy present
give hypoglycaemic agents (insulin MDI/pump, metformin)
consider continuous glucose monitoring
growth scans 4 weekly from 28 weeks
counsel about shoulder dystocia
deliver at 38 weeks (earlier if complications)

46
Q

risk factors for gestational diabetes?

A 
previous gestational diabetes
BMI >30
family history (in 1st degree relative)
south asian, middle eastern, black caribbean
previous big baby
polyhydramnios
big baby seen on US
glycosuria
47
Q

pathophysiology of gestational diabetes?

A

pregnancy hormones cause diabetes

- placental hormones cause relative insulin deficiency/insulin resistance

48
Q

consequences of gestational diabetes?

A

overgrowth of insulin sensitive tissues and macrosomnia
hypoxaemic state in utero
short term metabolic problems
fetal metabolic reprogramming leading to increased long term risk of obesity and diabetes

49
Q

screening and diagnosis in GD?

A 
look at risk factors at booking
if previous GD
- monitor BG
- or OGTT 1st trimester and repeat at 24-28 weeks if normal
always do OGTT at 24-28 weeks anyway
50
Q

how is OGTT taken?

A

measure venous FBS
give 75g glucose solution
measure 2 hr venous glucose (they should have minimal physical activity between tests)

51
Q

diagnostic OGTT values?

A

fasting = 5.1
2 hour = 8.5
(NICE is different)

52
Q

glycaemic targets in diabetes?

A

fasting = 3.5-5.5 mmol/L
1 hr post meal = <7.8mmol/L
should measure blood glucose minimum 4 times per day (premeal/1 hr post meal/before bed)

53
Q

potential advantages of oral hypoglycaemic agents?

A

avoidance of hypoglycaemia associated with insulin
less weight gain
less education required to ensure safe administration

54
Q

timing of delivery in diabetes?

A 
pre-existing
- 38 weeks onwards
- earlier if complications
gestational
- insulin treatment 38-39 weeks
- metformin 39-40 weeks
- diet alone 40-41 weeks
- if fetal macrosomnia/IUGR/PET earlier delivery
55
Q

mode of delivery in diabetes?

A

maternal preference
other indication for C/section
should discuss risks and benefits of vaginal birth (shoulder dystocia)
C/section if EFW >4.5kg

56
Q

post natal period in pregnancy + diabetes?

A

future development of type 2 diabetes is likely
risk factors
- obesity
- use of insulin during pregnancy
- fasting glucose levels from OGTT during pregnancy can indicate risk
- IGT post partum
- ethnic group

should do fasting blood sugar 6-8 weeks after birth
do OGTT 6 weeks after birth if picture of type 2 diabetes
annual FBS and lifestyle changes

57
Q

risk during labour in polyhydramnios?

A

malpresentation
cord prolapse
preterm labour
PPH (post partum haemorrhage)

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