Large for dates Flashcards
What is the definition for a large for date baby?
Symphyseal fundal height >2cm for gestational age
What are the causes for large for date babies?
Wrong EDD Foetal macrosomia Polyhydramnios Diabetic mother Multiple pregnancy
How is foetal macrosomia diagnosed?
USS EFW >90th centile
AC >97th centile
Generic population based charts and customised growth charts (ethnicity, BMI, parity(
What are the risks assoc with foetal macrosomia?
Clinical and maternal anxiety
Labour dystocia
Shoulder dystocia
PPH
How accurate is USS in diagnosis of foetal macrosomia?
EFW is commonly overestimated in comparison to actual weight
Gestation more accurate <38 weeks
BMI of women will impact
What formula is used for estimation of EFW?
Hadlock
What is the management of macrosomia?
Exclude diabetes
Reassure
Conservative vs IOL (by 40 wks) vs C/S
What are the nice recommendations for macrosomia?
In absence of any other indications, induction of labour should not be carried out simply because a healthcare professional suspects a baby is large for gestational age (macrosomic)
What is the recommendation if a baby is over 4.5 kg?
C/S
What is the definition of polyhydramnios?
Excess amniotic fluid
How is polyhydramnios diagnosed?
Amniotic fluid index > 25 cm
Deepest pool >8cm
What maternal factors can result in polyhydramnios?
Diabetes
What foetal factors can result in polyhydramnios?
Anomaly; GI atresia, cardia, tumours MCMA twin pregnancy Hydrops fetalis; rhesus isoimmunisation Viral infections; erythrovirus B19, toxoplasmosis, CMV Idiopathic
What are the symptoms of polyhydramnios?
Abdominal discomfort
Preterm rupture of membranes
Preterm labour; pressure on uterus
Cord prolapse
What are the signs of polyhydramnios?
LFD; large for days
Malpresentation
Tense shiny abdomen
Inability to feel foetal parts
What investigations should be performed when a diagnosis of polyhydramnios is confirmed?
OGTT; exclude diabetes
Serology; toxoplasmosis, CVM, parvovirus
Antibody screen
USS; foetal surgery for lips and stomach (is there a good swallowing mechanism)
What is the management of polyhydramnios?
Patient information
Serial USS; growth, liquor volume, presentation
IOL by 40 weeks
Labour; risk of malpresentation, risk of cord prolapse, risk of preterm labour, risk of PPH, neonatal examination
What is the incidence of multiple pregnancies?
Spontaneous twins; 1:80
Spontaneous triplets; 1:10,000
Increased with assisted conception
What increase the risks of multiple pregnancy?
Assisted conception; clomid, IVF Race; african FMHx Increased maternal age Increased parity Tall women > short women
What are the different types of twins?
Zygosity; monozygotic or dizygotic
Chorionicity; 1 or 2 placentas
What will splitting of the embryo at day 0-3 result in?
Dichorionic
Diamniotic
Monozygotic twins
What will splitting of the embryo at day 4-7 result in?
Monochorionic
Diamniotic
Monozygotic twins
What will splitting of the embryo at day 8-14 result in?
Monochorionic
Monoamniotic
Monozygotic twins
What will splitting of the embryo at day 15 result in?
Conjoined twins
How is chorionicity determined via USS?
Shape of membrane and thickness of membrane
Foetal sex
What is lambda sign?
Placental masses, appearance of membrane attachment and membrane thickness
Why is chorionicity important?
MCMA monozygous twins have a higher risk of pregnancy complications
What are the signs of a multiple pregnancy?
Exaggerated pregnancy symptoms e.g. hyperemesis
What are the signs of a multiple pregnancy?
High AFP
Large for dates uterus
Multiple foetal poles
USS confirmation at 12 weeks
What are the foetal complications of a multiple pregnancy?
Congenital anomalies IUD (single or both) Preterm birth Growth restriction CP TTTS; oly poly
What are the maternal complications of a multiple pregnancy?
HG Anaemia PET Antepartum haemorrhage; abruption, placental praevia Preterm labour C/S
What is the antenatal management of a multiple pregnancy?
Twin/ multiple pregnancy clinic
MC; every 2 weeks
DC; every 4 weeks
Maternal education; preterm labour, support, TAMBA
What medications should be given to multiple pregnant women?
Fe supplementation
Low dose aspirin; PET
Folic acid
What ultrasounds should be performed in antenatal management?
MC 2 weekly from 16/40
Anomaly USS 18-20 wks
DC 4 wkly
What should be assessed on USS for twins?
Deep vertical pool
Bladder
Umbilical artery doppler (UAPI)
EFW
For monochorionic twins; what are the complications?
Single foetal death
Selective growth restriction
TTTS
TAPS (twin anaemia polycythaemia sequence)
Absent EDV or reserved - issues with uterine artery
How is TAPS assessed?
Occurs following fetoscopic laser ablation for TTTS
Middle cerebral artery peak systolic velocity
What is TTTS?
Syndrome with artery vein anastomosis
Donor twin perfuses the recipient twin
How is TTTS diagnosed?
One twin with oligohydraminos
One twin with polyhydramnios
Oy Poly
Complications of TTTS?
Mortality >90% with no treatment
Neurological morbidity
How is TTTS treated?
Before 26/40; fetoscopic laser ablation
>26/40; amnioreduction/septostomy
Deliver 36-36/40
What is the risk with MCMA twins in birth?
Cord entanglement
Risk of foetal death
What is the recommendation for MCMA twins birth?
C/section 32-34+0 weeks
When should DCDA twins be delivered?
37-38 weeks
When should MCDA twins be delivered?
36 + 0 weeks
GIVE STEROIDS
What is the mode of delivery recommended for twins?
Triplets or MCMA; c/s
If one twin cephalic; vaginal
What should be the maximum time elapsed between twin deliveries?
Less than 30 mins
Oxytocin drip given after twin 1 delivered
USS to confirm presentation
How should the 3rd stage of delivery be managed in women with twins?
Actively
What is gestational diabetes?
Carbohydrate intolerance resulting in hyperglycemia of variable severity with onset or first recognition during pregnancy
Complications of diabetes in pregnancy?
Congenital anomalies; related to higher hbA1c
Miscarriage
IUD
Worsening diabetic cx; retinopathy, nephropathy
What maternal complications occur in diabetic mothers?
PET Polyhydramnios Macrosomia Shoulder dystocia Neonatal hypoglycaemia
With what HbA1c should pregnancy be avoided?
Above 86 mmol/mol (10%)
What medications that are commonly prescribed in diabetic women need to be stopped preconception?
ACEi
Statins
Should folic acid be given to diabetic women pre-pregnancy?
YES
5mg 3 months pre conception and first 12 weeks of pregnancy
RF for gestational diabetes?
Previous GDM Obesity BMI 30 or more FMHx 1st degree relative Ethnic variation Previous big baby Polyhydramnios Glycosuria (+1 on 2 occastions or +2 on one occasion warrants OGTT)
What is the pathophysiology of GDM?
Pregnancy is diabetogenic; hPL and cortisol result in a relative insulin resistance
What are the consequences of GDM?
Overgrowth of insulin sensitive tissues = macrosomia
Hypoxaemic state in utero
Short term metabolic cx
Foetal metabolic reprogramming leading to increased long term risks of obesity, insulin resistance and diabetes
Screening and diagnosis of GDM?
RF at booking
Previous GDM; BG monitoring or OGTT 1st trim
OGTT at 24-28 wks
How is OGTT performed?
Venous fasting blood glucose
75g glucose solution
2hr venous glucose
MINIMAL activity between tests; do NOT send home
What are the diagnostic values in the SIGN guidance?
Fasting >5.1 mmol/l
2 hour > 8.5 mmol/l
What is the general approach in terms of education for mothers with GDM?
Role of diet, body weight and exercise
Risks; macrosomia, neonatal hypoglycaemia
Importance of glycaemic control
Possibility of transient morbidity in baby
Increased risk for baby of obesity and diabetes in later life
What are the glycaemic targets in nGDM?
Minimum 4 times a day finger prick - pre meals and before bed
Fasting; 3.5-5.5 mmol/l
1hr post meal; <7.8
Management of GDM?
Diet, wt control and exercise
Monitor for PET
Growth scans
Consider hypoglycemic agents; insulin or oral tablet
Does injectable insulin cross the placenta?
No
When should delivery be aimed for in women with pregestational diabetes?
38 wks onwards
Earlier if complications
When should delivery be aimed for in women with GDM?
On insulin tx; 38-39 wks
Metformin; 39-40 wks
Diet alone 40-41 wks
If foetal macrosomia, IUGR, PET then delivery earlier
When should BG be checked in the postnatal period from women who had GDM?
FBG 6-8 wks PN
If T2DM picture; OGTT 6 wks PN
Annual FBG and lifestyle changes
