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3 Reproduction > Large for dates > Flashcards

Large for dates Flashcards

1
Q

what is large for dates

A

symphyseal-fundal height >2cm for gestational age

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2
Q

causes of large for dates

A 
wrong dates 
foetal macrosomia 
diabetes 
multiple pregnancy 
Polyhydramnios
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3
Q

causes for late booking in pregnancy

A

concealed pregnancy
vulnerable women
transfer of care eg. booked abroad

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4
Q

what is foetal macrosomia

A

‘big baby’

USS estimated foetal weight >90th gentile

abdominal circumference >97th percentile

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5
Q

risks of macrosomia

A

clinician and maternal anxiety

labour dystocia (baby physically cant get out)

shoulder dystocia (after head gets out, the anterior shoulder gets stuck behind the pubic bone)

post partum haemorrhage

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6
Q

what is the margin of error for ultrasound estimated foetal weight

A

10%

eg. could estimate 4000g but its actually 3600g

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7
Q

how do you manage macrosomia

A

exclude diabetes
reassure
Birth plan eg. conservative vs induction of labour vs caesarean section

induction of labour should not be carried out for macrosomia unless there are other indications

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8
Q

what is Polyhydramnios

A

excess amniotic fluid

Amniotic fluid index >25cm

Deepest pool >8cm

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9
Q

causes of Polyhydramnios

A

Maternal Diabetes

Anomaly- GI atresia, cardiac, tumours

Monochorionic twin pregnancy

hydros fetalis (accumulation of fluid in the foetus)

viral infection

idiopathic

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10
Q

how does Polyhydramnios present

A

Abdominal discomfort
Pre-labour rupture of membranes
Pre-term labour
Cord prolapse

Signs: 
large for dates 
malpresentation 
tense shiny abdomen 
inability to feel fatal parts
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11
Q

how do you investigate Polyhydramnios

A

Ultrasound
Amniotic fluid index >25
Deepest vertical pocket >8cm
Survey fetus

Oral glucose tolerance test
Serology - toxoplasmosis, CMV, parvovirus
Antibody screen

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12
Q

how do you manage Polyhydramnios

A

Inform patient fo complications
Serial USS -growth, presentation
Induce labour by 40 weeks

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13
Q

risks in labour caused by Polyhydramnios

A

Malpresentation
Cord collapse
Preterm labour
Post partum haemorrhage

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14
Q

what is a multiple pregnancy

A

more than one foetus - twins, triplets etc

spontaneous twins 1/80
spontaneous triplets 1/10,000
increased with assisted conception

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15
Q

what increases the risk of multiple pregnancy

A 
Assisted conception 
Race - African 
Geography - more common in Nigeria, less common in Japan and china 
FH
Increased maternal age 
Increased parity (have had kids before) 
Tall women>short women
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16
Q

what are monozygotic twins

A

splitting of a single fertilised egg

30% of twins

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17
Q

what are dizygotic twins

A

fertilisation of 2 ova by 2 sperm

70% of twins

always dicorchionic/diamniotic

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18
Q

what are dichorionic twins

A

twins that have 2 placentas

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19
Q

what are monochorionic twins

A

twins that share a placenta

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20
Q

what are monoamniotic twins

A

twins that share 1 amniotic sac

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21
Q

what are diamniotic twins

A

twins that have their own amniotic sacs

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22
Q

what combinations of chronicity and amnionicity can you get

A

Dichorionic/diamniotic
(2 placentas, 2 amniotic sacs) - get in dizygotic twins or day 3

Monochorionic/diamnionic
(1 placenta, 2 amniotic sacs)
-monozygotic twins that split on days 4-7

Monochorionic/monoamniotic
(1 placenta, 1 amniotic sac)
-monozygotic twins that split on days 8-14

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23
Q

what determines chronicity/amnionicity

A

time of splitting off of fertilised ovum in monozygotic twins

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24
Q

what days do monozygotic twins split to be conjoined

A

days 13-15

or >day 15

25
Q

monozygotic twins that split day 3

A

dichorionic/diamniotic

DCDA

26
Q

monozygotic twins that split days 2-7

A

monochorionic/diamniotic

MCDA

27
Q

monozygotic twins that split days 8-14

A

monochorionic/monoamniotic

MCMA

28
Q

monozygotic twins that split >15 days

A

conjoined

29
Q

how do you determine chorionicity

A

Ultrasound
-shape of membrane and thickness of membrane

Foetal sex

30
Q

what type of twins are at highest risk of pregnancy complications

A

Monochorionic monozygous twins

31
Q

ultrasound sign for DCDA twins

A

Lambda sign

curve in membrane as it is two separate ones coming together

32
Q

ultrasound sign for MCDA twins

A

T sign

Thick at top = single placenta

Thin down the middle - divides the two amniotic sacs

33
Q

symptoms of multiple pregnancy

A

Exaggerated symptoms of pregnancy eg- excessive sickness/hyperemesis gravidarum

34
Q

signs of multiple pregnancy

A

High AFP
Large for dates uterus
Multiple foetal poles

Confirm via ultrasound at 12 weeks

35
Q

Foetal complications of multiple pregnancy

A

Higher perinatal mortality (6x higher than singleton)

Congenital anomalies

Intrauterine death (one or both)

Preterm birth

Growth restriction (one or both)

Cerebral palsy (twins 8x higher, triplets 47x higher)

twin to twin transfusion (causes Oligohydramnios and Polyhydramnios)

36
Q

Maternal complications of multiple pregnancy

A 
Hyperemesis Gravidarum 
Anaemia 
Pre eclampsia 
Antepartum haemorrhage - abruption, placenta praaevia 
Preterm labour 
C-section
37
Q

how often are appointments needed with a consultant for twins

A

Monochorionic - every 2 weeks (including USS)

dichorionic - every 4 weeks
including USS

38
Q

what medications are given to mothers with multiple pregnancies

A

Iron supplements
Low dose aspirin
Folic acid

39
Q

complications of monochorionic twins

A

Single foetal death

Selective growth restriction

Twin-twin transfusion syndrome

Twin anaemia

Absent EDV (end diastolic flow) or reversed end diastolic flow - sign of cardiac stress on foetus/placental insufficiency

40
Q

what is twin-to-twin transfusion syndrome

A

Artery vein anastomoses
Donor twin perfuses recipient twin

rare after 26 weeks

causes Oligohydramnios and Polyhydramnios

41
Q

complications to twin-twin transfusion syndrome

A

mortality >90%

neurological morbidity 37% and high in surviving twin if intrauterine death

42
Q

treatment for twin-twin syndrome

A

<26 weeks - Fetoscopic laser ablation

> 26 weeks - Amnioreduction/septostomy

deliver 34-36 weeks

43
Q

when would you deliver dichorionic diamniotic twins

A

37-38 weeks

44
Q

twin would you deliver monochorionic monoamniotic twins

A

36 weeks with steroids

45
Q

how do you deliver triplets or more

A

c-section

46
Q

how do you deliver monochorionic monoamniotic twins

A

c-section

47
Q

how do manage labour for twins

A 
consultant led
epidural 
fetal monitoring 
syntocinon after twin 1 
USS to comfirm presentation 
Intertwin delivery time needs to be <30 mins 
risk of PPH
48
Q

what types of diabetes do you get in pregnancy

A

Pregestational
type 1
type 2
MODY

Gestational

49
Q

complications of pre-existing diabetes in pregnancy

A

Related to poor control

congenital abnormality (related to high HBA1C before booking)

Miscarriage

Intrauterine death

Worsening diabetic complications eg. retinopathy, nephropathy

50
Q

complications of gestational and pre-existing diabetes in pregnancy

A 
Pre eclampsia 
Polyhydramnios 
Macrosomnia 
Shoulter dystocia 
Neonatal hypoglycaemia
51
Q

Pre-pregnancy counselling for diabetes

A

aim for HBA1C to be 48mmol/mol (avoid pregnancy if >86)

stop teratogens eg. ACEis

Determine macro and micro vascular complications

high dose folic acid 3 months before conception to 12th week

general diabetes advice

52
Q

risk factors for gestational diabetes

A 
Previous GDM 
BMI >30 
FH
Previous big baby 
Polyhydramnios 
Glycosuria 
current big baby
53
Q

how is gestational diabetes caused

A

placental hormone cause relative insulin deficiency/insulin resistance

this leads to overgrowth of insulin sensitive tissues in the foetus - macrosomnia

hyperaemic state in utero

foetal metabolic reprogramming leading to increase in long term risk of obesity, insulin resistance and diabetes

54
Q

how do you screen for gestational diabetes

A

oral glucose tolerance test in 1st trimester, then repeated at 24-28 weeks

diagnostic values
fasting glucose >5.1
2 hour glucose >8.5

55
Q

management of gestational diabetes

A

diet, weight and exercise control

growth scans

use hypoglycaemic agents when diet and exercise fail to maintain targets

56
Q

when do you deliver a baby if mother has pregestational diabetes

A

> 38 weeks

57
Q

when do you deliver a baby is there is gestational diabetes

A

on metformin 38-39 weeks
diet alone 40-41 weeks

if fetal macrosomia earlier delivery

58
Q

what is the risk of future development of type 2 diabetes if the mother has had gestational diabetes

A

70%

Fasting blood sugar done 6-8 weeks postnatally

3 Reproduction (49 decks)

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