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Reproduction > Large for Dates > Flashcards

Large for Dates Flashcards

1
Q

what is considered large for dates

A

symphyseal fundal height > 2cm for gestational age

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2
Q

what is SFH

A

symphyseal gestational height

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3
Q

what can cause LFD (large for dates)

A 
wrong dates 
fetal macrosomia (big baby)
polydramnios
diabetes (can cause macrosomia or polydramnios) 
multiple pregnancy
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4
Q

why might someone be a ‘late booker’ and have the wrong dates of conception

A

concealed pregnancy- fit, muscular or obese
vulnerable women- hesitant to / cant engage with healthcare
transfer of care- booked abroad

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5
Q

what classifies as fetal macrosomia

A

USS estimated fetal weight > 90th centile
abdo circumference > 97th centile

(on generic population charts or customised growth charts - BMI, ethnicity and parity are considered)

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6
Q

what are the risks of fetal macrosomia

A

clinician and maternal anxiety
labour dystocia (obstructed labour, aka cervical dystocia)
shoulder dystocia - more with diabetes
post partum haemorrhage

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7
Q

where are the smallest and biggest babies in the world

A

smallest- SE asia

biggest- caucasian UK

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8
Q

what is the formula for EFW

A

hadlock- considered HC, AC and FL

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9
Q

accuracy of USS depends on operator, maternal BMI (harder if higher), gestation (more accurate <38 weeks)
is the EFW from USS usually higher or lower than actual weight

A

higher

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10
Q

what is the management for macrosomia

A

exclude diabetes
reassure mother
conservative vs IOL vs CS

IN THE ABSENCE OF ANY OTHER INDICATIOS IOL SHOULD NOT BE CARRIED OUT SIMPLY BECAUSE OF MACROSOMIA

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11
Q

at what EF weight would you recommend a CS

A

more than 4.5 kg

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12
Q

what is polyhydramnios

A

excess amniotic fluid

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13
Q

what classifies as polyhydramnios

A

amniotic fluid index >25cm

deepest pool in ant pocket of cord free ares >8cm

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14
Q

what are the maternal causes of polyhydramnios

A

diabetes

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15
Q

what are the fetal causes of polyhydramnios

A

anomaly- GI atresia (congenital malformation of the bowel causing obstruction), cardiac abnormalities, tumours
monochorionic twin pregnancy
hydrops fetalis (accumulation of fluid in at least 2 fetal compartments)
viral infections (erythrovirus B19, toxoplasmosis, CMV)
idiopathic (2nd most common after diabetes)

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16
Q

what are the signs and symptoms of polyhydramnios

A 
symptoms:
abdo discomfort 
pre labour rupture of membranes
preterm labour (due to overdistention of uterus)
cord prolapse 
signs:
LFD
malpresentation 
tense shiny abdomen 
inability to feel fetal parts
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17
Q

how is polyhydramnios diagnosed

A

USS
AFI >25
DVP >8cm

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18
Q

what investigations for polyhydramnios

A

OGTT to exclude diabetes
serology - toxoplasmosis, CMV, parovirus
antibody screen (rhesus isoimmunisation can cause hydrops fetalis)
USS fetal survey - lips, stomach (ensure patent oesophagus and good swallowing mechanism)

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19
Q

what is the management for polyhydramnios

A

patient information (complications)
serial USS- growth, liquor volume (volume of amniotic fluid), presentation
IOL by 40 weeks
neonate exam

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20
Q

what are the risk of labour in polyhydramnios

A

malpresentation
cord prolapse
preterm labour
PPH

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21
Q

what classifies as pre term labour

A

before 37 weeks

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22
Q

how common are spontaneous twins

A

1:80

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23
Q

what puts you at risksof having a multiple pregnancy

A 
assisted conception (in uk limit to 1 embryo)
race - african (esp nigerian)
FMHx
increased maternal age 
increased parity 
tall women > short women
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24
Q

why is there higher rates of twins in africa

A

higher perinatal mortality rates

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25
Q

what are the types of zygosity

A

monozygotic- splitting of a single fertilised egg (30%)

dizygotic- fertilisation of 2 ova by 2 spermatozoa (70%)

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26
Q

what are the types of chorionicity

A

(1 placenta/ 2 placenta)
dizygous always DCDA (dichorionic)

monozygous twins can be MCMA, MCDA, DCDA or conjoined

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27
Q

what does chorionicity depend on

A

in dizygous twins always DCDA

in monozygous twins depends on splitting of fertilised ovum

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28
Q

what do DCDA, MCDA, MCMA stand for

A

Dichorionic diamniotic
monochorionic diamniotic
monochorionic monoamniotic

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29
Q

what does monochorionic mean

A

share placenta

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30
Q

what does monoamniotic mean

A

share amnionic sac- can have one or two placenta

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31
Q

cleavage into twins at days 0-3 will result in what

A

dichorionic diamniotic (DCDA)

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32
Q

cleavage into twins at days 4-7 will result in what

A

monochorionic diamniotic (MCDA)

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33
Q

cleavage into twins at days 8-14 will result in what

A

monochorionic monoamniotic (MCMA)

34
Q

cleavage into twins after day 15 will result in what

A

conjoined twins

35
Q

how is chorionicity determined

A

USS:
-shape and thickness of membrane (twin peak at 11-13.6 weeks (CRL 45-84 mm), placental masses, appearance of membrane thickness (lamba sign))
fetal sex- determines if dichorionic or not

36
Q

what type of twins are at higher risk of pregnancy complications

A

monochorionic/ monozygous twins= MCMA

37
Q

what type of twins will have the lamba sign on USS

A

dichorionic diamniotic

38
Q

what forms the amnionic sac

A

chorion (outer) and amnion (inner)

39
Q

what are the signs and symptoms of multiple pregnancies

A

exaggerated pregnancy symptoms (excess sickness/ hyperemesis gravidarum)
high AFP
large for dates uterus
multiple fetal poles

40
Q

when can USS confirm multiple pregnancies

A

12 weeks

41
Q

what is recommended if a patient has hyperemesis before first scan

A

USS to see if multiple pregnancy

42
Q

what are the fetal complications of multiple pregnancies

A

higher perinatal mortality
congenital abnormalities (e.g. acardiac twin)
IUD (single/ both)
pre term birth
growth restriction (both/ discordant)
cerebral palsy (twins 8x higher, 47x higher in triplets)
twin to twin transfusion (oligohydramnios and polyhydramnios)

43
Q

what are the maternal complications of multiple pregnancies

A 
hyperemesis gravidarum 
anaemia 
pre eclampsia
antepartum haemorrhage (abruption (placenta dislocates from uterus), placenta praevia)
preterm labour 
caesarian section
44
Q

what is the antenatal management for multiple pregnancies

A 
MC- clinic every 2 weeks 
DC- clinic every 4 weeks 
maternal educations- preterm labour and risks, support (+ financial) 
consultant led care
Fe supplementation- risk of anaemia 
low dose aspirin- reduce pre eclampsia 
folic acid 
USS MC 2 weekly from 16 weeks 
DC 4 weekly 
anomaly USS at 18-20 weeks
45
Q

what extra scans do MC twins get

A

deep vertical pool
bladder and umbilical artery doppler (UAPI)
estimated fetal weight

46
Q

what complications are seen in MC twins

A

single fetal death (affects other twin in utero too)
selective growth restriction
twin to twin transfusion syndrome (TTTS)
twin anaemia polycythaemia sequence (TAPS)
absence end diastolic velocity or reversed end diastolic velocity

47
Q

what can cause TAPS

A

fetoscopic laser ablation for TTTS

48
Q

what is twin to twin transfusion syndrome

A

imbalance in circulation between twins from shared placenta due to atery vein anastomoses
donor twin will be olihydramniotic (and will be pale and small- anaemic)
recipient twin will by polyhydramniotic (larger and red- polycythemic)

49
Q

how is TTTS diagnosed

A

Oligohydramnios- polyhydramnios (Oly-Poly)

50
Q

what are the complications os TTTS

A

mortality >90% with no Tx

neurological morbidity 37% and high in surviving twin if IUD

51
Q

what is the treatment for TTTS

A

before 26/40 - fetoscopic laser ablation
> 26/40 amnioreduction/ septostomy
deliver 34-36/40

52
Q

what are the complec multiple births

A

MCMA twins:

  • risk for cord entanglement
  • higher risk of fetal death
  • always delivery by C section 32-34+o weeks

conjoined twins:
-MDT, specialised centres

trichorionic triplets/ MC or DC twins with sGR, TTTS, TAPS consider selective reduction

53
Q

when should you aim to deliver twins

A

DCDA- 37-38 weeks

MCDA after 36+0 weeks WITH steroids

54
Q

what mode of delivery for multiple pregnancies

A

MOTHERS choice
triplets or more rec CS
MCMA CS
twins if twin 1 cephalic aim for V, if twin 1 breech/ transverse C section

55
Q

what needs to be done in a multiple pregnancy delivery

A

consultant led
epidural
fetal monitoring- USS and fetal scalp electrode
syntocinon after twin 1
USS to confirm presentation
intertwin delivery time <30 mins
risk of PPH- active 3rd stage- oxytocin infusion

56
Q

what pre gestational diabetes types can you get

A

T1
T2
MODY

57
Q

what is gestational diabetes

A

carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy (ends when pregnancy ends)

58
Q

what complications are specific to pre existing diabetes in pregnancy

A

congenital abnormalities
miscarriage
IUD
worsening diabetic complications (retinopathy, nephropathy)

59
Q

what should you ask all women with diabetes

A

about contraception and family planning- save more babies by seeing in pre pregnancy clinics

60
Q

what pregnancy complications can you get in pre existing and gestational diabetes

A 
pre eclampsia
polyhydramnios
macrosomia
shoulder dystocia
neonatal hypoglycaemia
61
Q

what HBA1c level means you should avoid pregnancy

A

above 86mmol/mol (10%)

62
Q

what is the HBa1c aim in pregnancy

A

48mmol/mol (6.5%)

63
Q

what medication advice should you give diabetics pre pregnancy

A

Stop any embryopathic medication eg ACE inhibitors, cholesterol lowering agents
High Dose Folic Acid 5mg (3 months before conception to 12 weeks of pregnancy)

64
Q

what extra tests for diabetic (T1 and 2) pregnancies

A 
Fetal anomaly scan at 18-20 weeks
Regular eye checks for retinopathy
If nephropathy- refer renal team
Consider continuous glucose monitoring (libra)
Growth scans 4 weekly from 28 weeks
65
Q

management for diabetic pregnancies (T1 and T2)

A

Folic Acid 5mg
Low Dose Aspirin from 12 weeks- until delivery
Hypoglycaemic Agents:
Insulin- MDI /Insulin pump
Metformin (Type 2)
Counsel about shoulder dystocia
Deliver at 38 weeks ( earlier if complications)

66
Q

what are the risk factors for gestational diabetes

A 
Previous GDM
Obesity BMI 30 or more
FH: 1st degree relative
Ethnic variation: South Asia (India / Pakistan / Bangladesh), Middle Eastern, Black Caribbean
Previous big baby
Polyhydramnios
Big baby – AC / EFW on USS
Glycosuria (1+ on >1 occasion or >= 2+ on one occasion
67
Q

why is pregnancy diabetogenic

A

due to the hormones human placental lactogen and cortisol

placental hormones cause relative insulin deficiency and resistance

68
Q

what are the consequence of gestational diabetes

A

Overgrowth of insulin sensitive tissues and macrosomia
Hypoxaemic state in utero
Short term metabolic complications
Fetal metabolic reprogramming leading to increase long term risk of obesity, insulin resistance and diabetes

69
Q

what is the screening for GDM

A

Risk factors at booking
Previous GDM (recurrence risk >50%0= BG monitoring
or OGTT 1st Trimester- if normal repeat 24-28 weeks

OGTT 24-28 weeks (if just risk factors not previous GDM)

70
Q

how is GDM diagnosed

A

OGTT:
venous fasting blood sugar taken

75g glucose solution taken orally

rest for two hours

2hr venous glucose

diagnostic values:
Fasting >=5.1 mmol/l
2 hour >=8.5 mmol/l

71
Q

what is the general management for GDM

A

diet, body weight and exercise
Monitor for PET (pre-eclampsia)
Growth scans
Consider Hypoglycaemic agents (insulin or metformin) when
diet and exercise fail to maintain targets
macrosomia on ultrasound

care plan:
Antenatal and intrapartum
Targets for glycaemic control
Fetal surveillance
Post-natal care / review
72
Q

what are the risk of GDM

A

macrosomia and neonatal hypoglycaemia Possibility of transient morbidity in the baby
Increased risk for the baby of obesity and diabetes in later life
Increased risk of type 2 diabetes for the mother (gestational)

73
Q

what are the glycaemic targets for GDM

A 
Minimum 4 times a day- premeals (sometimes 1 hr  postmeal ) &amp; before bed.
Fasting 
3.5 -5.5 mmol/l
1 hr
<7.8mmol/l
74
Q

what are the advantages of metformin over insulin in pregnancy

A

Avoidance of hypoglycaemia associated with insulin
Less weight gain
Less ‘education’ required to ensure safe / effective administration

75
Q

does insulin treatment cross the placenta

A

no

76
Q

when should you deliver babies with maternal pre gestational diabetes

A

38 weeks onwards

Earlier if complications

77
Q

when should you delivery babies with maternal GDM

A

Insulin treatment 38-39 weeks
Metformin 39- 40 weeks
Diet alone 40 to 41 weeks
If fetal macrosomia/ IUGR/ PET earlier delivery

78
Q

what are the risk factors for mothers develop T2DM after GDM postnatally

A 
obesity
use of insulin during pregnancy 
fasting glucose levels from OGTT in pregnancy 
IGT post partum 
ethnic group
79
Q

when is FBS done postnatally after GDM

A

6-8 pn

80
Q

what dose of folic acid for diabetic women

A

5mg (normal dose 400 micrograms)

Reproduction (51 decks)

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