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Reproductive & Sexual Health > 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

What is the aetiology of large for dates?

A
  • Wrong dates
  • foetal macrosomia
  • polyhydramnios
  • diabetes
  • multiple pregnancy
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3
Q

What can cause wrong dates?

A
  • late booker
  • concealed pregnancy
  • vulnerable women
  • transfer of care: booked abroad
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4
Q

How is foetal macrosomia diagnosed?

A
  • USS EFW >90th centile, AC> 97th centile

(estimated foetal weight and abdominal circumference)

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5
Q

What are the risks of foetal macrosomia?

A

Clinician and maternal anxiety

Labour dystocia

Shoulder dystocia- common with diabetes

Post-partum haemorrhage

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6
Q

What is the margin of error for EFW?

A

10%

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7
Q

What is the mangement of foetal macrosomia?

A
  • exclude diabetes
  • reassure
  • conservative vs IOL vs C/S delivery
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8
Q

What is NICE’s suggestion on macrosomic babies and IOL

A

In the 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).

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9
Q

What is polyhydromnios?

A

Excess amniotic fluid

AFI >25cm

Deepest pool > 8cm

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10
Q

What is aetiology of polyhydramnios?

A
  • maternal
    • diabetes
  • foetal
    • anomaly- GI atresia, cardiac, tumours
    • monochorionic twin pregnancy
    • hydrops fetalis- Rh isoimmunisation
    • viral infection (erythrovirus B19, toxoplasmosis, CMV)
  • idiopathic
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11
Q

What are the symptoms of polyhydramnios?

A

Abdominal discomfort

Pre-labour rupture of membranes

Preterm labour

Cord Prolapse

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12
Q

What are the signs of polyhydramnios?

A

LFD

Malpresentation

Tense, shiny abdomen

Inability to feel foetal parts

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13
Q

How is polyhydramnios diagnosed?

A

Ultrasound Confirmation

  • AFI >25
  • DVP >8cm
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14
Q

What investigations should be done if polyhydramnios is diagnosed?

A
  • OGTT
  • Serology- toxoplasmosis, CMV, parvovirus
  • antibody screen
  • USS- foetal survey; lips, stomach
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15
Q

What is the management of polyhydramnios?

A

Patient information- complications

Serial USS- growth, LV, presentation

IOL by 40 weeks

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16
Q

What is the definition of multiple pregnancy and high order births?

A

Presence of more than one foetus

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17
Q

What is the incidence of spontaenous twins and spontaenous triplets?

A

1: 80
1: 10,000

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18
Q

What are the risk factors for multiple pregnancy?

A
  • Assisted conception- clomid, IVF ( UK limits to 2 embryos)
  • Race- African
  • Geography
    • Europe 6-9/1000 deliveries
    • Nigeria 40-50/1000 ( 1 in 25)deliveries
    • Japan & China 2/1000 ( 1 in 500) deliveries
  • Family History
  • Increased maternal age
  • Increased Parity
  • Tall women> short women
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19
Q

What is zygosity?

A

Monozygosity: splitting of a single fertilised egg (30%)

Dizygotic: fertilisation of 2 ova by 2 spermatozoa (70%)

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20
Q

What is chorionicity?

A
  • 1 placenta/2 placentas
    • dizygous- always dichorionic diamniotic (DCDA)
    • monozygous- monochorionic monoamniotic (MCMA), monochorionic diamniotic (MCDA), dichorionic diamniotic (DCDA), conjoined; depends on time of splitting of fertilised ovum
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21
Q

How is chorionicity determined?

A
  • Via ultrasound
    • The shape of membrane and thickness of membrane
      • twin peak at 11-13+6 weeks (CRL 45-84mm)
      • placental masses, appearance of membrane attachment & foetal membrane thickness (lambda sign)
    • fetal sex
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22
Q

Why is determining chorionicity important?

A

Monochorionic/monozygous twins are at higher risk of pregnancy complications

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23
Q

What are the symptoms of multiple pregnancy?

A

Exaggerated pregnancy symptoms e.g. excessive sickness/HG

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24
Q

What are the signs of multiple pregnancy?

A

High AFP

Large for dates uterus

Multiple foetal poles

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25
Q

When can USS confirm multiple pregnancy?

A

at 12 weeks

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26
Q

What are the complications of multiple pregnancy

A
  • higher perinatal mortality (6X higher than singleton pregnancy)
  • foetal
    • congenital anomalies
    • IUD
    • 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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27
Q

What are the maternal complications of multiple pregnancy?

A
  • Hyperemesis Gravidarum
  • Anaemia
  • Pre-eclampsia
  • Antepartum haemorrhage- abruption, placenta praevia
  • Preterm Labour
  • Caesarean section
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28
Q

monochorionic twins need clinic appointments every _ weeks, dichorionic twins need clinic appointments every _ weeks

A

monochorionic twins need clinic appointments every 2 weeks, dichorionic twins need clinic appointments every 4 weeks

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29
Q

What medications are given in mulitple pregnancy?

A

Fe supplements

Low dose aspirin

Folic acid

30
Q

MC twins need an USS every _ weeks from __/__

D/C twins need USS _ weekly

A

MC twins need an USS every 2 weeks from 16/40

D/C twins need USS 4 weekly

31
Q

What are the comploications of monochorionicity?

A
  • Single Fetal Death
  • Selective Growth Restriction (sGR)
  • Twin-To-Twin Transfusion Syndrome (TTTS)
  • Twin Anaemia- Polycythaemia Sequence (TAPS)
  • Absent EDV (AEDV) or Reversed (REDV)
32
Q

What is the risk to surviving monochorionic twin if single fetal death occurs?

A

IUD (15%)

Neurological abnormality (26%)

33
Q

What testing should be done if single fetal death occurs in monochorionic twins?

A

MRI fetal brain 4 weeks post IUD of co-twin

Middile cerebral artery (MCA) Peak systolic velocity (PSV) to check for foetal anaemia

34
Q

Define TTTS

A

Syndrome with artery-vein anastamoses. Donor twin perfuses the recipient twin.

Rare after 26/40

35
Q

How is TTTS diagnosed?

A

Oligohydramnios- polyhydramnios (Oly-Poly)

36
Q

What are the complications of TTTS?

A

Mortality >90% with no treatment

Neurological morbidity 37% and high in surviving twin if IUD

37
Q

What is the treatment for TTTS?

A

Before 26/40= Rx fetoscopic laser ablation

>26/40- amnioreduction/septostomy

Delivery 34-36/40

38
Q

What are the two types of complex multiple births?

A

Monochorionic Monoamniotic (MCMA) twins

Conjoined twins

39
Q

DCDA twins deliver __-__ weeks

MCDA twins deliver after __+_ weeks with _____

Triplets or more deliver via _________ ______

MCMA deliver via _______ ______

A

DCDA twins deliver 37-38 weeks

MCDA twins deliver after 36+0 weeks with steroids

Triplets or more deliver via caesarean section

MCMA deliver via caesarean section

40
Q

In twin delivery when should syntocinon be administered?

A

After twin 1

41
Q

Intertwin delivery time should be < __ minutes

A

Intertwin delivery time should be < 30 minutes

42
Q

Define gestational diabetes

A

Carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy.

43
Q

What do the complications of gestational diabetes all relate to?

A

Poor control

44
Q

What are the complications specific to pre-existing diabetes in pregnancy?

A
  • Congenital anomalies- related to high HBA1C at booking
  • Miscarriage
  • Intra-uterine death
  • worsening diabetic complications e.g. retinopathy, nephropathy
45
Q

What complications of diabetes are common to pre-existing and gestational diabetes?

A
  • pre eclampsia
  • polyhydramnios
  • macrosomia
  • shoulder dystocia- 10% risk vs 1% risk in general population
  • neonatal hypoglycaemia
46
Q

Pregestational diabetes: T1DM

Has a % prevalence?

Is commoner in which population?

A

5-10% prevalence

Younger

Slimmer

White

Insulin deficiency

47
Q

Pregestational T2DM has a _____ prevalence and is commoner in what population?

A

Rising prevalence

  • older
  • overweight/obese
  • asian, middle eastern, african, afro-carribean
  • Insulin resistance
48
Q

What HBA1C should be aimed for in pregnancy monitoring?

A

48 mmol/mol (6.5%)

49
Q

Above what HBA1C should pregnancy be avoided?

A

86mmol/mol 10%

50
Q

What should be stopped in prepregnancy diabetes counselling

A

Embryopathic medication e.g. ACE inhibitors, cholesterol lowering agents

51
Q

What should be determined in prepregnancy diabetes counselling

A

Macrovascular and microvascular complications

52
Q

What should be started in prepregnancy diabetes counselling?

A

High dose folic acid 5mg (3 months before conception to 12 weeks of pregnancy)

53
Q

What medication should be started 12 weeks into a pregnancy if mum has DM?

A

Low dose aspirin

54
Q

What hypoglucaemic agents are safe in pregnancy?

A

Insulin- MDI/insulin pump

Metformin (Type 2)

55
Q

What monitoring is required if mum is diabetic?

A
  • early booking in diabetic ANC
  • fetal anomaly scan at 18-20 weeks
  • regular eye checks for retinopathy
  • continuous glucose monitoring?
  • growth scans 4 weekly from 28 weeks
  • counselling about shoulder dystocia
  • deliver at 38 weeks
56
Q

What are the risk factors for GDM?

A
  • previous GDM
  • BMI 30 or more
  • FH: 1st degree relative
  • Ethnic variation: south asia (india/pakistan/bangladesh), middle eastern, black caribbean)
  • previous macrosomia
  • polyhydramnios
  • big baby- AC/EFW on USS
  • glucosuria (1+ on >1 occasion or >=2+ on one occasion)
57
Q

Why is pregnancy diabetogenic?

A

Human placental lactogen, cortisol

58
Q

What do placental hormones cause?

A

Relative insulin deficiency/insulin resistance

59
Q

What are the consequences of GDM?

A
  • overgrowth of insulin sensitive tissues and macrosomia
  • hypoxaemic state in utero
  • short term metabolic complications
  • foetal risk of reprogramming leading to long term risk of obesity, insulin resistance and diabetes
60
Q

Describe GDM screening and diagnosis?

A
  • Risk factors at booking
  • Previous GDM (recurrence risk >50%)
    • BG monitoring
    • or OGTT 1st Trimester- if normal repeat 24-28 weeks
  • OGTT 24-28 weeks
61
Q

Describe the process of OGTT

A
  • take venous fasting blood sugar
  • give 75g glucose solution
  • take 2 hr venous glucose

have minimal activity between tests

62
Q

What are the diagnostic values of OGTT for GDM according to SIGN guidance?

A

Fasting = > 5.1mmol/l

2 hour = > 8.5 mmol/l

63
Q

What is the NICE diagnostic criteria for GDM?

A

Fasting >=5.6 mmol/l

2 hour >=7.8 mmol/l

64
Q

How often should mum check BS levels?

What level should be aimed for?

A

Minimum 4 times a day- premeals (sometimes 1 hr postmeal) & before bed.

Fasting: 3.5-5.5mmol/l

1hr <7.8mmol/l

65
Q

Describe management of GDM?

A
  • Diet, weight control & Exercise
  • Monitor for PET
  • Growth scans
  • Consider Hypoglycaemic agents when
    • diet and exercise fail to maintain targets
    • macrosomia on ultrasound
  • Choice of agent:
    • tailored to glycaemic profile
    • individual woman
  • Choices:
    • Insulin or Oral tablet
66
Q

What are the potential advantages of oral hypoglycaemic agents in GDM?

A
  • avoidance of hypoglycaemia associated with insulin
  • less weight gain
  • less ‘education’ required to ensure safe/effective administration
67
Q

What are the options for insulin treatment?

A
  • short acting
  • long acting
  • pump therapy (T1DM)
  • does not cross the placenta
  • risk of hypoglycaemia
68
Q

What is the timing of delivery of pregestational diabetes?

A
  • 38 weeks onwards
  • earlier if complications
69
Q

What is the timing of delivery of GDM?

A
  • insulin treatment 38-39 weeks
  • metformin 39-40 weeks
  • diet alone 40 to 41 weeks
  • if foetal macrosomia/IUGR/PET earlier delivery
70
Q

Describe the choices of mode of delivery in diabetes?

A
  • maternal pregerence
  • other indication for c/section
  • discuss risks and benefits of vaginal birth including shoulder distocia (9-10% risk)
  • if EFW >4.5 kg then c/section
71
Q

What are the risk factors for developing T2DM after GDM?

A
  • obesity
  • use of insulin during pregnancy
  • fasting glucose levels from OGTT in pregnancy
  • insufficient glandular tissue (IGT) post partum
  • ethnic group
72
Q

How should risk of T2DM be assessed in post-natal period?

A

FBS 6-8 weeks postnatally

If picture of type 2 DM- OGTT 6 weeks PN

Annual FBS & lifestyle changes

Reproductive & Sexual Health (54 decks)

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