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Large for dates pregnancy Flashcards

1
Q

What does large for dates mean?

A

Fundal height larger than it should be?

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2
Q

What are the four main causes for a larger than expected fundal height?

A
  • Wrong dates
  • Multiple pregnancy
  • Diabetes
  • Polyhydramnios – (too much amniotic fluid)
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3
Q

What is polyhydramnios?

A

• Excess amniotic fluid

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4
Q

What are the 5 causes of polyhydramnios?

A 
♣	Monochorionic twin pregnancy
♣	Fetal anomaly
♣	Maternal diabetes
♣	Hydrops fetalis – Rh isoimmunisation, infection (erythrovirus B19)
♣	Ideopathic
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5
Q

What are the 4 symptoms/complications of polyhydramnios?

A

¥ Discomfort
¥ Labour
¥ Membrane rupture
¥ Cord prolapse – cord herniates cervix

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6
Q

How is polyhydramnios diagnosed?

A
  • USS

- Clinically

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7
Q

What does chorionicity and zygosity and amniocity mean?

A

Chorionicity and zygosity
¥ Zygosity refers to number of eggs fertilised to produce twins
¥ Chorionicity refers to the membrane pattern of the twins – do they share 1 placenta
Ð Amniocity is if they share an amniotic sac

¥ Why is it important?
Ð Monochorionic / monozygous twins at higher risk of pregnancy complications

Zygosity
Monozygous twins are identical.
100% of dizygotic twins are dichorionic.
With monovular twins – the earlier the division the less risk of monoamniotic.
Twin to twin transfusion only happens in monozyotic twins

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8
Q

At how many weeks is twin ‘peak’

A

12

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9
Q

How is multiple preg. diagnosed?5

A 
¥	Usually ultrasound at 12 weeks
¥	Exaggerated pregnancy symptoms e.g. excessive sickness
¥	High AFP
¥	Large for dates uterus
¥	Feeling more than two fetal poles
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10
Q

What are the 6 complications of multiple pregnancies?

A 
Ð	Congenital anomalies
Ð	Pre term labour
Ð	Growth restriction
Ð	Pre eclampsia
Ð	Antepartum haemorrhage
Ð	Twin to twin transfusion
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11
Q

What are the 5 ways that multiple pregnancies are managed?

A

¥ More frequent antenatal visits
¥ Detailed anomaly scan at 18 weeks
¥ Regular scans from 28 weeks for growth
¥ Routine iron supplementation – mums with multi pregnancies more likely to become anaemic
¥ Warning to mother re risk and signs of pre term labour

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12
Q

How are multiple pregnancies delivered?

A

¥ Triplets or more – Caesarean section
¥ Twins if twin one cephalic aim for vaginal delivery
¥ Much greater risk of Caesarean section (approx 50%)
¥ Epidural analgesia

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13
Q

What are the two ways that diabetes can present in pregnancy?

A

Pre-existing
o Type 1 or type 2

Gestational
o This is due to placental hormones causing an insulin resistance

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14
Q

What is the definition of diabetes mellitus?

A

‘carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy’

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15
Q

What can diabetes in pregnancy lead to? 4

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

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16
Q

How is gestational diabetes screened for and diagnosed?

A

♣ Women screened for GTT based on risk factors or random blood glucose at booking and 28 weeks gestation

♣ Diagnosis based on GTT at 28 weeks

♣ Diagnostic values:
♣ Fasting >=5.6 mmol/l
♣ 2 hour >=7.8 mmol/l

The adoption of internationally agreed 
criteria for gestational diabetes using 
75 g OGTT is recommended: 
fasting venous plasma glucose ≥5.1 mmol/l, or
one hour value ≥10 mmol/l, or
two hours after OGTT ≥8.5 mmol/l
17
Q

What are 3 complications of pre-existing DM?

A

Ð Congenital anomalies
Ð Miscarriage
Ð Intra uterine death

18
Q

What are the 5 complications of both pre-existing DM and gestational DM

A

Ð Pre eclampsia

Ð Polyhydramnios

Ð Macrosomia

Ð Shoulder dystocia
¥ Anterior shoulder stuck behind pubic symphysis

Ð Neonatal hypoglycaemia
¥ As the fetus is hyperinsulinaemic and they lose the glucose supply they had in utero when born, they quickly become hypoglycaemic

19
Q

What points are important to talk about when counselling a women who has diabetes in pregnancy?

A

¥ Role of diet, body weight and exercise
¥ Diet – don’t eat for 2/don’t put on more than 10kg
¥ Excersize - walking
¥ Risks: macrosomia and neonatal hypoglycaemia
¥ Only talk about this when baby is born
¥ Importance of glycaemic control
¥ 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)

20
Q

What are the target blood glucose levels in pregnancy?

A

Fasting: 3.5-5.9mmol/L

1 hour post-prandial: <7.8mmol/L

21
Q

When is hypoglycaemic therapy considered?

A
  • diet and exercise fail to maintain targets
  • macrosomia on USS

Metformin or glibenclamide may be
considered as initial pharmacological
glucose lowering treatment in women
with gestational diabetes

22
Q

What additional care is offered in antenatal setting for DM in pregnancy?

A

¥ Regular monitoring for PET (pre-eclampsia)
¥ Growth: 2-4 weekly FAC from 28 weeks or diagnosis
¥ Fetal wellbeing: Benefits of umbilical Doppler in high risk pregnancies and compared to CTG and BPP known
¥ Offer delivery from 38 weeks gestation

23
Q

When is c-sec offered in diabetes?

A
  • if baby 4.5kg or more

- DM not in itself containdication to vaginal birth

24
Q

What is the risk of developing type 2 diabetes after gestational diabetes?

A

risk up to 70%

25
Q

What are the main risk factors for type 2 diabetes after gestational diabetes?

A 
Ð	Obesity
Ð	Use of insulin during pregnancy
Ð	Fasting glucose levels from OGTT in pregnancy
Ð	IGT post partum
Ð	Ethnic group
26
Q

What lifestyle interventions/screening is offered to women to reduce risk of type 2 diabetes after gestational diabetes?

A 
¥	Evidence that lifestyle and pharmacological intervention can reduce risk in general population with IGT
¥	Offer women lifestyle advice:
Ð	Diet
Ð	Weight
Ð	Exercise
¥	Annual fasting blood glucose
27
Q

What additional care is given to women with pre-existing diabetes in pregnancy

A

♣ Pre pregnancy counselling
♣ Give these woman adequate contraception to allow them to plan their pregnancy
♣ Fetal anomaly scan at 18 weeks
♣ Regular eye checks for retinopathy

28
Q

What risk factors exist for development of gestational diabetes?

A

BMI >30 kg/m2

previous macrosomic baby weighing 4.5 kg or more

previous GDM

family history of diabetes (first degree
relative)

family origin with high prevalence of diabetes (South Asian, black Carribean, Middle Eastern).

Previous unexplained still birth

recurrent glycosuria

Reproduction (34 decks)

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