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Year 4 - Obs and Gynae > Obs: conditions in pregnancy > Flashcards

Obs: conditions in pregnancy Flashcards

1
Q

What are the risks of giving SSRIs in pregnancy?

A
  • Sodium valproate: CI in women of childbearing age. NTD/ cleft palette
  • Carbamazepine: cleft lip 0.1 %
  • Lithium: cause fetal hypotonia, poor reflexes, arrythmia, Ebstein’s anomaly, neonatal goitre (thyroid)
  • Lamotrigine: Steven Johnson syndrome
  • Olanzepine: fetal macrosomia, GDM
  • SSRI: pulmonary hypertension, Paroxetine in particular is associated with cardiac defects
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2
Q

What is the difference between chronic HT and pregnancy induced HT?

A
  • Chronic hypertension: is high BP that exists before 20 weeks gestation and is longstanding. This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia.
  • Pregnancy-induced is hypertension occurring after 20 weeks gestation, without proteinuria.
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3
Q

What is pre eclampsia?

A
  • New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
    • Proteinuria: quantified using the urine: protein creatinine + albumin: creatinine ration
    • Other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
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4
Q

What are some of the complications of preeclampsia?

A
  • CNS: eclampsia, IC haemorrhage, stroke, cortical blindness
  • Renal: RT necrosis (AKI)
  • Resp: pulmonary oedema
  • Liver: HELPP syndrome, liver capsule haemorrhage, liver rupture
  • Haem: DIC, VTE (due to involvement of the liver)
  • Placenta: placental abruption
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5
Q

What are some of the high + moderate RFs fo pre eclampsia?

A
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7
Q

What mx can be used for risk reduction in pre eclampsia?

A
  • Aspirin 150mg from 12 weeks if one high RF or >1 moderate RF
  • Dalteparin if anti phospholipid syndrome or other pro-coagulant disorders
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8
Q

What are some of the sx of pre eclampsia?

A
  • ↑ICP : headache, visual disturbance (papilloedema), N+V,
    • Liver swelling -> abdo pain (RUQ), sudden ↑ in swelling, generally unwell, vomiting
    • Reduced fetal movement
    • Bleeding
  • ​S**igns: hypertension, proteinuria, non-dependent oedema, hyperreflexia, clonus fetal growth restriction, oligohydramnios, abnormal fetal doppler
  • Ask about: headache, flashing lights, epigastric, RUQ pain
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9
Q

What are the fx of pre eclampsia?

A
  • Features: asymptomatic (only detected at antenatal app): BP and urinalysis
  • BP: hypertension: typically > 160/110 mmHg
  • Proteinuria: dipstick ++/+++
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10
Q

What Ix are used for pre eclampsia?

A
  • Maternal: FBC, renal (UE, eGFR), LFT (transaminases), DIC (coag profile: PT, APTT), proteinuria (protein creatinine ratio, 24hr collection), raised serum uric acid
  • Monitoring: close BP monitoring every 48h
    • Fetal:
  • Every 2 weeks: growth velocity (fetal growth USS), fetal wellbeing (CTG, amniotic fluid volume, fetal Doppler),
  • notching of uterine arteries on doppler, abnormal umbilical artery doppers
    • NICE recommend placental GF testing (↓usually) on one occasion
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11
Q

What monitoring scoring sx are used for pre eclampsia

A
  • fullPIERS + PREP-S
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12
Q

How is pre eclampsia mxd?

A
  • Gestational HT: Control BP
    • Act: reduce BP of it is severely high (160/110) – admit and observe
    • Offer offer treatment if BP is sustained >140/9
    • Aim: for 135/85
    • Review: review medication if BP stays below 110/70
  • Pre-eclampsia: Medication:
    • Monitoring: Scoring systems: fullPIERS + PREP-S,
    • Oral treatment: 1st: labetalol
      • 2nd: nifedipine
      • 3rd: methyldopa
    • Emergency: 1st: IV hydralazine
  • If severe of fulminating pre-eclampsia
    • Prevent seizures (IV magnesium sulfate infusion during labour and post 24h)
    • Give steroids for lung maturation if pre-term and considering delivery
    • Strict fluid balance (prevent)
  • IOL
  • Post delivery
    • 1st: Enalapril (first-line)
    • 2nd: CCB: Nifedipine or amlodipine (1st if black African or Caribbean patients)
    • 3rd: Labetolol or atenolol
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13
Q

How is fetal growth measured?

A
  • Assessed routinely during antenatal care.
  • >AFTER 24 weeks – useless before
  • Methods: Clinical:
    • Abdominal palpation of fundal height (sensitivity 20-30%)
    • Symphysis-fundal height measurement using a measuring tape (sensitivity: 30-40%)
  • Ultrasound assessment: key measurements (90-95% sensitivity)
  • Head circumference (and Biparietal diameter)
  • Abdominal Circumference
  • Femur length
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14
Q

What is considered SGA/ small for date?

A
  • SMALL FOR DATES/SGA: describes anthropometric variables <10th population centile for GA
  • Severe SGA: < 3rd centile for their gestational age.
  • LBW: birth weight <2.5kg
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15
Q

What Ix are used for pre eclampsia?

A
  • Maternal: FBC, renal (UE, eGFR), LFT (transaminases), DIC (coag profile: PT, APTT), proteinuria (protein creatinine ratio, 24hr collection), raised serum uric acid
  • Monitoring: close BP monitoring every 48h

Fetal:

  • Every 2 weeks: growth velocity (fetal growth USS), fetal wellbeing (CTG, amniotic fluid volume, fetal Doppler),
  • Notching of uterine arteries on doppler, abnormal umbilical artery doppler

NICE recommend placental GF testing (↓usually) on one occasion

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16
Q

What is eclampsia?

A
  • Defined as the development of seizures in association pre-eclampsia in pregnancy OR within 10 days of delivery
    • At least two of the following features within 24h of seizure (tonic-clonic)
      • Hypertension
      • Proteinuria + plus or at least 0.3g/ 24h
      • Thrombocytopenia less than 100,000 /il
      • Raised transaminases
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17
Q

How is eclampsia?

A
  • Call for senior help: A-E management; IV access
  • Bolus of 4g Magnesium Sulphate over 5-10 minutes then 1g/h for 24h IV infusion. Treat further fits with 2g bolus.
  • Monitor: UO, reflexes, RR, 02 sats
    • SE: resp. depression. Stop if RR<12/ reduced UO or lost reflexes. Mx 1st line: calcium gluconate
  • Continue for 24h after last seizure or delivery
  • Stop if RR <12/min, or reduced UO or reflexes lost: have IV calcium gluconate ready in case of MgSO4 toxicity
  • Mx rpt seizures w/ diazepam and rule out IC haemorrhage
  • Cathetarised for hourly UO

Antenatal – plan for delivery by most appropriate route.

  • Monitor 3rd stage w oxytocin. CI Syntometrine + ergometrine - ↑ risk of stroke 2nd to HT
  • Other: fetal HR monitoring with CTG, fluid balance (to avoid overload)
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18
Q

How is eclampsia/ pre eclampsia mxd post natally?

A
  1. May require antihypertensive treatment for 6-12 wks post natally
  2. Increased risk of VTE particularly in severe proteinuria
  3. Severe PET may require follow up bloods
  4. Post-natal hypertension where appropriate
  5. Discuss contraception + implications for future pregnancy before discharge
  6. Write to GP with details of delivery and treatment etc
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19
Q

What is HELPP syndrome?

A

Combination of features that occurs as a complication of pre-eclampsia and eclampsia

  • Haemolysis
  • Elevated Liver enzymes
  • Low Platelets
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20
Q

What are some of the risks of diabetes in pregnancy?

A
  • Miscarriage
  • 4x congenital anomalies
  • Macrosomia
  • Large for date fetus
  • Pre-eclampsia
  • Polyhydramnios
  • Pre-term birth
  • C-delivery
  • Short and long term morbidity
  • Obesity and diabetes later in life
  • Shoulder dystocia
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21
Q

What pre pregnancy care is provided for pre existing DM?

A
  • Use contraception until blood glucose controlled: aim for <48mmol HBA1c and BMI <27
  • Retinal assessment via digital imaging: attempted before attempting glycaemic control associated with worsening retinopathy (treat retinopathy pre pregnancy)
  • Kidneys: micro albuminuria measures before stopping contraception, creatinine + eGFR checked – women w poorly controlled HT are at risk of permanent kidney damage e.g. ESKD.
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22
Q

How is pre existing DM mxd?

A
  • Weight loss for women BMI >27kg/m2
  • LMWH for VTE prophylaxis depending on risk stratification
  • Stop oral hypoglycaemics statins and ACEi and A2a (use other hypertensives)
  • Can continue Metformin but other oral hypoglycaemics to be substituted with insulin
  • Folic acid 5mg OD until 12 weeks gestation + aspirin 75mg from 1st trimester (reduce pre eclampsia risk)
  • Tight glycaemic control: Blood glucose targets
    • Fasting : 5.3
    • > 1h: 7.8
    • >2h: 6.4
  • USS scans: dating by 12 weeks, detailed cardiac 18-22 weeks, fetal growth and liquor volume: 28, 32, 36
    • Anomaly scan: 20 weeks. Including cardiac: detailed four chamber view of the heart and outflow tracts
    • ANC: 1-2 weekly
    • Repeat retinopathy screen at 28 weeks
  • Planned delivery 37-38+6): NICE 2015
    • IOL: 37-38 weeks
    • Elective CS: 38-39 weeks
    • Intra partum +T1DM: insulin sliding scale: insulin + dextrose during labour
    • If preterm: give corticosteroids for fetal lung maturity
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23
Q

What are some RFs for GDM?

A
  • BMI of > 30 kg/m²
  • Previous macrosomic baby > 4.5 kg
  • Previous gestational diabetes
  • First-degree relative with diabetes
  • Ethnic minority with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
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24
Q

What happens with high risk of GDM?

A
  • Any women with RFs (above) or previous GD to be offered screening: OGTT (2h 75g load rapilose gel),
    • ​16-18 weeks (soon after booking)
    • 24-28 weeks if 1st test is normal - not HbA1c due to short duration of pregnancy
  • Also screen if there are fx of GD:
    • Large for dates fetus
    • Polyhydramnios (increased amniotic fluid)
    • Glucose on urine dipstick
  • Diagnosis: # STEPS 5678! Fasting >5.6mmol/ 2h OR BG > 7.8mmol
  • Frequent follow up, ANC with GDM trained healthcare provider, self monitoring blood glucose for all women with diabetes.
  • Fetal sonographic assessment to help determine size of the baby and diagnose fetal macrosomia
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25
Q

What is the Management of Gestational Diabetes?

A
  • Monitoring: Scans: dating scan 12 weeks, detailed scan 20 weeks, growth + LV 2 weeks > 26 weeks
  • 1st: Conservative/ lifestyle: if fasting glucose <7: Weight loss, nutrition counselling and physical activity (30 mins per day)
  • Pharmacological: if fasting glucose >7: stop oral hypoglycaemics but metformin 1g BD (if targets not met in 1-2 wks) and + insulin
  • Insulin commencement: if macrosomia or polyhydramnios – 4 weekly scans from 28 weeks or if fasting blood glucose is >7mmol/L
  • Folic acid 5mg OD till 12 weeks
  • Aspirin 75mg OD from 12 weeks till delivery
  • Planning delivery: 39 – 40+6
    • IOL: 39-40
    • Elective CS 39-40
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26
Q

How is GDM mxd post natally? ?

A
  • Stop all treatment + BG monitoring at delivery
  • Check for resolution of hyperglycaemia via Fasting BG 6-13 weeks post-partum
  • HbA1 at 13 weeks + yearly thereafter (risk of T2DM)
  • Lifestyle advice
  • Contraception and need for pre-conception care in future
  • Encourage breast feeding (insulin, metformin, glibenclamide), discuss contraception, retinopathy
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27
Q

What are some of the risks to the baby PN for GDM?

A
  • Blood: Neonatal hypoglycaemia (Mx: close monitoring, frequent feeds, maintain blood sugar >2mmol/l, if less MX: IV dextrose + NGT)
    • Polycythaemia, Jaundice
  • Heart: Congenital heart disease; Cardiomyopathy
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28
Q

What are some of the sx of obstetric cholestasis?

A
  • pruritus - may be intense - typical worse palms, soles and abdomen
    • intense at night causing insomnia and malaise; no rash
  • clinically detectable jaundice occurs in around 20% of patients
  • raised bilirubin is seen in > 90% of cases
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29
Q

What IX are used for obs cholestasis?

A
  • LFT + bile acids: ↑ bilirubin
  • Viral screen: hep ABC, EBV, CMV
  • Liver autoimmune screen: chronic active hepatitis, PBC, anti-smooth muscle and AMA abs
  • USS abdomen – liver + gall stones
  • Diagnosis of exclusion:
    • ↑ transminases
    • ALP
    • ↑ GGT
    • Mild ↑ in bilirubin (in 90% cases)
    • Primary bile acids increased up to x100
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30
Q

How is obstetric cholestasis mxd?

A
  • Drug treatment to reduce pruritis: ursodeoxycholic acid (reduces pruritis and abnormal LFTs, antihistamine, calamine
  • IOL at 37-38 weeks is common practice but may not be evidence based
  • Ursodeoxycholic acid - again widely used but evidence base not clear
  • Vitamin K supplementation
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31
Q
A
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32
Q

What are the risks of thromboembolism?

A
  • Pregnancy increases risk of VTE x4-6
  • Puerperium ↑risk x5 compared to pregnancy - Absolute risk peaked in the first 3 weeks PP
33
Q

What are some of the RFs for VTE?

A
  • Pre-existing: obesity BMI > 30, age > 35, parity > 3, smoking, grow varicose veins, paraplegia, medical comorbidities, thrombophilia, previous VTE
  • Obstetrics: multiple pregnancy, PET, CS, prolonged labour > 24h, mid cavity or rotational operative delivery, still birth, preterm birth, PPH >1L, IVF
  • New onset reversible: bone fracture, surgical procedure in pregnancy + puerperium, hyperemesis, dehydration, OHSS/ ART, immobile for > 3 days, long-haul travel > 4h, current systemic infection
35
Q

How is VTE in pregnancy Ixd + mxd?

A
  • Gold standard: venography + fetal shield
    • Dopper USS of leg veins – good alternative, less risk to baby, direct image of clot and lack of compressibility of veins
  • Mx: if 4 of >4 RFs: commence LMWH till 6 weeks post-natal
  • If dx of DVT is made shortly before delivery: continue anticoagulation treatment for at least 3 month
36
Q

How are DVTs/ PEs mxd?

A
  • Conservative: TEDs, Leg care , Advice re need for future prophylaxis for: pregnancy, surgery, flying etc.
  • Medical: Full anticoagulation with LMWH e.g. dalteparin or enoxaparin
  • High risk cases: vena cava filters
37
Q

What psychiatric drugs can be prescribed during pregnancy?

A
  • SSRIs – wait till 2nd trimester till prescribing. Fine.
    • Avoid: paroxetine: CHD
    • High concentration: fluoxetine + citalopam
    • Low conc.: sert racine, paroxetine, imipramine, motriptyline
  • Mood stabilised AEDs
    • NO: sodium valproate,lamotrigine carbamazepine – high malformation. Craniofacial abnormalities ans neurodevelopental problems
    • Lithium – NO. Teratogenicity. Same as warfarin
  • Benzodiazepines- NO. Cleft palette
38
Q

What is PPH?

What is primary vs 2ndary?

A
  • Blood loss of >500ml from the genital tract within 24h delivery
  • Minor 500-1000ml
  • Major > 1L
  • Moderate 1L-2L
  • Massive >2L OR 250 mL/min
  • Primary PPH – within 24h
  • Secondary PPH – from 24h to 12 weeks after birth
39
Q

What are some of the RFs for APH, intra partum + PPH?

40
Q

What are the causes of PPH?

A

Tone

Tissue

Thrombin

Trauma

41
Q

What are the RFs for uterine atony?

A
  • Maternal profile: Age >40, BMI > 35, asian ethnicity
  • Uterine over-distension – multiple pregnancy, polyhydramnios, fetal macrosomia.
  • Labour – induction, prolonged (>12 hours).
  • Placental problems – placenta praevia, placental abruption, previous PPH.
42
Q

What other RFs (the 3 other Ts) increased your risk of PPH?

A
  • Tissue - retention of placental tissue –prevents the uterus from contracting (2nd most common cause) -> 2ndary PPH (endometritis)
  • Trauma - damage to reproductive tract during delivery (e.g. vaginal/cervical tears).
    • RFs: Instrumental vaginal deliveries (forceps or ventouse), episiotomy, c section
  • Thrombin
    • Vascular – Placental abruption, hypertension, pre-eclampsia.
    • Coagulopathies – vWB, haemophilia A/B, ITP or acquired coagulopathy i.e. DIC, HELLP.
43
Q

How is PPH mxd specifically?

A
  • Uterine atony
    • Conservative: bimanual compression to stimulate uterine contraction, give birth on an empty bladder
    • Pharmacological: IV tranexamic acid, recombinant factor VII. Cell salvage
    • Surgical
      • Uterine tamponade - intrauterine balloon (bakri balloon), uterine haemostatic suture, suture around uterus
      • Bilateral uterine or internal iliac ligation
      • Hysterectomy – haemostatic drugs
  • Trauma - repair of laceration, if uterine rupture – laparotomy or repair of hysterectomy
  • Tissue – IV oxytocin, manual removal of placenta + prophylactic abx
  • Thrombin – correct any anti coagulation problems, haemocue and teg
44
Q

How would you mx PPH?

A

A-E approach

Ix: FBC, GS, cross match 4-6L of blood, coagulation, UE, LFT, 2 wide bore cannulaes, warmed IV fluids + blood resuscitation, oxygen, FFP (for clotting abnormalities), keep her flat

Activate major haemorrhage protocol: 4 units 0-ve blood

Mx: mechanical, medical, surgical

  • Mechanical: rub uterus, cathetarisation
  • Medical: oxytocin (40u in 500ml) + tranexamic acid + those below
  • Surgical
    • Balloon tamponade
    • B lynch suture
    • Uterine artery ligation
    • Hysterectomy – last resort
45
Q

How do you prevent PPH?

A
  • Active management of the 3rd stage of labour reduces PPH risk by 60%: oxytocin
  • Vaginal delivery: 5-10 units of IM Oxytocin prophylactically.
  • C-section: 5 units of IV Oxytocin
46
Q

What are the main differentials for APH?

A

Placenta praevia, vasa praevia, placental abruption, cervical polyps, vaginitis and vulval varicosities

47
Q

What are the fx of placenta praevia?

A
  • Painless bleeding!
  • Shock in proportion to visible loss
  • No pain and uterine tenderness
  • Lie and presentation may be abnormal
  • Fetal heart usually normal – fetus unaffected unless a massive obstructive haemorrhage
  • Coagulation problems rare
  • Small bleeds before large
48
Q

What Ix are used for placenta praevia?

A

Do not examine!

FBC, clotting, Kleihauer test, G+S, crossmatch, U+E, LFT,

  • CTG –> 26 weeks
  • Imaging: USS – usually picked up routinely on 20-week anomaly USS
  • TVS
49
Q
A
  • Placenta praevia minor – repeat scan at 36 weeks,
  • Placenta praevia major – a repeat scan at 32 weeks + a plan for delivery
  • Confirmed placenta praevia: delivery via elective C-section at 38 weeks.
  • APH all: give anti-D within 72h of bleeding if rh-ve
  • Corticosteroids: fetal lung maturity if pre term

If actively bleeding: admit, A-E, emergency C section

50
Q

What is vasa praevia?

A

Where fetal blood vessels run near the internal cervical os (so are exposed and prone to bleeding during labour + birth)

Characterised by a triad of

  • Vaginal bleeding
  • Rupture of membranes
  • Fetal compromise.
51
Q
A
  • Painful vaginal bleeding + absent FM (HB absent/ distressed)
  • Tense tender abdomen + uterus
  • Coagulopathy PPT
  • Woody uterus (couvelair uterus)
  • Normal lie/ presentation
  • Beware: pre-eclampsia, DIC, anuria
52
Q

How is placental abruption mxd?

A
  • Fetus alive and < 36 weeks
    • fetal distress: immediate caesarean
    • no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
  • Fetus alive and > 36 weeks
    • Fetal distress: immediate caesarean
    • No fetal distress: deliver vaginally
  • Fetus dead: induce vaginal delivery
53
Q

What are the RFs for placental abruption?

A

Abruption (PMH)

BP (HT/ pre eclampsia)

Rupture membrane

Uterine injury

Polyhydramnios

Twins

Infection

O

Narcotics

54
Q

What is considered prematurity?

A
  • <37 wks gestation
  • Extremely preterm - <28 weeks
  • Very preterm 28-32 weeks
  • Moderate to late preterm 32-36+6 week
55
Q

What are the risks to the foetus for prematurity?

A
  • Neonatal death
  • Respiratory distress syndrome
  • Chronic lung disease
  • Intraventricular hemorrhage
  • NEC
  • Sepsis
  • Retinopathy of prematurity
  • < 28 weeks: physical/ learning disabilities, behavioural problems, visual and hearing problems
56
Q

What are the causes / RFs of prematurity?

A
  • APH (25%)
  • cervical incompetence
  • Chorioamnionitis
  • Uterine abnormalities
  • Diabetes
  • Polyhydramnios
  • Pyelonephritis or other infections.
  • Abnormal genital colonization: BV, ureaplasma, mycoplasma hominis
  • RFs: previous preterm birth, multiparity, cervical surgery (LLETZ, cone biopsy), uterine abnormalities, pre existing medical conditions, pre eclampsia, IUGR, abnormal genital tract colonisation
57
Q

What are some of the complications of PPROM?

A
  • fetal: prematurity, infection, pulmonary hypoplasia, sepsis, cord prolapse
  • maternal: chorioamnionitis
59
Q

What is PPROM?

A
  • Water breaks when amniotic sack ruptures
  • <37 weeks and pre-labour
60
Q

What is the hx of

A
  • Gush of fluid from vagina
  • Leaking vaginal fluid
  • Increased watery discharge
  • Concern or uncertainty about urinary incontinence
61
Q

How is PPROM ixd?

A
  • Avoid digital vaginal examination – can re-introduce bacteria up and pre-dispose to infection
  • Gold standard: Sterile speculum examination
    • Pool of fluid -> Confirmed
    • No fluid seen -> test (different brands) – bedside swab tests detecting markers not usually present in vagina
  • AmniSure
  • ActimPROM: based on highly specific monoclonal abs for IGFBP-1 (insulin like growth factor binding protein-1)
    • Sample posterior fornix
  • High vaginal swab
  • Bloods: FBC (WCC), CRP, HVS
62
Q

How is PPROM mxd?

A
  • Admit + observe 48h - chorioamnionitis
  • GBS – early delivery preferred. Give prophylactic abx benzylpenicillin
  • Erythromycin – for 10 days till labour - delays delivery and allows time for steroids to take effect
  • Corticosteroid - FL maturity
63
Q

What is pre term labour?

A
  • Labour/regular contractions resulting in changes in cervix <37/40 (effacement/ shortening OR dilation)
  • Threatened – up to 4cm
  • Established – after 4cm (same as in term labour)
64
Q

Who is at risk from pre term labour?

A
  • Spontaneous preterm birth
  • Mid-trimester loss (16+)
  • PPROM
  • Cervical trauma
65
Q

How are women at risk of pre term labour mxd?

A
  • TV USS cervical length
  • HVS: BV
66
Q

How does pre term labour present

A
  • Menstrual-like cramping
  • Mild, irregular contraction
  • Low back ache
  • Pressure sensation in the vagina or pelvis
  • Vaginal discharge of mucus, which may be clear, pink, or slightly bloody (ie, mucus plug, bloody show)
  • Spotting, light bleeding
67
Q

How is preterm labour ixd?

A
  • USS: Gold standard. TVS for cervical length:
    • >15mm – unlikely PTL – discuss risks/ benefits of going home vs in hospital monitoring
    • < 15mm – confirmed PTL and offer treatment
  • Fetal fibronectin – (NICE recommended)
  • Alternatives: Actim partus, partosure
68
Q

How is pre term labour mxd?

A
  • Admit
  • Tocolysis: atosiban + nifedipine
  • Corticosteroids (<34 w)
  • Rescue cerclage - if dilated cervix + exposed FM, < 28 weeks, no PPROM/ infections/ contractions
  • IN LABOUR - MgS04 (neuroprotection), abx, continuous monitoring
69
Q

How fetal growth is assessed in the antenatal period?

A

>AFTER 24 weeks – useless before

  • Methods: Clinical:
    • Abdominal palpation of fundal height (sensitivity 20-30%)
    • Symphysis-fundal height measurement using a measuring tape (sensitivity: 30-40%)
  • Ultrasound assessment: key measurements (90-95% sensitivity)
    • Head circumference (and Biparietal diameter)
    • Abdominal Circumference
    • Femur length
70
Q

What are the definitions for

A

SMALL FOR DATES/SGA: describes anthropometric variables <10th population centile for GA

o Severe SGA: < 3rd centile for their gestational age.

o LBW: birth weight <2.5kg

LARGE FOR DATES/LGA: describes anthropometric variables >95th population centile for GA

71
Q

What are some RFs for FGR?

72
Q

What are some signs of FGR?

A

Reduced amniotic fluid volume

Abnormal Doppler studies

Reduced fetal movements

Abnormal CTG

73
Q

What are some complications of FGR

74
Q

What are some of the causes of FGR

A

Placenta mediated growth restriction: Idiopathic, Pre-eclampsia, Maternal smoking, Maternal alcohol, Anaemia, Malnutrition, Infection, Maternal health condition

Non-placenta mediated growth restriction:

  • Genetic/ structural
  • Fetal infection
  • Errors of metabolism
75
Q

How are SFH monitored?

A

Low-risk women: SFH monitoring at every AN app >24 weeks onwards to identify potential SGA

If SFH <10th centile, women are booked for serial growth scans with umbilical artery doppler.

Women are booked for serial growth scans with umbilical artery doppler if they have:

  • > 3 RFS minor RFs
  • >+1 major RFs
  • Issues with measuring the SFH (e.g. large fibroids or BMI > 35)

Women at risk or with SGA are monitored closely with serial ultrasound scans measuring:

  • Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity
  • Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery
  • Amniotic fluid volume
76
Q

How are SGA foetuses mxd?

A
  • Identifying those at risk of SGA
  • Aspirin is given to those at risk of pre-eclampsia
  • Treating modifiable risk factors (e.g. stop smoking)
  • Serial growth scans to monitor growth
  • Early delivery where growth is static, or there are other concerns
    • NORMAL umbilical artery Doppler: delay delivery until at least 37 weeks (+ satisfactory additional assessment)
    • With Absent or reversed end-diastolic flow in the umbilical artery (AREDF) + Normal additional assessment: >34/40
    • Abnormal additional assessment (BPP/ CTG abnormal, or other Doppler parameters are abnormal (MCA, umbilical vein): deliver

Year 4 - Obs and Gynae (7 decks)

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