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Reproduction > Problems in Pregnancy: Large for Dates > Flashcards

Problems in Pregnancy: Large for Dates Flashcards

1
Q

What is the symphyseal-fundeal height when baby is large for dates?

A

Symphyseal-fundal height >2cm for gestational age

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2
Q

Aetiology for large for dates (large for dates)

A 
Wrong dates of LMP
Fetal Macrosomia
Polyhydramnios
Diabetes
Multiple Pregnancy
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3
Q

Wrong dates as a cause for LFD

A

Late Booker

  • Concealed pregnancy
  • Vulnerable women
  • Transfer of Care: Booked abroad
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4
Q

How to diagnose fetal macrosomia

A
  • USS EFW >90th centile AC>97TH Centile
  • Generic population based charts and customised growth charts (ethnicity, BMI, parity) - might lead to misdiagnosis in women of different ethnicity
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5
Q

Risks of Fetal Macrosomia

A

Clinican & maternal anxiety

Labour dystocia

Shoulder dystocia- more with diabetes

PPH

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6
Q

How accurate is the USS?

A

Ultrasound estimated foetal weight (EFW) is commonly overestimated in comparison to actual weight

Operator dependent- training essential

Gestation- more accurate <38 weeks

BMI of women - large woman is gonna have quite a lot of fat between probe and baby so obtaining measurements is difficult and estimating baby’s size is difficult

Formula for EFW- Hadlock better

Margin of error up to 10%

Eg Baby EFW 4000g ( actual birth weight 3600g)

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7
Q

Management of fetal macrosomia

A

Exclude diabetes
Reassure
Conservative vs IOL vs C/S delivery

NICE Recommendation: 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).

Consider C-sec if baby is >4.5kg

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8
Q 
Case 2: 
25 years old P1, BMI 24
28/40 pregnant with abdominal discomfort
Midwife measure SFH 35cm
USS performed
Diagnosis?
A

Polyhyrdramnios - excessive amniotic fluid

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9
Q

What is Polyhydramnios?

A

Definition: Excess amniotic fluid

Amniotic Fluid Index (AFI >25cm)

Deepest Pool >8cm

(Subjective impression)

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10
Q

Maternal aetiology of polyhydramnios

A

Diabetes

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11
Q

Fetal aetiology of polyhydramnios

A

Anomaly- GI atresia, cardiac, tumours
Monochorionic twin pregnancy
Hydrops fetalis – Rh isoimmunisation
Viral infection

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12
Q

Other causes of polyhydramnios

A

Idiopathic

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13
Q

List fetal viral infections that may cause polyhydramnios

A

erythrovirus B19, Toxoplasmosis, CMV

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14
Q

Symptoms of polyhydramnios

A

Abdominal discomfort
Pre-labour rupture of membranes
Preterm labour
Cord prolapse - obs emergency

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15
Q

Signs of polyhydramnios

A

LFD
Malpresentation
tense shiny abdomen
inability to feel fetal parts

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16
Q

Diagnosing polyhydramnios

A

Ultrasound Confirmation

  • AFI >25
  • DVP >8cm

(Subjective)

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17
Q

Investigation for polyhydramnios

A

Oral Glucose Tolerance Test (OGTT)
Serology- toxoplasmosis, CMV, Parvovirus
Antibody Screen
USS – fetal survey- lips, stomach

Polyhydramnios has an association with trisomy- counsel patient

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18
Q

Management of polyhydramnios

A 
Patient information- complications
Serial USS- growth, LV, presentation
IOL by 40 weeks
Labour
- Risk malpresentation
- Risk of cord prolapse
- Risk of Preterm Labour
- Risk of PPH
- Neonatal examination
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19
Q

Define multiple pregnancy

A

presence of more than 1 fetus- twins, triplets etc

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20
Q

Incidence of multiple pregnancy and high order births

A

Spontaneous twins 1:80
Spontaneous triplets 1:10,000
Increased with Assisted conception

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21
Q

Factors increasing incidence of multiple pregnancy

A

Race- African – highest rate of twins

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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22
Q

Why is the twinning rate so high in AFrica?

A

Higher perinatal morbidity in africa, nature increases the chance of survival of offspring by giving twins (increases chance of survival)

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23
Q

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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24
Q

Type of Chorionicity - 1 Placenta/ 2 Placentas

A

This is how you asses risk of twin pregnancy

Dizygous – always Dichorionic Diamniotic (DCDA)

Monozygous- MCMA, MCDA, DCDA, conjoined; depends on time of splittingof fertilised ovum

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25
Q

Which stage is important in determining chorionicity

A

Time of cleavage

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26
Q

Monochorionic Twins

A

Day0-3 after fertilisation: Dichorionic, diamniotic (DCDA)
Day 4-7 after fertilisation: Monochorionic , diamniotic (MCDA)
Day 8-14 after fertilisation: Monochorionic , monoamniotic (MCMA)
Day 15 after fertilisation onwards: Conjoined twins

27
Q

How to determine chorionicity

A

Ultrasound:
- Shape of membrane and thickness of membrane
twin peak at 11-13+6 weeks (CRL 45-84mm)
Placental masses, appearance of membrane attachment & membrane thickness ( Lambda sign)

  • Fetal sex
28
Q

Importance of determining chorionicity

A

Monochorionic / monozygous twins at higher risk of pregnancy complications

29
Q

Symptoms of multiple pregnancy

A

Exaggerated pregnancy symptoms e.g. excessive sickness/ hyperemesis gravidarum

30
Q

Signs of multiple pregnancy

A

High AFP
Large for dates uterus
Mutiple fetal poles

31
Q

At what gestational age can a multiple pregnancy be confirmed by USS?

A

12 weeks

32
Q

Fetal complications of multiple pregnancy

A

Higher perinatal mortality ( 6X higher than singleton)

Fetal

  • Congenital anomalies eg acardiac twin
  • IUD ( single/both)
  • Pre term birth
  • Growth restriction- both /discordant
  • Cerebral Palsy-(twins 8X higher, triplets 47X higher)
  • Twin to twin transfusion- oligohydramnios& polyhydramnios
33
Q

Maternal complications of multiple pregnancy

A 
Hyperemesis Gravidarum
Anaemia
Pre eclampsia
Antepartum haemorrhage- abruption, placenta praevia
Preterm Labour
Caesarean section
34
Q

Antenatal management of multiple pregnancy

A

Consultant Led care

Twin/Multiple Pregnancy Clinic

Clinic appointments

  • MC: every 2 weeks
  • DC every 4 weeks

Maternal education

  • Preterm labour & risks
  • Support
  • TAMBA

Medication

  • Fe supplementation
  • Low Dose Aspirin
  • Folic Acid

USS

  • MC 2 weekly from 16/40
  • Anomaly USS 18-20 weeks
  • DC 4 weekly
  • Anomaly USS 18-20 weeks
  • Deep Vertical Pool, bladder &Umbilical Artery Doppler (UAPI), EFW
35
Q

Complications of monochorionic twins

A

Single Fetal Death
Selective Growth Restriction (sGR) - increased perinatal risk if EFW discordance > 20%
Twin-To- Twin Transfusion Syndrome (TTTS)
Twin Anaemia-P0lycythaemia Sequence (TAPS)
Absent EDV (AEDV) or Reversed (REDV)

36
Q

Define Twin to Twin transfuision Syndrome

A

Syndrome with artery-vein anastomoses. Donor twin perfuses the recipient twin.
Rare after 26/40

37
Q

Diagnosis of TTTS

A

Oligohydramnios- polyhydramnios (Oly-Poly)

38
Q

Complications of TTTS

A

Mortality >90% with no treatment

Neurological morbidity 37% and high in surviving twin if IUD

39
Q

Treatment of TTTS

A

Before 26/40 – Rx fetoscopic laser ablation
>26/40- amnioreduction /septostomy
Deliver 34-36/40

40
Q

List the types of complex multiple births

A

Monochorionic Monoamniotic (MCMA) Twins

  • Risk for cord entanglement
  • Higher Risk of Fetal Death
  • Deliver by C/Section 32-34+0 weeks

Conjoined Twins
- MDT, Specialised centres

41
Q

Higher Order Births

A

Trichorionic triplets

Monochorionic-Dichorionic
Twins – higher morbidity (sGR,

Fetal-fetal Transfusion Syndrome, TAPs)

Consider selective reduction

42
Q

Delivery of multiple pregnancies

A

Timing:

  • DCDA Twins deliver 37-38 weeks
  • MCDA Twins deliver after 36+0 weeks with steroids.

Mode of Delivery

  • Triplets or more – Caesarean section
  • MCMA- Caesarean section
  • Twins if twin one cephalic aim for vaginal delivery
  • Much greater risk of Caesarean section with twins (approx 50%)

Labour is high risk, therefore:

  • Consultant Led Unit
  • Epidural analgesia
  • fetal monitoring: USS & FSE
  • Syntocinon after twin 1
  • USS to confirm presentation
  • Intertwin delivery time <30min
  • Risk of PPH- active 3rd stage and oxytocin infusion
43
Q

Types of Diabetes in pregnancy

A

Pregestational

  • Type I
  • Type II
  • MODY

Gestational diabetes
WHO Definition: carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy

44
Q

Complications of diabetes in pregnancy

A

(Do not forget to ask a young diabetic about contraception)

All relate to poor control

Specific to pre-existing:
Congenital anomalies- related to high HBA1C at booking
- Miscarriage
- Intra uterine death
- Worsening diabetic complications eg retinopathy, nephropathy

Common to pre-existing and gestational:

  • Pre eclampsia
  • Polyhydramnios
  • Macrosomia
  • Shoulder dystocia- 10% risk vs 1% in general population
  • Neonatal hypoglycaemi
45
Q

Type I pregestational diabetes

A 
5-10% prevalence
Younger
Slimmer
White
Insulin Deficiency
46
Q

Type II pregestational diabetes

A 
Rising Prevalence
Older
Overweight/obese
Asian, Middle Eastern, African, Afro-Carribean
Insulin resistance
47
Q

Type I & II diabetes pre pregnancy counselling

A

HBA1C Monitoring Aim for 48mmol/mol (6.5%)

Avoid pregnancy if HBA1C above 86 mmol/mol (10%)

Stop any embryopathic medication eg ACE inhibitors, cholesterol lowering agents

Determine macrovascular & microvascular complications

High Dose Folic Acid 5mg (3 months before conception to 12 weeks of pregnancy)

Advice about diabetes & hypoglycaemia

Contraception

48
Q

Management of type I and II diabetes in pregnancy

A 
Early Booking in Diabetic ANC
Folic Acid 5mg
Low Dose Aspirin from 12 weeks
Fetal anomaly scan at 18-20 weeks
Regular eye checks for retinopathy
If nephropathy- refer renal team
Hypoglycaemic Agents:
- Insulin- MDI /Insulin pump
- Metformin (Type 2)
Consider continuous glucose monitoring
Growth scans 4 weekly from 28 weeks
Counsel about shoulder dystocia
Deliver at 38 weeks ( earlier if complications)
49
Q

Risk factors of gestational diabetes mellitus

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
50
Q

Pathophysiology of GDM

A

Pregnancy is diabetogenic
- Human placental lactogen, cortisol

Placental hormones- relative insulin deficiency/insulin resistance

Consequences

  • 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
51
Q

Screening and diagnosis of GDM

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
52
Q

Procedure of OGTT

A 
Venous FBS 
		↓
75 g glucose solution
		↓
2hr venous glucose
- Minimal activity between tests!
53
Q

Interpretation of OGTT

A

Diagnostic value (SIGN)

  • Fasting >=5.1 mmol/l
  • 2 hour >=8.5 mmol/

Diagnostic value (NICE)

  • Fasting >=5.6 mmol/l
  • 2 hour >=7.8 mmol/l
54
Q

Development of care plan for GDM

A

Antenatal and intrapartum
Targets for glycaemic control
Fetal surveillance
Post-natal care / review

55
Q

What are the points to be covered when educating mother about GDM?

A

Role of diet, body weight and exercise
Risks: macrosomia and neonatal hypoglycaemia
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)

56
Q

Glycaemic targets in 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
57
Q

Management of GDM

A 
Diet, weight control &amp; 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
58
Q

What are the 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

59
Q

Features of insulin treatment during pregnancy

A

Long acting or short acting
Pump Therapy (Type 1)
Does not cross the placenta
Risk of hypoglycaemia

60
Q

Timing of delivery in pre-gestational DM

A

38 weeks onwards

Earlier if complications

61
Q

Timing of delivery in GDM

A

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

62
Q

Mode of delivery

A

Maternal preference
Other indications for C-sec
Discuss risks and benefits of vaginal birth including shoulder dystocia (9-10% risk)
If EFW>4.5kg - Csec

63
Q

Post natal period monitoring in LFD babies

A

Future development of Type 2 diabetes
- Risk up to 70%

Main risk factors*:

  • Obesity
  • Use of insulin during pregnancy
  • Fasting glucose levels from OGTT in pregnancy
  • IGT post partum
  • Ethnic group

Fasting blood sugar(FBS) 6-8 weeks postnatally

If picture of Type 2 DM- OGTT 6 weeks PN

Annual FBS & lifestyle changes

Reproduction (32 decks)

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