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Reproduction > Problems in Pregnancy: Large for Dates > Flashcards

Problems in Pregnancy: Large for Dates Flashcards

1
Q

what is the definition of a large for date baby?

A

symphyseal-fundal height >2cm for gestational age

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2
Q

what is the possible cause of a large for date baby?

A 
wrong dates 
foetal macrosomia 
polydramnios 
diabetes 
multiple pregnancy
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3
Q

how is foetal macrosomnia diagnosed?

A

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

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4
Q

what are the risks of foetal macrosomnia?

A

clinician and maternal anxiety
labour dystocia
shoulder dystocia - more with diabetes
PPH

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5
Q

what is the management of foetal macrosomnia?

A

exclude diabetes
reassure
conservative vs IOL vs C/S delivery

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

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6
Q

what is polyhydramnios?

A

excess amniotic fluid

amniotic fluid index (AFI >25cm)
deepest pool >8cm

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7
Q

what are the different causes 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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8
Q

what are the symptoms of polyhydramnios?

A 
abdominal discomfort 
pre-labour rupture of membranes
preterm labour 
cord prolapse 
PPH
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9
Q

what are the signs of polyhydramnios?

A

large for date
malpresentation
tense shiny abdomen
inability to feel foetal parts

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10
Q

how is polyhydramnios diagnosed?

A

USS

  • AFI >25
  • DVP >8cm

*this is subjective

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11
Q

what investigations should take place following diagnosis of polyhydramnios?

A

OGTT
serology - toxoplasmosis, CMV, parvovirus
antibody screen
USS - foetal survey (lips, stomach)

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12
Q

what is the management of polyhydramnios?

A

patient information of complications
serial USS - growth, LV, presentation
IOL by 40 weeks

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13
Q

what are the risks during labour in polyhydramnios?

A

risk malpresentation
risk of cord prolapse
risk of preterm labour
risk of PPH

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14
Q

what are the risk factors of multiple pregnancies?

A 
assisted conception - clomid, IVF
race - African 
family history 
increased maternal age 
increased parity 
tall women > short women
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15
Q

what is the difference between monozygotic and dizygotic twins?

A

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

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

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16
Q

what type of monozygotic twins occur which cleavage occurs at the following different stages:

a) morula (0-3 days)?
b) blastocyst (4-7 days)?
c) implanted blastocyst (8-14 days)?
d) formed embryonic disc (15 onwards)?

A

a) dichorionic / diamniotic (different placenta and amniotic sac)
b) monochorionic / diamniotic (same placenta, different inner membrane)
c) monochorionic / monoamniotic (both share placenta and membranes)
d) conjoined

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17
Q

how can chorionicity be determined?

A

US

  • shape of membrane and thickness of membrane (twin peak at 11-13+6 weeks / CRL 45-84mm and placental masses, appearance of membrane attachment and thickness - Lambda sign)
  • foetal sex
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18
Q

why is determining chorionicity important?

A

monochortionic / monozygous twins at higher risk of complications

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19
Q

what are the symptoms of multiple pregnancy?

A

exaggerated pregnancy symptoms eg excessive sickness / hyperemesis gravidarum

20
Q

what are the signs of multiple pregnancy?

A

high AFP
large for dates uterus
multiple foetal poles

21
Q

when is USS confirmation of multiple pregnancy carried out?

A

12 weeks

22
Q

what are the fetal complications in multiple pregnancy?

A 
congenital anomalies eg acardiac twins 
IUD 
pre term birth 
growth restriction
cerebral palsy 
twin to twin transfusion - oligohydramnios & polyhydramnios
23
Q

what are the maternal complications in multiple pregnancy?

A 
HG
anaemia 
pre eclampsia 
antepartum haemorrhage (abruption, placenta praevia)
preterm labour 
c-section
24
Q

how often do multiple pregnancies attend clinic appointments for USS?

A

MC: every 2 weeks from 16/40
DC: every 4 weeks

25
Q

what is the medical management in multiple pregnancies?

A

Fe supplementation
low dose aspirin
folic acid

26
Q

what complications are specific to monochorionic twins?

A

single foetal death

selective growth restriction (sGR)

twin to twin transfusion syndrome (TTTS)

twin anaemia-polycythaemia sequence (TAPS following laser ablation for TTTS)

absent EDV or reversed EDV

27
Q

what is twin to twin transfusion syndrome (TTTS)?

A

syndrome with artery-vein anastomoses
donor twin perfuses the recipient twin

*rare after 26/40

28
Q

what is the diagnosis criteria of TTTS?

A

oligohydramnios - polyhydramnios

29
Q

what are the complications of TTTS?

A

mortality >90% with no treatment

neurological morbidity 37% and high in surviving twin if IUD

30
Q

what is the treatment of TTTS?

A

before 26/40 = fetoscopic laser ablation

> 26/40 = amnioreduction / septostomy

deliver at 34-36/40

31
Q

what is the timing of delivery of twins?

A

DCDA = 37-38 weeks

MCDA = after 36 weeks with steroids

MCMA = 32-34 weeks

32
Q

what should the mode of delivery be for twins?

A

triplets or more = c-section

MCMA = c-section

twins if twin one cephalic = aim for vaginal delivery

33
Q

what should be given after delivery of twin 1?

A

syntocinon

34
Q

what are the complications of pre-existing diabetic pregnancies which all relate to poor control?

A

congenital anomalies - related to high HBA1C at booking
misscarriage
intra uterine death
worsening diabetic complications eg retinopathy, neuropathy

35
Q

what are the complications of diabetic pregnancies which are common to pre-existing and gestational diabetes?

A 
pre eclampsia 
polyhydramnios 
macrosomnia 
shoulder dystocia 
neonatal hypoglycaemia
36
Q

for type 1 and 2 diabetics, pregnancy should be avoided if HBA1C level is what?

A

above 86mmol/mol

37
Q

what medications should be taken by type 1 and 2 diabetics?

A

folic acid 5mg

low dose aspirin from 12 weeks

38
Q

what are the risk factors for gestational DM?

A 
previous GDM
obesity BMI 30 or more 
FH (1st degree relative)
previous big baby 
polyhydramnios 
big baby 
glycosuria (1+ on >1 occasion or >=2+ on one occasion)
39
Q

what is the pathophysiology of GDM?

A

pregnancy is diabetogenic - HPL, cortisol

placental hormones - relative insulin deficiency / insulin resistance

40
Q

what are the consequences of GDM?

A

overgrowth of insulin sensitive tissues and macrosomia

hypoxaemic state in utero

short term metabolic complications

foetal metabolic reprogramming leading to increased long term risk of obesity, insulin resistance and diabetes

41
Q

when should OGTT be carried out to screen for GDM?

A

risk factors at booking

OGTT at 24-28 weeks

42
Q

how is OGTT carried out in pregnant women?

A

venous FBS -> 75g glucose solution -> 2hr venous glucose

43
Q

what are the potential advantages of oral hypoglycaemic agents?

A

avoidance of hypoglycaemia associated with insulin

less weight gain

less education required to ensure safe / effective administration

44
Q

what should be the timing of delivery in diabetics?

A

pregestational

  • 38 weeks onwards
  • earlier if complications

GDM

  • insulin treatment 38-39 weeks
  • metformin 39-40 weeks
  • diet alone 40-41 weeks
  • if foetal macrosomia / IUGR / PET then earlier delivery
45
Q

what should be the mode of the delivery in diabetics?

A

maternal preference
other indications for c-section
discuss risks and benefits of vaginal birth inc shoulder dystocia (9-10% risk)

if EFW >4.5kg - c section

46
Q

what tests should be undertaken postnatally in GDM?

A

fasting blood sugar 6-8 weeks postnatally

if picture of T2DM - OGTT 6 weeks PN

annual FBS & lifestyle changes

Reproduction (45 decks)

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