Problems of late pregnancy Flashcards
Outline the different types of SGA
- Normal SGA
- no structural abnormalities
- normal growth velocity
- normal liquor - Abnormal SGA
- structural or genetic abnormalities - Foetal growth restriction
- “starvation small”
- placental insufficiency
- growth velocity changes
- may be symmetrical or asymmetrical IUGR
- symmetrical: caused by early pregnancy complication
- asymmetrical: abnormality after 28wks that interferes with foetal demands
Risks of FGR
Cognitive impairment
Hypoglycemia, hypothermia
Neonatal encephalopathy
Perinatal hypoxic acidaemia
Outline the diagnostic criteria for FGR
Any of the following: EFW <10th percentile AC <10th percentile. Drop in growth velocity >30% in 3 wks Single EFW <3rd percentile confirms FGR
Aetiology of FGR
Maternal causes:
Alcohol, smoking and drugs
Teratogenic drugs: ACEi, carbemazepine, phenytoin, warfarin
Uteroplacental causes: Placental insufficiency (MOST COMMON): - DM with vasculopathy - chronic HTN - PET - severe anaemia - anorexia nervosa - sickle cell Placenta praevia Multiple gestations Placental abruption
Investigations for IUGR
Arterial and venous dopplers:
- umbilical artery and vein
- MCA doppler
- ductus arteriosus
Biophysical profile:
- foetal tone dec
- movements dec
- breathing absent
- FHR
- liquor volume dec
CTG
Serial US (most sensitive)
- EFW/AC <10%
- oligohydramnios
- small placenta, placenta praevia
- placental calcifications
Outline the management of IUGR
Early onset (<32 wks)
- probably infection or chromosomal abnormality
- TORCH screen
- karyotyping via chorionic villus sampling or amniocentesis
- consider CS delivery
Late onset (>32 wks)
- inc foetal surveillance
- delivery if foetal compromise
Delivery:
- abnormal doppler –> CS
- if <37wks –> CS
Prevention of IUGR
Low dose aspirin staring at 12 wks
Cease smoking
Risk factors for breech pregnancy
Uterine/pelvic abnormality:
- fibroids, uterine anomaly
- small pelvis
- multiple gestation
Placenta abnormality:
- placenta praevia
- short umbilical cord
Extremes of amniotic fluid
- polyhydramnios
- oligohydramnios
Foetal anomalies:
- preterm
- IUGR
- anencephaly, hydrocephaly
Epidemiology:
- advanced maternal age
- prev hx breech
Outline the management options for breech babies at term
Discuss this at the 36 wks antenatal appt with the consultant.
- ECV (external cephalic version)
- do at 37 wks
- 60% success rate
- Risks: placental abruption, ROM and early labour, dec BF to foetus (squeezing cord)
- often unsuccessful if macrosomia, no liquor, engaged, high BMI
- give anti-D and tocolytics - Breech delivery
- can do unless footling breech
- complications: foetal asphyxia, head entrapment, cord prolapse, birth trauma, brachial plexus injury - CS
- at >39wks
- assoc with lowest perinatal morbidity and mortality
- small inc in short term maternal morbidity
RANZCOG recommendations for Rh -ve women
- Anti-D in all of the following situations
- ectopic pregnancy
- miscarriage
- abortion
- obstetric haemorrhage
- amniocenetesis
- abdo trauma - Anti-D injections at 28 and 34 wks for all Rh -ve women
- Post-birth Anti-D (dose guided by EBL)
- Rh Ab titres prior to injection
Complications of twin pregnancy
Foetal:
- inc risk stillbirth
- preterm birth –> chronic lung disease
- SGA, IUGR
Monochorionic complications:
- twin-twin transfusion syndrome
Monoamniotic complications:
- cord entanglement and foetal death
Maternal:
- anaemia
- miscarriage
- hyperemesis
- inc risk GDM and PET
- PPH
Intrapartum management of twin pregnancy
Can do VB if the first twin is cephalic and DCDA.
Continuous CTG
Epidural likely required
