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MK SR INDEX CASES REPRODUCTIVE CARE > High risk pregnancy: Small for date/large for date foetus) > Flashcards

High risk pregnancy: Small for date/large for date foetus) Flashcards

1
Q

Whom to screen for gestational diabetes

A
  • Asian/Afro Caribbean
  • BMI>30
  • Family history of DM in first degree relative
  • Previous unexplained still birth
  • Polyhydramnios and big baby
  • Previous GDM
  • Previous macrosomia >4.5kg
  • Women with PCOS
  • Glycosuria in 2 occasions in pregnancy
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2
Q

When to screen for gestational diabetes

A

• 26-28 weeks

At that time, Maximum placental function -> Human placental lactogen (HPL) secreted by placenta decreases maternal insulin sensitivity

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3
Q

Describe WHO- OGTT Test

A
  • 75gms of glucose load
  • Fasting blood sample, give 75gms of glucose and take sample after 2hours
  • Fasting blood glucose >5.6mmol
  • 2hour blood glucose > 7.8mmol
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4
Q

Management of suspected large baby in utero

A
  • Big baby on palpation
  • Refer for ultrasound
  • If big baby on scan- do OGTT
  • If abnormal OGTT-refer to diabetic team
  • If normal OGTT, treat as normal pregnancy
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5
Q

Is C section indicated for Previous big baby?

A
  • Previous severe shoulder dystocia- offer elective caesarean section
  • Previous mild shoulder dystocia- treat as normal
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6
Q

Management of large-for-gestational-age pregnancy in non-diabetic women

A

BMI <30, favourable cervix induction of labour at 41 weeks

BMI >30, unfavourable cervix -> consider elective LSCS or induction of labour

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7
Q

Large for date Management of labour stage one

A
  • Intravenous line/group and save
  • Continuous CTG monitoring
  • Adequate pan relief
  • Regular cervical assessment
  • Augmentation of labour if needed
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8
Q

Large for date Management of labour stage two

A
  • Early recourse to caesarean section if no descent
  • Senior midwife for delivery
  • Obstetric registrar and consultant in attendance
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9
Q

Complications of shoulder dystocia: maternal

A
  • PPH

* Trauma

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10
Q

Complications of shoulder dystocia: fetal

A
  • Brachial plexus injury
  • Asphyxia
  • Erb’s palsy (C5,C6)
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11
Q

Large for date management: HELPERR

A
  • Help (call for plenty)
  • Evaluate for episiotomy
  • Legs (McRoberts’ manoeuvre)
  • Pressure (suprapubic)
  • Enter (rotational manoeuvre)
  • Remove the posterior arm
  • Roll the patient onto her hands and knees.
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12
Q

Large for date Management of labour stage three

A
  • Active management of third stage
  • 40units syntocinon, 125/min
  • Syntometrine (syntocinon 5 Units+ Ergometrine 500micrograms)
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13
Q

Definition of IUGR

A

SGA birth is defined as an estimated fetal weight (EFW) is less than the 10th centile for its gestation.

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14
Q

What is the most common cause of SGA foetuses?

A

50-70% of SGA fetuses are constitutionally small, based on Maternal size and ethnicity.

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15
Q

Differentials for symmetrical vs asymmetrical fetal growth restriction

A

Symmetrical: intrauterine infections, congenital anomalies, environmental factors

Assymetrical: pre-eclampsia, IUGR, smoking, Essential HTN

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16
Q

Pathophysiology of Asymmetric IUGR

A
  • Fetus adjusts to inadequate nutrition
  • Redistribution of blood flow
  • More to heart, lungs and adrenal glands
  • Less to liver and kidneys
  • Abdominal circumference and fat stores are reduced more than the head.
  • Brain sparing effect
17
Q

Maternal behavioural factors that can cause fetal growth restriction

A
  • Smoking
  • Low booking weight (<50 kg)
  • Poor nutrition
  • Age <16 or >35 years at delivery
  • Alcohol
  • Drugs
  • High altitude
  • Social deprivation
  • Maternal caffeine consumption ≥ 300 mg per day in the 3rd trimester
  • Maternal exposure to domestic violence
  • Low maternal weight gain
18
Q

Maternal medical factors that can cause fetal growth restriction

A
  • Chronic hypertension
  • Connective tissue disease
  • Severe chronic infection
  • Diabetes mellitus
  • Anaemia
  • Uterine abnormalities
  • Maternal malignancy
  • Pre-eclampsia
  • Thrombophilic defects
19
Q

Fetal factors that can cause fetal growth restriction

A
  • Multiple pregnancy
  • Structural abnormality
  • Chromosomal abnormalities
  • Intrauterine (congenital) infection
  • Inborn errors of metabolism
20
Q

placental factors that can cause asymmetrical fetal growth restriction

A
  • Impaired trophoblast invasion
  • Partial abruption or infarction
  • Chorioamnionitis
  • Placental cysts
  • Placenta praevia

Main pathology is impaired trophoblastic invasion leads to reduced perfusion in intervillous space.

21
Q

Risks from IUGR

A
  • Still birth
  • Premature birth
  • Fetal distress in labour
  • 3-10 fold increase in perinatal mortality
  • Neonatal unit admission
  • Long term handicap

Conditions: necrotising enterocolitis, brain injury, respiratory distress, retinopathy

22
Q

Major risk factors for IUGR

A
  • Previous history of SGA or still birth
  • Heavy smoking
  • Cocaine abuse
  • Heavy daily exercise
  • Maternal illness –diabetes
  • Parental SGA
23
Q

Three key components of prevention of IUGR

A
  • Aspirin (antiplatelet agent) from 16wks in women who are high risk for Pre-eclampsia and IUGR
  • Smoking cessation
  • Antithrombotic therapy in high risk women
24
Q

Management of IUGR

A

Early onset: detailed scan, karyotype, screen for infections

Late onset: increased fetal surveillance, deliver early, steroids if <36 weeks

25
Q

List 2 key components of Fetal Surveillance in IUGR

A
  • Pregnancy associated plasma protein A (PAPPA)- low level indicates high risk for IUGR
  • Maternal uterine artery doppler- 20-23weeks
  • Abnormal wave forms and notch indicates high risk for IUGR
  • Integrated screening for pregnancy risk- combining history/PAPPA/uterine artery doppler
  • Pre-eclampsia/vagina bleeding/abdominal palpation –small for dates
26
Q

How should Uterine Artery doppler scans be interpreted

A

Doppler can help identify cases of IUGR, or hypoxic and/or distressed fetuses. Changes occur in the umbilical artery waveform pattern obtained using Doppler ultrasound as placental resistance increases

  • Uterine artery develops low resistance in pregnancy
  • Presence of notch indicates high risk for IUGR /early onset pre-eclampsia and abruption.
  • These women are given low dose Aspirin 75mg all through out pregnancy to prevent these complications
27
Q

Uterine Artery doppler: Pulsatality Index (PI)

A
  • Pulsatility index (PI) being the difference between peak systolic and end diastolic velocity divided by the mean velocity (PI = (Vmax - Vmin) / V mean).
  • PI increases with increased placental resistance.
28
Q

Management of IUGR < 34 weeks

A
  • Gestation <34 weeks –aim is to prevent in utero demise or neurological damage
  • Fetal weight should be > 500gms and the gestation > 25-26 weeks for gestation for fetus to be potentially viable.
  • Umbilical artery doppler at least twice a week
  • If doppler shows absent end diastolic flow – admitted for steroids
  • If >32 weeks- delivery by LSCS
  • IF <32 weeks- daily CTG and deliver if CTG abnormal
  • Give magnesium prior to delivery
29
Q

Management of IUGR 34 - 37 weeks gestation

A

delivery can be by induction or caesarean if CTG is abnormal.

30
Q

Management of IUGR > 37 weeks gestation

A

delivery indicated by induction or caesarean if CTG is abnormal.

MK SR INDEX CASES REPRODUCTIVE CARE (23 decks)

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