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REPRODUCTION & GYNAECOLOGY > Large for Dates > Flashcards

Large for Dates Flashcards

1
Q

What does it mean if a foetus is considered “large for date”?

A

Symphyseal-fundal height >2cm for Gestational age

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2
Q

What are the possible reasons for a baby being large for date?

A
  • Wrong dates
  • Fetal Macrosomia
  • Polydramnios
  • Diabetes
  • Multiple Pregnancy
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3
Q

Why may a patient have wrong dates which contribute to healthcare professionals thinking the baby is large for dates?

A
  • Late Booker
  • Concealed pregnancy (undiagnosed)
  • Vulnerable women (e.g. children already in social care => not engaging with healthcare during pregnancy)
  • Transfer of Care: Booked abroad
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4
Q

How is foetal macrosomia diagnosed?

A

Ultrasound Scan

  • Estimated Foetal Weight >90th centile
  • plotted on population based charts OR customised growth charts
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5
Q

How are growth charts “customised” to the mother?

A

Take into account:

  • ethnicity (caucasian population = largest babies > african >asian)
  • BMI
  • parity (previous children and their birth weights)
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6
Q

What are the risks of foetal macrosomia?

A
  • Labour dystocia (difficulty to progress)
  • Shoulder dystocia (shoulder gets stuck - more common with diabetes)
  • Post Partum Haemorrhage
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7
Q

How should foetal macrosomia be managed?

A
  • Exclude diabetes
  • Reassure
  • Plan for Conservative Mx vs Induction of Labour vs C-Section delivery
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8
Q

What name is given to a condition of excess amniotic fluid which can cause a baby to be large for date?

A

Polyhydramnios

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9
Q

How is Polyhydramnios diagnosed?

A

Amniotic Fluid Index (AFI >25cm)
Deepest Pool >8cm

experienced clinicians may be able to diagnose this clinically

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10
Q

What is the most common maternal cause of polyhydramnios?

A

Diabetes

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11
Q

After diabetes, what is the next most common cause of polyhydramnios?

A

Idiopathic

=> no cause identified

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12
Q

What causes of polyhydramnios are usually due to the foetus?

A
  • Anomaly- GI atresia, cardiac, tumours
  • Monochorionic twin pregnancy
  • Hydrops fetalis (abnormal fluid in>2 fetal compartment => ascites, pleural effusion, pericardial effusion, oedema)
  • Viral infection (erythrovirus B19, Toxoplasmosis, CMV)
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13
Q

What symptoms of polyhydramnios does the mother often present with?

A
  • Abdominal discomfort
  • Pre-labour rupture of membranes
  • Preterm labour
  • Cord prolapse through cervix
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14
Q

What signs of polyhydramnios may be present on clinical examination?

A
  • Large for date
  • Malpresentation
  • tense shiny abdomen
  • inability to feel foetal parts on examination
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15
Q

How is polyhydramnios investigated?

A
  • Oral Glucose Tolerance Test (OGTT)
  • Viral Serology
  • Antibody Screen
  • USS – fetal survey- lips, stomach
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16
Q

How is polhydramnios managed?

A
  • Serial USS for growth, presentation

- Induction of Labour by 40 weeks

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17
Q

What complications should you warn the patient about before labour?

A
  • Risk malpresentation
  • Risk of cord prolapse
  • Risk of Preterm Labour
  • Risk of Post Partum Haemorrhage
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18
Q

What is the incidence of spontaneous twins and triplets?

A

Spontaneous twins 1:80

Spontaneous triplets 1:10,000

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19
Q

What can increase a woman’s risk of multiple pregnancy?

A
  • Assisted conception (less common now as only one embryo is transferred)
  • Race - African
  • Geography (Africa > Europe > Asia)
  • Family History
  • Increased maternal age
  • Increased Parity (no. of children born)
  • Tall women> short women
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20
Q

What is the difference between Gravidity and Parity?

A

Gravidity - number of times a woman has been pregnant

Parity - number of times a woman has given birth to a foetus with gestational age of >24 weeks
(regardless of whether born alive or still born)

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21
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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22
Q

Describe the potential chorionicity of monozygotic and dizygotic twins

A

Chorionicity = ONE or TWO placentas (i.e. do they share)

Dizygous

  • always DCDA
  • Dichorionic (2 placentas), Diamniotic (2 amniotic sacs)

Monozygous-
DCDA = Dichorionic, Diamniotic (2 placentas and 2 amniotic sacs)
MCDA = Monochorionic, Diamniotic (1 placenta, 2 amniotic sacs)
MCMA = Monochorionic, Monoamioniotic (shared placenta and amniotic sac)

Conjoined

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23
Q

What factor can change the chorionicity of monozygotic twins?

A

Depends on time of splitting of fertilised ovum

- later splitting = sharing of more structures (up to conjoinment)

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24
Q

What days of gestation can the fertilised egg split and change the chorionicity of monozygotic twins?

A

Day 1-3 = DCDA
Day 4-8 = MCDA
Day 8-13 = MCMA
Day 13-15 = Conjoined

25
Q

How can the chorionicity be determined on an US scan?

A
  • Assessing shape/thickness of membrane
    • Lambda sign = DCDA
    • T shape = MCDA
  • foetal sex may give indication (if opposite sexes => Dizygotic => DCDA)
26
Q

What symptoms experienced by the pregnant mother may indicate a multiple pregnancy?

A

Exaggerated pregnancy symptoms

e.g. excessive sickness/ hyperemesis gravidarum

27
Q

What signs may point towards a potential multiple pregnancy?

A
  • High AFP
  • Large for dates uterus
  • Mutiple fetal poles
  • USS confirmation at 12 weeks
28
Q

What complications can present in a multiple pregnancy?

A
  • Higher perinatal mortality
  • Congenital anomalies
  • IUD (single twin/both)
  • Preterm birth
  • Growth restriction- both /discordant
  • Cerebral Palsy
  • Twin to twin transfusion
29
Q

What are the maternal complications of multiple pregnancy?

A
  • Hyperemesis Gravidarum
  • Anaemia (as BOTH babies need lots of iron)
  • Pre eclampsia
  • Antepartum haemorrhage- abruption, placenta praevia
  • Preterm Labour
  • C section
30
Q

How are pregnant mothers with multiple pregnancy managed antenatally?

A
  • Consultant Led care
  • Attend Twin/Multiple Pregnancy Clinic
    Appointments:
    =>MC: every 2 weeks
    => DC every 4 weeks
  • Maternal education and Support (e.g. schemes to give discounts on baby food/clothes)
31
Q

What medication should mothers of multiple pregnancy be started on?

A
  • Iron supplementation
  • Low Dose Aspirin
  • Folic Acid
32
Q

How often do mothers of multiple pregnancy require Ultrasound scanning?

A
  • MC 2 weekly from 16/40
  • DC 4 weekly
    Anomaly USS 18-20 weeks
33
Q

What are the main complications of monochorionic twins?

A
  • Single Fetal Death (also causes risk to survivor => neuro abnormality)
  • Selective Growth Restriction (sGR)
  • Twin-To- Twin Transfusion Syndrome (TTTS)
34
Q

What do twins look like after being born with Twin-To- Twin Transfusion Syndrome (TTTS)?

A
  • one = small and pale
  • other = polycythaemic and larger

due to one being donor and one being receiver twin`

35
Q

What other complications does Twin Transfusion Syndrome (TTTS) cause?

A

Oligohydramnios- polyhydramnios (Oly-Poly)

  • One twin with oligo, other with polyhydramnios
36
Q

HOw can Twin Transfusion Syndrome (TTTS) be treated?

A

Before 26/40 RARE – Mx = Foetoscopic laser ablation

> 26/40- amnioreduction /septostomy

Deliver 34-36/40 wks

37
Q

What risks are present in an MCMA birth and how are these babies deliveres as a result?

A
  • Risk for cord entanglement
  • Higher Risk of Foetal Death
    => Deliver by C/Section 32-34 weeks
38
Q

When are DCDA and MCDA twins typically delivered?

A

DCDA Twins deliver 37-38 weeks

MCDA Twins deliver after 36 weeks with steroids.

39
Q

HOw should twins or multiple pregnancies usually be delivered?

A
  • Triplets or more – Caesarean section
  • MCMA- Caesarean section as highest risk
  • If first twin presents cephalic => aim for vaginal delivery
    (if second then presents breech might actually still be possible for vaginal birth after first one)
40
Q

What types of diabetes must we be aware of during pregnancy?

A

Pregestational - Type 1,2, MODY

Gestational diabetes

41
Q

What is common to all complications from diabetes which occur in pregnancy?

A
  • they all occur due to poor glycaemic control and high HbA1c levels
42
Q

What complications are specific to pre-existing diabetes?

A

Congenital anomalies- due to high HBA1C at booking
Miscarriage
Intra-uterine death

43
Q

What complications of diabetes in pregnancy is common to both pre-existing and gestational?

A
  • Pre eclampsia
  • Polyhydramnios
  • Macrosomia
  • Shoulder dystocia
  • Neonatal hypoglycaemia
44
Q

What counselling and advice should be given to women with pre-existing diabetes who are pregnant or considering getting pregnant?

A
  • HbA1c Monitoring Aim = 48mmol/mol (6.5%)
  • Avoid pregnancy HBA1C >86 mmol/mol (10%)
  • Stop diabetic medication that may harm foetus eg ACEi, cholesterol lowering
  • Determine macro/ microvascular complications
  • High Dose Folic Acid 5mg
  • Advice about DKA/hypo (e.g. during morning sickness)
  • Contraception
45
Q

How should women with diabetes in pregnancy be managed and followed up?

A
  • Low Dose Aspirin from 12 weeks
  • Foetal anomaly scan (18-20 wks)
  • Eye checks for retinopathy
  • Check for nephropathy- refer to renal
  • Hypoglycaemic Agents (insulin or metformin)
  • Continuous glucose monitoring (Libre)
  • Growth scans 4 wkly from 28 weeks
  • Counsel about shoulder dystocia
  • Deliver at 38 weeks
46
Q

What are the main risk factors for gestational diabetes?

A
  • Previous GDM
  • Obesity BMI >30
  • FHx: 1st degree relative
  • Ethnic variation
  • Previous big baby
  • Polyhydramnios
  • Glycosuria
47
Q

HOw is gestational diabetes screened for and diagnosed?

A

OGTT in 1st Trimester at booking appointment

  • If patient is deemed high risk, but OGTT is normal in 2st trimester, then repeat at 24-28 weeks
48
Q

What values on an OGTT would indicate a diagnosis of gestational diabetes?

A

Fasting >=5.1 mmol/l

2 hour >=8.5 mmol/l

49
Q

How is an OGTT carried out?

A 
Venous Fasting Blood Sugar 
		↓
75 g glucose given to patient
		↓
2hr venous glucose taken
50
Q

Who is involved in the antenatal care of mothers with diabetes in pregnancy?

A 
Obstetrician
Endocrinologist
Midwife
Diabetic Specialist Nurse
Dietician
51
Q

What should a pregnant mother with diabetes be educated on?

A
  • diet, body weight and exercise
  • Importance of glycaemic control
  • Risks: macrosomia and neonatal hypoglycaemia
  • Increased risk of baby having obesity/diabetes in later life
  • Increased risk of T2DM for mother
52
Q

How often should pregnant mothers with diabetes check their blood sugar throughout the day?

A

Minimum 4 times a day- premeals

(sometimes 1 hr postmeal ) and before bed.

53
Q

What are the glycaemic targets for glucose monitoring during pregnancy?

A

Fasting = 3.5 -5.5 mmol/l

1 hr after meal <7.8mmol/l

54
Q

How should diabetic pregnant women be managed?

A
  • Diet and Exercise
  • Monitor for Pre-eclampsia
  • Growth scans
  • Consider Hypoglycaemic agents if diet/exercise fail to maintain targets and macrosomia is visible on US
55
Q

What are the benefits of oral hypoglycaemic agents as opposed to insulin?

A
  • Avoidance of hypo associated with insulin
  • Less weight gain
  • Less ‘education’ required to ensure safe / effective administration
56
Q

Insulin does NOT cross the placenta. TRUE/FALSE?

A

TRUE

57
Q

When should babies be delivered if their mother has pre-existing diabetes VS gestational diabetes?

A

Pregestational Diabetes:
38 weeks onwards

Gestational:
On Insulin = 38 weeks
On Metformin = 39- 40 weeks
Diet alone = 40 to 41 weeks

58
Q

An Estimated foetal weight over what would indicate the need for a C-section?

A

If EFW >4.5kg- c/section

59
Q

What are the main risk factors for the development of Type 2 Diabetes in the post-natal period?

A
  • Obesity
  • Use of insulin during pregnancy
  • Insufficient Glandular Tissue post partum (low/no milk)
  • Ethnic group

REPRODUCTION & GYNAECOLOGY (58 decks)

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