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

Question 1

Whom to screen for gestational diabetes

Answer 1

• 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

Question 2

When to screen for gestational diabetes

Answer 2

• 26-28 weeks

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

Question 3

Describe WHO- OGTT Test

Answer 3

• 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

Question 4

Management of suspected large baby in utero

Answer 4

• 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

Question 5

Is C section indicated for Previous big baby?

Answer 5

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

Question 6

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

Answer 6

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

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

Question 7

Large for date Management of labour stage one

Answer 7

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

Question 8

Large for date Management of labour stage two

Answer 8

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

Question 9

Complications of shoulder dystocia: maternal

Answer 9

• PPH

* Trauma

Question 10

Complications of shoulder dystocia: fetal

Answer 10

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

Question 11

Large for date management: HELPERR

Answer 11

• 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.

Question 12

Large for date Management of labour stage three

Answer 12

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

Question 13

Definition of IUGR

Answer 13

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

Question 14

What is the most common cause of SGA foetuses?

Answer 14

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

Question 15

Differentials for symmetrical vs asymmetrical fetal growth restriction

Answer 15

Symmetrical: intrauterine infections, congenital anomalies, environmental factors

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

Question 16

Pathophysiology of Asymmetric IUGR

Answer 16

• 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

Question 17

Maternal behavioural factors that can cause fetal growth restriction

Answer 17

• 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

Question 18

Maternal medical factors that can cause fetal growth restriction

Answer 18

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

Question 19

Fetal factors that can cause fetal growth restriction

Answer 19

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

Question 20

placental factors that can cause asymmetrical fetal growth restriction

Answer 20

• 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.

Question 21

Risks from IUGR

Answer 21

• 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

Question 22

Major risk factors for IUGR

Answer 22

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

Question 23

Three key components of prevention of IUGR

Answer 23

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

Question 24

Management of IUGR

Answer 24

Early onset: detailed scan, karyotype, screen for infections

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

Question 25

List 2 key components of Fetal Surveillance in IUGR

Answer 25

* 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

Question 26

How should Uterine Artery doppler scans be interpreted

Answer 26

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

Question 27

Uterine Artery doppler: Pulsatality Index (PI)

Answer 27

* 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.

Question 28

Management of IUGR < 34 weeks

Answer 28

* 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

Question 29

Management of IUGR 34 - 37 weeks gestation

Answer 29

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

Question 30

Management of IUGR > 37 weeks gestation

Answer 30

delivery indicated by induction or caesarean if CTG is abnormal.