Large for Dates

Question 1

What are the possible causes for a ‘LFD’ pregnancy?

Answer 1

Wrong dates
Multiple pregnancy
DM
Polyhydramnios

Question 2

What is polyhydramnios?

Answer 2

Excess amniotic fluid

Question 3

What are some causes of polyhydramnios?

Answer 3

Monochorionic twin pregnancy
Fetal anomaly
Maternal diabetes
Hydrops fetalis – Rh isoimmunisation, infection (erythrovirus B19)
Ideopathic

Question 4

What are some symptoms/complications of polyhydramnios?

Answer 4

Discomfort
Labour
Membrane rupture
Cord prolapse

Question 5

How is polyhydramnios diagnosed?

Answer 5

US

Clinical

Question 6

What are the incidences of spontaneous multiple pregnancies?

Answer 6

Twins 1:80

Triplets 1:10000

Question 7

What is zygosity?

Answer 7

The number of eggs fertilised to produce twins

Question 8

What is chorionicity?

Answer 8

The membrane pattern of the twins

Question 9

What types of twins are at a higher risk of pregnancy complications?

Answer 9

Monochorionic/monozygous

Question 10

What chorionicities can occur in monozygotic twins?

Answer 10

Monochorionic diamnotic ~2/3
Dichorionic diamnotic ~1/3
Monochorionic monoamniotic ~1%

Question 11

What chorionicity occurs in dizygotic twins?

Answer 11

Dichorionic diamniotic

Question 12

How can the chroionicity be discovered before birth?

Answer 12

US- shape of membrane and thickness of membrane: twin peak at 12 weeks

Question 13

When is multiple pregnancy usually diagnosed?

Answer 13

12 weeks at US

Question 14

What clinical features can indicate multiple pregnancy?

Answer 14

Exaggerated pregnancy symptoms e.g. excessive sickness
High AFP
Large for dates uterus
Feeling more than two fetal poles

Question 15

Why does a multiple pregnancy have a much higher perinatal mortality?

Answer 15

Congenital anomalies
Pre term labour
Growth restriction
Pre eclampsia
Antepartum haemorrhage
Twin to twin transfusion

Question 16

How is a multiple pregnancy managed?

Answer 16

More frequent antenatal visits
Detailed anomaly scan at 18wks
Regular scans from 28wks for growth
Routine iron supplementation
Warning to mother re risk and signs of pre term labour

Question 17

How is a multiple pregnancy delivered?

Answer 17

Twins- if twin one cephalic aim for SVD, possibly with epidural. Much greater risk for C-section (50%)
Triplets or more- C section

Question 18

What is the definition of GDM?

Answer 18

Carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy

Question 19

What is the incidence and ethnic variation of GDM?

Answer 19

2-18%
South Asia, Middle Eastern
Black Caribbean

Question 20

What is the pathophysiology of GDM?

Answer 20

Placental hormones lead to relative insulin deficiency or resistance
Aberrant fuel mixture> glucose, aa’s and lipids
Enter placenta
Leads to hyperinsulinaemia

Question 21

What are the consequences of GDM?

Answer 21

Overgrowth of insulin sensitive tissues and macrosomia
Hypoxaemic state in utero
Short term metabolic complications
Fetal metabolic reprogramming leading to increase long term risk of obesity, insulin resistance and diabetes

Question 22

What screening is carried out for GDM?

Answer 22

Women screened for GTT based on RF’s or random blood glucose at booking and 28wks

Question 23

How is GDM diagnosed?

Answer 23

Based on GTT at 28wks
Fasting >5.1mmol/l
2 hour>=8.5mmol/l

Question 24

What are the risk factors for GDM?

Answer 24

FHx of DM
Previous big baby
Previous unexplained still birth
Recurrently glycosuria
Maternal obesity
Previous GDM

Question 25

What complications occur in pregnancy due to pre-existing DM?

Answer 25

Congenital anomalies Miscarriage Intra uterine death

Question 26

What complications in pregnancy are common to pre-existing and GDM?

Answer 26

``` Pre eclampsia Polyhydramnios Macrosomia Shoulder dystocia Neonatal hypoglycaemia ```

Question 27

What do all complications in pregnancy due to diabetes relate to?

Answer 27

Poor control

Question 28

What should target levels of glucose be in pregnancy?

Answer 28

Fasting 3.5-5.9mmol/l | 1hr post prandial <7.8mmol/l

Question 29

What should initially be done in prevention of hyperglycaemia in pregnancy?

Answer 29

Diet Wt control Exercise

Question 30

When should hypoglycaemic therapy be used in pregnancy?

Answer 30

Diet and exercise fail to maintain targets | Macrosomia on US

Question 31

How is the choice of hypoglycaemic agent decided in pregnancy?

Answer 31

Tailored to glycaemic profile | Individual woman

Question 32

What are the advantages of oral hypoglycaemics in pregnancy?

Answer 32

Avoidance of hypoglycaemia associated with insulin Less wt gain Less education required to ensure safe/effective administration

Question 33

What specific obstetric care should be carried out in diabetes-related pregnancies?

Answer 33

Regular monitoring for PET Growth: 2-4weekly FAC from 28wks or diagnosis Fetal wellbeing: benefits of umbilical Doppler in high risk pregnancies and compared to CTG/BPP Offer delivery from 38wks

Question 34

What has a 38wk delivery shown to improve in insulin dependent pregnancies?

Answer 34

Reduction in Macrosomia No cases of shoulder dystocia No significant difference in C-section rates

Question 35

What mode of delivery should be carried out in diabetes-related pregnancies?

Answer 35

Pregnant women with DM who have US diagnosed macrosomia should be informed of risks of vaginal birth and C-section (Diabetes should not be a contraindication to attempting vaginal birth)

Question 36

What risk of developing T2DM do GDM mothers have?

Answer 36

Up to 70%

Question 37

What are the main risk factors for GDM mothers to develop T2DM?

Answer 37

``` Obesity Use of insulin during pregnancy Fasting glucose levels from OGTT in pregnancy IGT post partum Ethnic group ```

Question 38

What lifestyle advice should women be offered post pregnancy who have IGT?

Answer 38

Diet, weight, exercise | Also have annual fasting blood glucose

Question 39

What general management should occur with pregnant mothers who have T1/T2DM?

Answer 39

Pre pregnancy counselling Fetal anomaly scan at 18 wks Regular eye checks for retinopathy