Large for dates Flashcards by Joanna Mitchell

What is the definition for a large for date baby?

Symphyseal fundal height >2cm for gestational age

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What are the causes for large for date babies?

Wrong EDD
Foetal macrosomia
Polyhydramnios
Diabetic mother
Multiple pregnancy

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How is foetal macrosomia diagnosed?

USS EFW >90th centile
AC >97th centile
Generic population based charts and customised growth charts (ethnicity, BMI, parity(

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What are the risks assoc with foetal macrosomia?

Clinical and maternal anxiety
Labour dystocia
Shoulder dystocia
PPH

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How accurate is USS in diagnosis of foetal macrosomia?

EFW is commonly overestimated in comparison to actual weight
Gestation more accurate <38 weeks
BMI of women will impact

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What formula is used for estimation of EFW?

Hadlock

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What is the management of macrosomia?

Exclude diabetes
Reassure
Conservative vs IOL (by 40 wks) vs C/S

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What are the nice recommendations for macrosomia?

In absence of any other indications, induction of labour should not be carried out simply because a healthcare professional suspects a baby is large for gestational age (macrosomic)

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What is the recommendation if a baby is over 4.5 kg?

C/S

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What is the definition of polyhydramnios?

Excess amniotic fluid

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How is polyhydramnios diagnosed?

Amniotic fluid index > 25 cm

Deepest pool >8cm

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What maternal factors can result in polyhydramnios?

Diabetes

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What foetal factors can result in polyhydramnios?

Anomaly; GI atresia, cardia, tumours
MCMA twin pregnancy 
Hydrops fetalis; rhesus isoimmunisation 
Viral infections; erythrovirus B19, toxoplasmosis, CMV
Idiopathic

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What are the symptoms of polyhydramnios?

Abdominal discomfort
Preterm rupture of membranes
Preterm labour; pressure on uterus
Cord prolapse

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What are the signs of polyhydramnios?

LFD; large for days
Malpresentation
Tense shiny abdomen
Inability to feel foetal parts

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What investigations should be performed when a diagnosis of polyhydramnios is confirmed?

OGTT; exclude diabetes
Serology; toxoplasmosis, CVM, parvovirus
Antibody screen
USS; foetal surgery for lips and stomach (is there a good swallowing mechanism)

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What is the management of polyhydramnios?

Patient information
Serial USS; growth, liquor volume, presentation
IOL by 40 weeks
Labour; risk of malpresentation, risk of cord prolapse, risk of preterm labour, risk of PPH, neonatal examination

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What is the incidence of multiple pregnancies?

Spontaneous twins; 1:80
Spontaneous triplets; 1:10,000
Increased with assisted conception

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What increase the risks of multiple pregnancy?

Assisted conception; clomid, IVF
Race; african 
FMHx
Increased maternal age
Increased parity
Tall women > short women

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What are the different types of twins?

Zygosity; monozygotic or dizygotic

Chorionicity; 1 or 2 placentas

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What will splitting of the embryo at day 0-3 result in?

Dichorionic
Diamniotic
Monozygotic twins

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What will splitting of the embryo at day 4-7 result in?

Monochorionic
Diamniotic
Monozygotic twins

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What will splitting of the embryo at day 8-14 result in?

Monochorionic
Monoamniotic
Monozygotic twins

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What will splitting of the embryo at day 15 result in?

Conjoined twins

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How is chorionicity determined via USS?

Shape of membrane and thickness of membrane | Foetal sex

What is lambda sign?

Placental masses, appearance of membrane attachment and membrane thickness

Why is chorionicity important?

MCMA monozygous twins have a higher risk of pregnancy complications

What are the signs of a multiple pregnancy?

Exaggerated pregnancy symptoms e.g. hyperemesis

What are the signs of a multiple pregnancy?

High AFP Large for dates uterus Multiple foetal poles USS confirmation at 12 weeks

What are the foetal complications of a multiple pregnancy?

``` Congenital anomalies IUD (single or both) Preterm birth Growth restriction CP TTTS; oly poly ```

What are the maternal complications of a multiple pregnancy?

``` HG Anaemia PET Antepartum haemorrhage; abruption, placental praevia Preterm labour C/S ```

What is the antenatal management of a multiple pregnancy?

Twin/ multiple pregnancy clinic MC; every 2 weeks DC; every 4 weeks Maternal education; preterm labour, support, TAMBA

What medications should be given to multiple pregnant women?

Fe supplementation Low dose aspirin; PET Folic acid

What ultrasounds should be performed in antenatal management?

MC 2 weekly from 16/40 Anomaly USS 18-20 wks DC 4 wkly

What should be assessed on USS for twins?

Deep vertical pool Bladder Umbilical artery doppler (UAPI) EFW

For monochorionic twins; what are the complications?

Single foetal death Selective growth restriction TTTS TAPS (twin anaemia polycythaemia sequence) Absent EDV or reserved - issues with uterine artery

How is TAPS assessed?

Occurs following fetoscopic laser ablation for TTTS | Middle cerebral artery peak systolic velocity

What is TTTS?

Syndrome with artery vein anastomosis | Donor twin perfuses the recipient twin

How is TTTS diagnosed?

One twin with oligohydraminos One twin with polyhydramnios Oy Poly

Complications of TTTS?

Mortality >90% with no treatment | Neurological morbidity

How is TTTS treated?

Before 26/40; fetoscopic laser ablation >26/40; amnioreduction/septostomy Deliver 36-36/40

What is the risk with MCMA twins in birth?

Cord entanglement | Risk of foetal death

What is the recommendation for MCMA twins birth?

C/section 32-34+0 weeks

When should DCDA twins be delivered?

37-38 weeks

When should MCDA twins be delivered?

36 + 0 weeks | GIVE STEROIDS

What is the mode of delivery recommended for twins?

Triplets or MCMA; c/s | If one twin cephalic; vaginal

What should be the maximum time elapsed between twin deliveries?

Less than 30 mins Oxytocin drip given after twin 1 delivered USS to confirm presentation

How should the 3rd stage of delivery be managed in women with twins?

Actively

What is gestational diabetes?

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

Complications of diabetes in pregnancy?

Congenital anomalies; related to higher hbA1c Miscarriage IUD Worsening diabetic cx; retinopathy, nephropathy

What maternal complications occur in diabetic mothers?

``` PET Polyhydramnios Macrosomia Shoulder dystocia Neonatal hypoglycaemia ```

With what HbA1c should pregnancy be avoided?

Above 86 mmol/mol (10%)

What medications that are commonly prescribed in diabetic women need to be stopped preconception?

ACEi | Statins

Should folic acid be given to diabetic women pre-pregnancy?

YES | 5mg 3 months pre conception and first 12 weeks of pregnancy

RF for gestational diabetes?

``` Previous GDM Obesity BMI 30 or more FMHx 1st degree relative Ethnic variation Previous big baby Polyhydramnios Glycosuria (+1 on 2 occastions or +2 on one occasion warrants OGTT) ```

What is the pathophysiology of GDM?

Pregnancy is diabetogenic; hPL and cortisol result in a relative insulin resistance

What are the consequences of GDM?

Overgrowth of insulin sensitive tissues = macrosomia Hypoxaemic state in utero Short term metabolic cx Foetal metabolic reprogramming leading to increased long term risks of obesity, insulin resistance and diabetes

Screening and diagnosis of GDM?

RF at booking Previous GDM; BG monitoring or OGTT 1st trim OGTT at 24-28 wks

How is OGTT performed?

Venous fasting blood glucose 75g glucose solution 2hr venous glucose MINIMAL activity between tests; do NOT send home

What are the diagnostic values in the SIGN guidance?

Fasting >5.1 mmol/l | 2 hour > 8.5 mmol/l

What is the general approach in terms of education for mothers with GDM?

Role of diet, body weight and exercise Risks; macrosomia, neonatal hypoglycaemia Importance of glycaemic control Possibility of transient morbidity in baby Increased risk for baby of obesity and diabetes in later life

What are the glycaemic targets in nGDM?

Minimum 4 times a day finger prick - pre meals and before bed Fasting; 3.5-5.5 mmol/l 1hr post meal; <7.8

Management of GDM?

Diet, wt control and exercise Monitor for PET Growth scans Consider hypoglycemic agents; insulin or oral tablet

Does injectable insulin cross the placenta?

When should delivery be aimed for in women with pregestational diabetes?

38 wks onwards | Earlier if complications

When should delivery be aimed for in women with GDM?

On insulin tx; 38-39 wks Metformin; 39-40 wks Diet alone 40-41 wks If foetal macrosomia, IUGR, PET then delivery earlier

When should BG be checked in the postnatal period from women who had GDM?

FBG 6-8 wks PN If T2DM picture; OGTT 6 wks PN Annual FBG and lifestyle changes