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Large for Dates Flashcards

1
Q

what is considered large for dates

A

symphyseal fundal height > 2cm for gestational age

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2
Q

what is SFH

A

symphyseal gestational height

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3
Q

what can cause LFD (large for dates)

A 
wrong dates 
fetal macrosomia (big baby)
polydramnios
diabetes (can cause macrosomia or polydramnios) 
multiple pregnancy
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4
Q

why might someone be a ‘late booker’ and have the wrong dates of conception

A

concealed pregnancy- fit, muscular or obese
vulnerable women- hesitant to / cant engage with healthcare
transfer of care- booked abroad

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5
Q

what classifies as fetal macrosomia

A

USS estimated fetal weight > 90th centile
abdo circumference > 97th centile

(on generic population charts or customised growth charts - BMI, ethnicity and parity are considered)

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6
Q

what are the risks of fetal macrosomia

A

clinician and maternal anxiety
labour dystocia (obstructed labour, aka cervical dystocia)
shoulder dystocia - more with diabetes
post partum haemorrhage

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7
Q

where are the smallest and biggest babies in the world

A

smallest- SE asia

biggest- caucasian UK

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8
Q

what is the formula for EFW

A

hadlock- considered HC, AC and FL

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9
Q

accuracy of USS depends on operator, maternal BMI (harder if higher), gestation (more accurate <38 weeks)
is the EFW from USS usually higher or lower than actual weight

A

higher

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10
Q

what is the management for macrosomia

A

exclude diabetes
reassure mother
conservative vs IOL vs CS

IN THE ABSENCE OF ANY OTHER INDICATIOS IOL SHOULD NOT BE CARRIED OUT SIMPLY BECAUSE OF MACROSOMIA

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11
Q

at what EF weight would you recommend a CS

A

more than 4.5 kg

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12
Q

what is polyhydramnios

A

excess amniotic fluid

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13
Q

what classifies as polyhydramnios

A

amniotic fluid index >25cm

deepest pool in ant pocket of cord free ares >8cm

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14
Q

what are the maternal causes of polyhydramnios

A

diabetes

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15
Q

what are the fetal causes of polyhydramnios

A

anomaly- GI atresia (congenital malformation of the bowel causing obstruction), cardiac abnormalities, tumours
monochorionic twin pregnancy
hydrops fetalis (accumulation of fluid in at least 2 fetal compartments)
viral infections (erythrovirus B19, toxoplasmosis, CMV)
idiopathic (2nd most common after diabetes)

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16
Q

what are the signs and symptoms of polyhydramnios

A 
symptoms:
abdo discomfort 
pre labour rupture of membranes
preterm labour (due to overdistention of uterus)
cord prolapse 
signs:
LFD
malpresentation 
tense shiny abdomen 
inability to feel fetal parts
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17
Q

how is polyhydramnios diagnosed

A

USS
AFI >25
DVP >8cm

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18
Q

what investigations for polyhydramnios

A

OGTT to exclude diabetes
serology - toxoplasmosis, CMV, parovirus
antibody screen (rhesus isoimmunisation can cause hydrops fetalis)
USS fetal survey - lips, stomach (ensure patent oesophagus and good swallowing mechanism)

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19
Q

what is the management for polyhydramnios

A

patient information (complications)
serial USS- growth, liquor volume (volume of amniotic fluid), presentation
IOL by 40 weeks
neonate exam

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20
Q

what are the risk of labour in polyhydramnios

A

malpresentation
cord prolapse
preterm labour
PPH

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21
Q

what classifies as pre term labour

A

before 37 weeks

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22
Q

how common are spontaneous twins

A

1:80

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23
Q

what puts you at risksof having a multiple pregnancy

A 
assisted conception (in uk limit to 1 embryo)
race - african (esp nigerian)
FMHx
increased maternal age 
increased parity 
tall women > short women
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24
Q

why is there higher rates of twins in africa

A

higher perinatal mortality rates

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25
what are the types of zygosity
monozygotic- splitting of a single fertilised egg (30%) dizygotic- fertilisation of 2 ova by 2 spermatozoa (70%)
26
what are the types of chorionicity
(1 placenta/ 2 placenta) dizygous always DCDA (dichorionic) monozygous twins can be MCMA, MCDA, DCDA or conjoined
27
what does chorionicity depend on
in dizygous twins always DCDA | in monozygous twins depends on splitting of fertilised ovum
28
what do DCDA, MCDA, MCMA stand for
Dichorionic diamniotic monochorionic diamniotic monochorionic monoamniotic
29
what does monochorionic mean
share placenta
30
what does monoamniotic mean
share amnionic sac- can have one or two placenta
31
cleavage into twins at days 0-3 will result in what
dichorionic diamniotic (DCDA)
32
cleavage into twins at days 4-7 will result in what
monochorionic diamniotic (MCDA)
33
cleavage into twins at days 8-14 will result in what
monochorionic monoamniotic (MCMA)
34
cleavage into twins after day 15 will result in what
conjoined twins
35
how is chorionicity determined
USS: -shape and thickness of membrane (twin peak at 11-13.6 weeks (CRL 45-84 mm), placental masses, appearance of membrane thickness (lamba sign)) fetal sex- determines if dichorionic or not
36
what type of twins are at higher risk of pregnancy complications
monochorionic/ monozygous twins= MCMA
37
what type of twins will have the lamba sign on USS
dichorionic diamniotic
38
what forms the amnionic sac
chorion (outer) and amnion (inner)
39
what are the signs and symptoms of multiple pregnancies
exaggerated pregnancy symptoms (excess sickness/ hyperemesis gravidarum) high AFP large for dates uterus multiple fetal poles
40
when can USS confirm multiple pregnancies
12 weeks
41
what is recommended if a patient has hyperemesis before first scan
USS to see if multiple pregnancy
42
what are the fetal complications of multiple pregnancies
higher perinatal mortality congenital abnormalities (e.g. acardiac twin) IUD (single/ both) pre term birth growth restriction (both/ discordant) cerebral palsy (twins 8x higher, 47x higher in triplets) twin to twin transfusion (oligohydramnios and polyhydramnios)
43
what are the maternal complications of multiple pregnancies
``` hyperemesis gravidarum anaemia pre eclampsia antepartum haemorrhage (abruption (placenta dislocates from uterus), placenta praevia) preterm labour caesarian section ```
44
what is the antenatal management for multiple pregnancies
``` MC- clinic every 2 weeks DC- clinic every 4 weeks maternal educations- preterm labour and risks, support (+ financial) consultant led care Fe supplementation- risk of anaemia low dose aspirin- reduce pre eclampsia folic acid USS MC 2 weekly from 16 weeks DC 4 weekly anomaly USS at 18-20 weeks ```
45
what extra scans do MC twins get
deep vertical pool bladder and umbilical artery doppler (UAPI) estimated fetal weight
46
what complications are seen in MC twins
single fetal death (affects other twin in utero too) selective growth restriction twin to twin transfusion syndrome (TTTS) twin anaemia polycythaemia sequence (TAPS) absence end diastolic velocity or reversed end diastolic velocity
47
what can cause TAPS
fetoscopic laser ablation for TTTS
48
what is twin to twin transfusion syndrome
imbalance in circulation between twins from shared placenta due to atery vein anastomoses donor twin will be olihydramniotic (and will be pale and small- anaemic) recipient twin will by polyhydramniotic (larger and red- polycythemic)
49
how is TTTS diagnosed
Oligohydramnios- polyhydramnios (Oly-Poly)
50
what are the complications os TTTS
mortality >90% with no Tx | neurological morbidity 37% and high in surviving twin if IUD
51
what is the treatment for TTTS
before 26/40 - fetoscopic laser ablation > 26/40 amnioreduction/ septostomy deliver 34-36/40
52
what are the complec multiple births
MCMA twins: - risk for cord entanglement - higher risk of fetal death - always delivery by C section 32-34+o weeks conjoined twins: -MDT, specialised centres trichorionic triplets/ MC or DC twins with sGR, TTTS, TAPS consider selective reduction
53
when should you aim to deliver twins
DCDA- 37-38 weeks | MCDA after 36+0 weeks WITH steroids
54
what mode of delivery for multiple pregnancies
MOTHERS choice triplets or more rec CS MCMA CS twins if twin 1 cephalic aim for V, if twin 1 breech/ transverse C section
55
what needs to be done in a multiple pregnancy delivery
consultant led epidural fetal monitoring- USS and fetal scalp electrode syntocinon after twin 1 USS to confirm presentation intertwin delivery time <30 mins risk of PPH- active 3rd stage- oxytocin infusion
56
what pre gestational diabetes types can you get
T1 T2 MODY
57
what is gestational diabetes
carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy (ends when pregnancy ends)
58
what complications are specific to pre existing diabetes in pregnancy
congenital abnormalities miscarriage IUD worsening diabetic complications (retinopathy, nephropathy)
59
what should you ask all women with diabetes
about contraception and family planning- save more babies by seeing in pre pregnancy clinics
60
what pregnancy complications can you get in pre existing and gestational diabetes
``` pre eclampsia polyhydramnios macrosomia shoulder dystocia neonatal hypoglycaemia ```
61
what HBA1c level means you should avoid pregnancy
above 86mmol/mol (10%)
62
what is the HBa1c aim in pregnancy
48mmol/mol (6.5%)
63
what medication advice should you give diabetics pre pregnancy
Stop any embryopathic medication eg ACE inhibitors, cholesterol lowering agents High Dose Folic Acid 5mg (3 months before conception to 12 weeks of pregnancy)
64
what extra tests for diabetic (T1 and 2) pregnancies
``` Fetal anomaly scan at 18-20 weeks Regular eye checks for retinopathy If nephropathy- refer renal team Consider continuous glucose monitoring (libra) Growth scans 4 weekly from 28 weeks ```
65
management for diabetic pregnancies (T1 and T2)
Folic Acid 5mg Low Dose Aspirin from 12 weeks- until delivery Hypoglycaemic Agents: Insulin- MDI /Insulin pump Metformin (Type 2) Counsel about shoulder dystocia Deliver at 38 weeks ( earlier if complications)
66
what are the risk factors for gestational diabetes
``` Previous GDM Obesity BMI 30 or more FH: 1st degree relative Ethnic variation: South Asia (India / Pakistan / Bangladesh), Middle Eastern, Black Caribbean Previous big baby Polyhydramnios Big baby – AC / EFW on USS Glycosuria (1+ on >1 occasion or >= 2+ on one occasion ```
67
why is pregnancy diabetogenic
due to the hormones human placental lactogen and cortisol | placental hormones cause relative insulin deficiency and resistance
68
what are the consequence of gestational diabetes
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
69
what is the screening for GDM
Risk factors at booking Previous GDM (recurrence risk >50%0= BG monitoring or OGTT 1st Trimester- if normal repeat 24-28 weeks OGTT 24-28 weeks (if just risk factors not previous GDM)
70
how is GDM diagnosed
OGTT: venous fasting blood sugar taken 75g glucose solution taken orally rest for two hours 2hr venous glucose diagnostic values: Fasting >=5.1 mmol/l 2 hour >=8.5 mmol/l
71
what is the general management for GDM
diet, body weight and exercise Monitor for PET (pre-eclampsia) Growth scans Consider Hypoglycaemic agents (insulin or metformin) when diet and exercise fail to maintain targets macrosomia on ultrasound ``` care plan: Antenatal and intrapartum Targets for glycaemic control Fetal surveillance Post-natal care / review ```
72
what are the risk of GDM
macrosomia and neonatal hypoglycaemia Possibility of transient morbidity in the baby Increased risk for the baby of obesity and diabetes in later life Increased risk of type 2 diabetes for the mother (gestational)
73
what are the glycaemic targets for GDM
``` Minimum 4 times a day- premeals (sometimes 1 hr postmeal ) & before bed. Fasting 3.5 -5.5 mmol/l 1 hr <7.8mmol/l ```
74
what are the advantages of metformin over insulin in pregnancy
Avoidance of hypoglycaemia associated with insulin Less weight gain Less ‘education’ required to ensure safe / effective administration
75
does insulin treatment cross the placenta
no
76
when should you deliver babies with maternal pre gestational diabetes
38 weeks onwards | Earlier if complications
77
when should you delivery babies with maternal GDM
Insulin treatment 38-39 weeks Metformin 39- 40 weeks Diet alone 40 to 41 weeks If fetal macrosomia/ IUGR/ PET earlier delivery
78
what are the risk factors for mothers develop T2DM after GDM postnatally
``` obesity use of insulin during pregnancy fasting glucose levels from OGTT in pregnancy IGT post partum ethnic group ```
79
when is FBS done postnatally after GDM
6-8 pn
80
what dose of folic acid for diabetic women
5mg (normal dose 400 micrograms)

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