Large for Dates Flashcards
(72 cards)
1
Q
What is large for dates?
A
Symphyseal- fundal height > 2cm for gestational age
2
Q
What is the aetiology of large for dates?
A
- Wrong dates
- foetal macrosomia
- polyhydramnios
- diabetes
- multiple pregnancy
3
Q
What can cause wrong dates?
A
- late booker
- concealed pregnancy
- vulnerable women
- transfer of care: booked abroad
4
Q
How is foetal macrosomia diagnosed?
A
- USS EFW >90th centile, AC> 97th centile
(estimated foetal weight and abdominal circumference)
5
Q
What are the risks of foetal macrosomia?
A
Clinician and maternal anxiety
Labour dystocia
Shoulder dystocia- common with diabetes
Post-partum haemorrhage
6
Q
What is the margin of error for EFW?
A
10%
7
Q
What is the mangement of foetal macrosomia?
A
- exclude diabetes
- reassure
- conservative vs IOL vs C/S delivery
8
Q
What is NICE’s suggestion on macrosomic babies and IOL
A
In the 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).
9
Q
What is polyhydromnios?
A
Excess amniotic fluid
AFI >25cm
Deepest pool > 8cm
10
Q
What is aetiology of polyhydramnios?
A
- maternal
- diabetes
- foetal
- anomaly- GI atresia, cardiac, tumours
- monochorionic twin pregnancy
- hydrops fetalis- Rh isoimmunisation
- viral infection (erythrovirus B19, toxoplasmosis, CMV)
- idiopathic
11
Q
What are the symptoms of polyhydramnios?
A
Abdominal discomfort
Pre-labour rupture of membranes
Preterm labour
Cord Prolapse
12
Q
What are the signs of polyhydramnios?
A
LFD
Malpresentation
Tense, shiny abdomen
Inability to feel foetal parts
13
Q
How is polyhydramnios diagnosed?
A
Ultrasound Confirmation
- AFI >25
- DVP >8cm
14
Q
What investigations should be done if polyhydramnios is diagnosed?
A
- OGTT
- Serology- toxoplasmosis, CMV, parvovirus
- antibody screen
- USS- foetal survey; lips, stomach
15
Q
What is the management of polyhydramnios?
A
Patient information- complications
Serial USS- growth, LV, presentation
IOL by 40 weeks
16
Q
What is the definition of multiple pregnancy and high order births?
A
Presence of more than one foetus
17
Q
What is the incidence of spontaenous twins and spontaenous triplets?
A
1: 80
1: 10,000
18
Q
What are the risk factors for multiple pregnancy?
A
- Assisted conception- clomid, IVF ( UK limits to 2 embryos)
- Race- African
- Geography
- Europe 6-9/1000 deliveries
- Nigeria 40-50/1000 ( 1 in 25)deliveries
- Japan & China 2/1000 ( 1 in 500) deliveries
- Family History
- Increased maternal age
- Increased Parity
- Tall women> short women
19
Q
What is zygosity?
A
Monozygosity: splitting of a single fertilised egg (30%)
Dizygotic: fertilisation of 2 ova by 2 spermatozoa (70%)
20
Q
What is chorionicity?
A
- 1 placenta/2 placentas
- dizygous- always dichorionic diamniotic (DCDA)
- monozygous- monochorionic monoamniotic (MCMA), monochorionic diamniotic (MCDA), dichorionic diamniotic (DCDA), conjoined; depends on time of splitting of fertilised ovum
21
Q
How is chorionicity determined?
A
- Via ultrasound
- The shape of membrane and thickness of membrane
- twin peak at 11-13+6 weeks (CRL 45-84mm)
- placental masses, appearance of membrane attachment & foetal membrane thickness (lambda sign)
- fetal sex
- The shape of membrane and thickness of membrane
22
Q
Why is determining chorionicity important?
A
Monochorionic/monozygous twins are at higher risk of pregnancy complications
23
Q
What are the symptoms of multiple pregnancy?
A
Exaggerated pregnancy symptoms e.g. excessive sickness/HG
24
Q
What are the signs of multiple pregnancy?
A
High AFP
Large for dates uterus
Multiple foetal poles
25
When can USS confirm multiple pregnancy?
at 12 weeks
26
What are the complications of multiple pregnancy
* higher perinatal mortality (6X higher than singleton pregnancy)
* foetal
* congenital anomalies
* IUD
* pre-term birth
* growth restriction- both/discordant
* cerebral palsy- twins 8X higher, triplets 47X higher
* twin to twin transfusion- oligohydramnios & polyhydramnios
27
What are the maternal complications of multiple pregnancy?
* Hyperemesis Gravidarum
* Anaemia
* Pre-eclampsia
* Antepartum haemorrhage- abruption, placenta praevia
* Preterm Labour
* Caesarean section
28
monochorionic twins need clinic appointments every _ weeks, dichorionic twins need clinic appointments every _ weeks
monochorionic twins need clinic appointments every 2 weeks, dichorionic twins need clinic appointments every 4 weeks
29
What medications are given in mulitple pregnancy?
Fe supplements
Low dose aspirin
Folic acid
30
MC twins need an USS every _ weeks from \_\_/\_\_
## Footnote
D/C twins need USS _ weekly
MC twins need an USS every 2 weeks from 16/40
## Footnote
D/C twins need USS 4 weekly
31
What are the comploications of monochorionicity?
* Single Fetal Death
* Selective Growth Restriction (sGR)
* Twin-To-Twin Transfusion Syndrome (TTTS)
* Twin Anaemia- Polycythaemia Sequence (TAPS)
* Absent EDV (AEDV) or Reversed (REDV)
32
What is the risk to surviving monochorionic twin if single fetal death occurs?
IUD (15%)
Neurological abnormality (26%)
33
What testing should be done if single fetal death occurs in monochorionic twins?
MRI fetal brain 4 weeks post IUD of co-twin
Middile cerebral artery (MCA) Peak systolic velocity (PSV) to check for foetal anaemia
34
Define TTTS
Syndrome with artery-vein anastamoses. Donor twin perfuses the recipient twin.
Rare after 26/40
35
How is TTTS diagnosed?
Oligohydramnios- polyhydramnios (Oly-Poly)
36
What are the complications of TTTS?
Mortality \>90% with no treatment
Neurological morbidity 37% and high in surviving twin if IUD
37
What is the treatment for TTTS?
Before 26/40= Rx fetoscopic laser ablation
\>26/40- amnioreduction/septostomy
Delivery 34-36/40
38
What are the two types of complex multiple births?
Monochorionic Monoamniotic (MCMA) twins
Conjoined twins
39
DCDA twins deliver \_\_-\_\_ weeks
MCDA twins deliver after \_\_+\_ weeks with \_\_\_\_\_
Triplets or more deliver via _________ \_\_\_\_\_\_
MCMA deliver via _______ \_\_\_\_\_\_
DCDA twins deliver 37-38 weeks
MCDA twins deliver after 36+0 weeks with steroids
Triplets or more deliver via caesarean section
MCMA deliver via caesarean section
40
In twin delivery when should syntocinon be administered?
After twin 1
41
Intertwin delivery time should be \< __ minutes
Intertwin delivery time should be \< 30 minutes
42
Define gestational diabetes
Carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy.
43
What do the complications of gestational diabetes all relate to?
Poor control
44
What are the complications specific to pre-existing diabetes in pregnancy?
* Congenital anomalies- related to high HBA1C at booking
* Miscarriage
* Intra-uterine death
* worsening diabetic complications e.g. retinopathy, nephropathy
45
What complications of diabetes are common to pre-existing and gestational diabetes?
* pre eclampsia
* polyhydramnios
* macrosomia
* shoulder dystocia- 10% risk vs 1% risk in general population
* neonatal hypoglycaemia
46
Pregestational diabetes: T1DM
Has a % prevalence?
Is commoner in which population?
5-10% prevalence
Younger
Slimmer
White
Insulin deficiency
47
Pregestational T2DM has a _____ prevalence and is commoner in what population?
Rising prevalence
- older
- overweight/obese
- asian, middle eastern, african, afro-carribean
- Insulin resistance
48
What HBA1C should be aimed for in pregnancy monitoring?
48 mmol/mol (6.5%)
49
Above what HBA1C should pregnancy be avoided?
86mmol/mol 10%
50
What should be stopped in prepregnancy diabetes counselling
Embryopathic medication e.g. ACE inhibitors, cholesterol lowering agents
51
What should be determined in prepregnancy diabetes counselling
Macrovascular and microvascular complications
52
What should be started in prepregnancy diabetes counselling?
High dose folic acid 5mg (3 months before conception to 12 weeks of pregnancy)
53
What medication should be started 12 weeks into a pregnancy if mum has DM?
Low dose aspirin
54
What hypoglucaemic agents are safe in pregnancy?
Insulin- MDI/insulin pump
Metformin (Type 2)
55
What monitoring is required if mum is diabetic?
* early booking in diabetic ANC
* fetal anomaly scan at 18-20 weeks
* regular eye checks for retinopathy
* continuous glucose monitoring?
* growth scans 4 weekly from 28 weeks
* counselling about shoulder dystocia
* deliver at 38 weeks
56
What are the risk factors for GDM?
* previous GDM
* BMI 30 or more
* FH: 1st degree relative
* Ethnic variation: south asia (india/pakistan/bangladesh), middle eastern, black caribbean)
* previous macrosomia
* polyhydramnios
* big baby- AC/EFW on USS
* glucosuria (1+ on \>1 occasion or \>=2+ on one occasion)
57
Why is pregnancy diabetogenic?
Human placental lactogen, cortisol
58
What do placental hormones cause?
Relative insulin deficiency/insulin resistance
59
What are the consequences of GDM?
* overgrowth of insulin sensitive tissues and macrosomia
* hypoxaemic state in utero
* short term metabolic complications
* foetal risk of reprogramming leading to long term risk of obesity, insulin resistance and diabetes
60
Describe GDM screening and diagnosis?
* Risk factors at booking
* Previous GDM (recurrence risk \>50%)
* BG monitoring
* or OGTT 1st Trimester- if normal repeat 24-28 weeks
* OGTT 24-28 weeks
61
Describe the process of OGTT
* take venous fasting blood sugar
* give 75g glucose solution
* take 2 hr venous glucose
**have minimal activity between tests**
62
What are the diagnostic values of OGTT for GDM according to SIGN guidance?
Fasting = \> 5.1mmol/l
2 hour = \> 8.5 mmol/l
63
What is the NICE diagnostic criteria for GDM?
Fasting \>=5.6 mmol/l
2 hour \>=7.8 mmol/l
64
How often should mum check BS levels?
What level should be aimed for?
Minimum 4 times a day- premeals (sometimes 1 hr postmeal) & before bed.
Fasting: 3.5-5.5mmol/l
1hr \<7.8mmol/l
65
Describe management of GDM?
* Diet, weight control & Exercise
* Monitor for PET
* Growth scans
* Consider Hypoglycaemic agents when
* diet and exercise fail to maintain targets
* macrosomia on ultrasound
* Choice of agent:
* tailored to glycaemic profile
* individual woman
* Choices:
* Insulin or Oral tablet
66
What are the potential advantages of oral hypoglycaemic agents in GDM?
* avoidance of hypoglycaemia associated with insulin
* less weight gain
* less 'education' required to ensure safe/effective administration
67
What are the options for insulin treatment?
* short acting
* long acting
* pump therapy (T1DM)
* does not cross the placenta
* risk of hypoglycaemia
68
What is the timing of delivery of pregestational diabetes?
* 38 weeks onwards
* earlier if complications
69
What is the timing of delivery of GDM?
* insulin treatment 38-39 weeks
* metformin 39-40 weeks
* diet alone 40 to 41 weeks
* if foetal macrosomia/IUGR/PET earlier delivery
70
Describe the choices of mode of delivery in diabetes?
* maternal pregerence
* other indication for c/section
* discuss risks and benefits of vaginal birth including shoulder distocia (9-10% risk)
* if EFW \>4.5 kg then c/section
71
What are the risk factors for developing T2DM after GDM?
* obesity
* use of insulin during pregnancy
* fasting glucose levels from OGTT in pregnancy
* insufficient glandular tissue (IGT) post partum
* ethnic group
72
How should risk of T2DM be assessed in post-natal period?
FBS 6-8 weeks postnatally
If picture of type 2 DM- OGTT 6 weeks PN
Annual FBS & lifestyle changes
