Large For Dates (Polyhydramnios, Macrosomia, Multiple Pregnancy, Diabetes) Flashcards by Claire O'Regan

Definition of large for dates

Symphyseal-fundal hieght >2cm for gestational age or in 90th centile or above

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List 6 causes of large for dates?

Wrong dates, 
Fetal macrosomia, 
Polyhydramnios, 
Diabetes, 
Multiple pregnancy, 
Obesity

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Definition and diagnosis of fetal macrosomia?

Big baby - diagnosis when USS EFW >90th centile, AC >97th centile

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Risks of fetal macrosomia? (3)

Labour dystocia,
Shoulder dystocia,
PPH

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USS EFW is commonly over/under estimated in comparison to actual weight?

Commonly overestimated

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Management of fetal macrosomia?

Exclude diabetes,
Conservative vs IOL vs C/S delivery:
Conservative if baby fine, IOL if gets to 40weeks and C/S if EFW >/ = 5kg

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Definition and diagnosis of polyhydramnios?

Excess amniotic fluid - if amniotic fluid index > 25cm or if deepest pool >8cm

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What is amniotic fluid index?

Sum of deepest pool of amniotic fluid in all 4 quadrants

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List maternal cause of polyhydramnios?

Diabetes

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List fetal causes of polyhydramnios? (4)

Anomaly e.g. GI atresia, cardiac, tumours,
Monochorionic twin pregnancy,
Hydrops fetalis - Rh isoimmunisation,
Viral infection e.g. erythrovirus B19, toxoplasmosis, CMV

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Symptoms of polyhydramnios? (4)

Abdo discomfort,
Pre-labour rupture of membranes,
Preterm labour,
Cord prolapse

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Signs of polyhydramnios? (4)

LFD,
Malpresentation cos baby can swim around,
Tense shiny abdo,
Inability to feel fetal parts

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Investigations for polyhydramnios? (4)

OGTT,
Serology - toxoplasmosis, CMV, parvovirus,
Antibody screen,
USS - fetal survery - lips, stomach (if stomach bubble then baby can swallow fluid)

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Management of polyhydramnios?

Serial USS for growth, volume assesment, presentation,
IOL by 40weeks,
Labour risks consider - malpresentation, cord prolapse, preterm labour, PPH

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What is hydrops fetalis?

Accumulation of fluid in >2 body cavities of baby

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Incidence of multiple pregnancies - twins/triplets?

Twins 1:80,

Triplets 1:10,000

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What increases risks of multiple pregnancy? (6)

Assisted conception, 
African race (Geographically more in Africa, then europe, then Asia), 
FH, 
Increased maternal age, 
Increased parity, 
Tall women > short women

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30% of multiple pregnancies are monozygotic/dizygotic and 70% of multiple pregnancies are monozygotic/dizygotic?

30% - monozygotic,

70% - dizygotic

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In terms of chorionicity, dizygous pregnancies are always ?

Dichorionic diamniotic

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In terms of chorionicity, monozygous twins are either? (4)

Monochorionic monoamnitoic, monochorionic diamniotic, dichorionc diamniotic or conjoined

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If morula undergoes cleavage in day 1-3, you get what type of chorionicity?

Dichorionic diamniotic (DCDA)

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If blastocyst undergoes cleavage in day 4-8, you get what type of chorionicity?

Monochorionic diamniotic (MCDA)

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If implanted blastocyst undergoes cleavage in day 8-13, you get what type of chorionicity?

Monochorionc monoamniotic (MCMA)

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If formed embryonic disc undergoes cleavage in day 13-15, you get what type of chorionicity?

Conjoined twins

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How is chorionicity determined?

USS to look at membrane for lambda sign or T sign and for fetal sex (will be DCDA if diff sexes)

What is lambda sign and what is T sign?

Lammda - AKA twin peak sign, is measured on USS at 11-13 weeks and indicated DCDA twins, T-sign - monochorionic diamniotic

Which type of chorionicity has highest risk of pregnancy complications?

Monochorionic twins

Signs & symptoms of multiple pregnancy? (4) When confirmed on USS?

``` Excessive sickness due to excessive bHCG, High AFP, (alpha fetal protein) Large for dates uterus, Multiple fetal poles, Confirmed at 12 weeks ```

Perinatal mortality is _ times more likely with multiple pregnancy than with singleton pregnancy?

6 times!!

List 6 fetal complications of multiple pregnancy?

Congenital abnormalities, IUD, Pre-term birth, Growth restriction, Cerebral palsy ( x8 higher for twins, x47 for triplets), Twin to twin transfusion - oligohydramnios & polyhydramnios

List 6 maternal complications of multiple pregnancy?

``` Hyperemesis gravidarum, Anaemia, Pre-eclampsia, Antepartum haemorrhage (e.g. abruption, placenta praevia), Preterm labour, C-section ```

Antenatal medical management for multiple pregnancy? (3)

Iron supplements, Low dose aspirin, Folic acid to reduce anaemia risk

USS antenatal management for MC and DC twins?

MC: 2 weekly until birth from 16/40 and anomaly at 18-20wks, DC: 4 weekly from anomaly until birth

USS MC scans need to assess? (4)

Deep vertical pool, Bladders, umbilical artery doppler, EFW

List 5 complications for monochorionic twins?

``` Single fetal death, Selective growth restriction, Twin-to-Twin transfusion syndrome, Twin anaemia-polycythaemia sequence, Abnormal dopplers - absent edf or reversed edf ```

If one fetus dies in monochorionic twins, other baby needs what every 4 weeks to assess for IUD and neurologically abnormality risks?

MRI fetal brain and MCA doppler

Twin-to-twin transfusion syndrome definition and diagnosis?

Definition: Artery-vein anastomoses so donor twin perfuses the recipient twin, Diagnosis: oligohydramnios-polyhydramnios

Complications of twin-to-twin transfusion syndrome? (2)

Mortality >90% w/o treatment, | Neurologicaly morbidity high for surviving twin

Twin-to-twin transfusion syndrome is rare after 26/40. What is treatment before 26/40 and treatment after 26/40 and for delivery?

Before 26/40 - fetoscopic laser ablation, After 26/40 - amnioreduction/septostomy, Deliver 34-36/40

Complex multiple births occur in?

MCMA (cord entangelemnt so c/section at 32-34 weeks) or conjoined twins

Delivery times for DCDA twins and MCDA twins respectively?

DCDA - 37-38 weeks, | MDA - 36 weeks

Mode of delivery for triplets & MCMA?

C/section

Delivery of twins - what is given after twin 1 and what is intertwin delivery time aim?

Syntocinon after twin 1, aim to delivery twin 2 within 3o mins

Definition of gestational diabetes and when usually diagnosed?

Carb intolerance resulting in hyperglycaemia with onset or first recognition during pregnancy that resolves by end of pregnancy, usually diagnosed in 3rd trimester

Effect of pregnancy on diabetes? (7)

``` Increases insulin requirements, N&V can precipitate DKA, Ketosis more common, Diabetic retinopathy worsens especially after rapid control of diabetes, Diabetic nephropathy can worsen, More hypos, more hypers, Pre-eclampsia ```

Complications of diabetes on baby? (7)

``` Congenital anomalies, Miscarriage, IUD, Polyhydramnios, Macrosomia, Shoulder dystocia, Neonatal hypoglycaemia ```

Parent with gene mutation for MODY they have __ chance of passing onto child

50%

MODY type HFN1alpha - prevalence, presentation age and treatment?

70% of MODY cases, Presents teenage/early 20s, Treatment sulphonylureas

MODY type HFN4alpha - prevalence, presentation age and treatment?

Rare, Hypoglycaemia soon after birth, Treatment sulphonylureas -> insulin

MODY type HFN1beta - presentation, presentation age and treatment?

Renal cysts, uterine abnormalities and gout, Renal cysts may be seen in utero but diabetes develops later, Treatment insulin & lifestyle

MODY type glucokinase - presentation and treatment?

Presentation: usually picked up through routine testing e.g. in pregnancy, Treatment: nothing

HbA1C aim in pregnancy? | HbA1C level at which pregnancy should be avoided?

48mmol/mol, | Avoid pregnancy if above 86 mmol/mol

What meds for diabetic women in pregnancy?

5mg (high dose) folic acid 3 months prior and 12 weeks pregnancy, Low dose aspirin from 12 weeks until delivery, Review diabetic meds

USS how often for diabetic women in pregnancy?

20, 28, 32 and 36 weeks

Delivery aim for women with Type 1& 2 Diabetes?

38+6/40 weeks

Delivery aim for GDM - insulin treatment, diet controlled and metformin controlled GDM?

Insulin treatment - 38-39 wks, Diet controlled - 40/41 wks, Metformin - 39/40 wks

GDM occurs in approx 2-18% of pregnancies in UK. WHy does GDM occur?

State of insulin resistance due to human placental lactogen and cortisol

What is risk of developing T2 DM within 5 years if diagnosed with GDM during pregnancy?

50%

List 6 factors for GDM?

``` Previous GDM, Obesity BMI 30, FH, Ethnic variation, asia, africa, caribbean, Polyhydramnios, Big baby ```

Screening of GDM?

Risk factors at booking, OGTT 24-28wks, If Previous GDM - BG monitoring, OGTT 1st trimester and repeat at 24-28 wks

OGTT done how?

Fasted for 8 hours -> venous fasting blood glucose -> 75g glucose solution -> 2hr venous glucose after minimal activity

Diagnostic values for OGTT?

Fasting > = 5.1mmol/l, | 2 hour > = 7.5mmol/l

GDM patients should check BG minimum 4 times a day. What are fasting, 1hr and 2hr glycaemic targets for GDM?

Fasting: 3.5-5.5 mmol/l, 1hr: <7.8 mmol/l, 2hr: <6.4 mmol/l

GDM can be managed with diet, weight control and exercise. However when should hypolgycaemia agents (insulin/metformin) be considered? (2)

When diet & exercise fail, | When macrosomia on USS

Insulin treatment crosses the placenta. T/F?

False - does not cross

If EFW > _kg, offer c/section to women with diabetes

EFW > 4.5kg

RIsk of shoulder dystocia in diabetic pregnancy?

10%

BG of mother should be maintained between 4-7mmol/litre during delivery. Baby should be fed within _mins after delivery?

30mins

Women with GDM get FBS how many weeks post natally?

6-8wks and yearly HbA1c

Gestational diabetes management

Antenatal clinic within 1 week, Dietician, BG monitoring, If fasting BG <7: diet & exercise, metformin if targets not reached in 1-2 weeks, insulin if metformin not enough, glibenclamide if still not enough. If fasting BG >7: immediate treatment with insulin +/- metformin, consider glibenclamide if not enough/effective