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Reproduction and Sexual Health > large for gestational dates > Flashcards

large for gestational dates Flashcards

1
Q

what is large for dates?

A

SFH > 2cm for gestational age

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2
Q

reasons for large for dates?

A
  • multiple pregnancy
  • wrong dates
  • fetal macrosomia
  • polyhydramnios
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3
Q

how do you diagnose fetal macrosomia?

A
  • USS EFW (estimated fetal weight)
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4
Q

what is the diagnosis for fetal macrosomia?

A

USS EFW >90th centile

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5
Q

what are risks of fetal macrosomia?

A
  • clinician and maternal anxiety
  • labour dystocia
  • shoulder dystocia - more w diabetes
  • PPH
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6
Q

how accurate is USS?

A
  • commonly overestimated
  • training essential - operator dependent
  • BMI of women
  • margin of error up to 10%
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7
Q

management for large for dates?

A
  • exclude diabetes
  • reassure
  • conservative vs IOL vs C/S delivery (based on previous pregnancies, complications etc)
  • ‘IOL should not be carried out simply because a baby is large for ges age (macrosomic)’
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8
Q

deepest pool is 9.56cm what does this image show?

A
  • polyhydramnios
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9
Q

what is polyhydramnios

A

amniotic fluid index AFI >25cm
deepest pool >8cm
= excess amniotic fluid in the amniotic sac

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10
Q

causes of polyhydramnios?

A

maternal - diabetes, red cell antibodies

fetal - anomaly (GI atresia, cardiac, tumours), monochorionic twin pregnancy, hydrops fetalis (Rh isoimmunisation), viral infection (erythrovirus B19, toxoplasmosis, CMV)

idiopathic

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11
Q

clinical features of polyhdramnnios?

A
  • abdominal discomfort
  • pre-labour rupture of membranes
  • preterm labour
  • cord prolapse
  • inability to feel fetal parts
  • tense shiny abdomen
  • malpresentation
  • large for dates
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12
Q

how can you confirm diagnosis of polyhyramnios?

A
  • USS
    DVP >8cm
    AFI >25
    subjective
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13
Q

investigations for polyhydramnios?

A
  • OGTT
  • viral serology, toxoplasmosis, CMV, parvovirus
  • antibody screen
  • USS - fetal survey - lips (ability to swallow), stomach bubble
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14
Q

polyhydramnios management

A
  • patient info - complications inc preterm rupture of membranes
  • serial USS - growth, LV, presentation
  • IOL by 40 weeks
  • labour
    i.e. risk malpresentation
    risk of cord prolapse -> if happens at home chances of survival are slim
    risk of preterm labour
    risk of PPH
    neonatal examination
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15
Q

what is this position used in the management of?

A
  • cord prolapse
  • knee-chest position
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16
Q

what is a cord prolapse?

A
  • umbilical cord prolapse occurs when cord descends through cervix and is alongside or below presentating part of fetus
  • obstetric emergency - fetal mortality 91/100
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17
Q

when should you suspect cord prolapse?

A
  • non-reassuring fetal heart trace and absent membranes
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18
Q

multiple pregnancy risks?

A
  • assisted conception - clomid, IVF
  • race - african
  • geography
  • family history
  • inc maternal age
  • inc parity
  • tall women > short women
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19
Q

monozygous twins

A

splitting of a single fertilised egg (30%)

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20
Q

dizygotic twins?

A
  • fertilisation of 2 ova by 2 spermatozoa (70%)
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21
Q

chorionicity?

A
  • 1 placenta/2 placentas
22
Q

dizygous is always what?

A

DCDA

23
Q

monozygous options?

A

MCMA
MCDA
DCDA
conjoined
-> depends on time of splitting of fertilised ovum

24
Q

chorioncity

A

study

25
Q

monochorionic twins

A

Day0-3 after fertilisation: Dichorionic, diamniotic (DCDA)
Day 4-7 after fertilisation: Monochorionic , diamniotic (MCDA)
Day 8-14 after fertilisation: Monochorionic , monoamniotic (MCMA)
Day 15 after fertilisation onwards: Conjoined twins

26
Q

determining chorionicty?

A

US
- shape of membrane and thickness of membrane
- twin peak at 11-13+6 weeks (CRL 45-84mm)
- placental masses, appearance of membrane attachment and membrane thickness (Lamda sign)
- FETAL SEX

27
Q

why is determining chorioncity important?

A
  • monochorionic/monozygous twins at higher risk of px complications
28
Q

what is lambda sign?

A
29
Q

multiple pregnancy symptoms and signs?

A

symptoms
- exaggerated pregnancy symptoms i.e. excessive sickness -> hyperemesis gravidarum

signs
- high AFP
- large for dates uterus
- multiple fetal poles

30
Q

how many weeks can you confirm a multiple pregnancy?

A
  • USS confirmation at 12 weeks
31
Q

complications of multiple pregnancy?

A
  • higher perinatal mortality - 6x higher than singleton
  • fetal complications - congenital anomalies e.g. acardiac twin, IUD (single/both), pre term birth, growth restriction (both/discordant), cerebral palsy (twins 8x higher, triplets 47x higher), twin to twin tranfusion - oligohydramnios and polyhydramnios
32
Q

maternal complications of multiple pregnancy?

A
  • hyperemesis gravidarum
  • anaemia
  • pre eclampsia
  • antepartum haemorrhage - abruption, placenta praevia
  • preterm labour
  • caesarean section
33
Q

antenatal mx for multiple pregnancy?

A
  • consultant led care
  • twin/multiple pregnancy clinic
  • clinic appointments: MC: every 2 weeks, DC: every 4 weeks
  • maternal education - preterm labour and risks, support, TAMBA
34
Q

antenatal mx medications for multiple pregnancy?

A
  • Fe supplementation
  • low dose aspirin
  • folic acid
35
Q

antenatal mx for USS of multiple pregnancy?

A
  • MC 2 weekly from 16/40
  • anomaly USS 18-20 weeks
  • DC 4 weekly
36
Q

monochorionic twins mx?

A
  • MC 2 weekly from 16/40
  • anomaly USS 18-20 weeks
  • deep vertical pool, bladder and umbilical artery doppler (UAPI), EFW
37
Q

monochorionic twins complications?

A
  • single fetal death
  • selective growth restriction (sGR)
  • twin-to-twin transfusion syndrome (TTTS)
  • twin anaemia - polycythaemic sequence (TAPS_
  • absent EDV (AEDV) or reversed (REDV)
  • twin-to-twin transfusion syndrome (TTTS)
38
Q

what is twin-to-twin transfusion syndrome?

A
  • syndrome w artery-vein anasotomoses. donor twin perfuses the recipient twin
  • rare after 26/40
39
Q

how do you diagnose TTTS

A
  • oligohydramnios - polyhydramnios (oly-poly)
40
Q

complications of TTTS

A

mortality >90% w no treatment
neurological morbidity 37% and high in surviving twin if IUD

41
Q

tx of TTTS?

A
  • before 26/40 - Rx fetoscopic laser ablation
  • > 26/40 - amnioreduction/septostomy
  • deliver - 34-36/40
42
Q

complex multiple birth?

A
  • MCMA - monochorionic monoamniotic twins
    -> risk for cord entanglement, higher risk of fetal death, deliver by C section 32-34+0 weeks
    -> conjoined twins - MDT, specialised centres
43
Q

delivery of multiple pregnancies

A

Timing:
DCDA Twins deliver 37-38 weeks
MCDA Twins deliver after 36+0 weeks with steroids.
Mode of Delivery
Triplets or more – Caesarean section
MCMA- Caesarean section
Twins if twin one cephalic aim for vaginal delivery
Much greater risk of Caesarean section (approx 50%)

44
Q

labour of multiple pregnancy

A
  • high risk
  • consultant led unit
  • epidural analgesia
  • fetal monitoring: USS and FSE
  • syntocinon after twin 1
  • USS to confirm presentation
  • intertwin delivery time <30 min
  • risk of PPH - active 3rd stage
45
Q

what is syntocinon?

A
  • hormone causes uterus to contract
46
Q

diabetes important mx

A
  • high dose folic acid 5mg - 3 months before conception to 12 weeks of pregnancy
47
Q

complications of pre-existing diabetes in pregnancy

A

all relate to poor control
- congenital anomalies - related to high HBA1C at booking
- miscarriage
- intra uterine death
- worsening diabetic complications e.g. retinopathy, nephropathy

48
Q

pre-existing and gestational complications of diabetes

A
  • pre-eclampsia
  • polyhydramnios
  • macrosomia
  • shoulder dystocia
  • neonatal hypoglycaemia
49
Q

type 2 DM risk factors?

A
  • rising prevalence
  • older
  • overweight/obese
  • asian, middle eastern, african, afro-carribean, insulin resistance
50
Q

type 1 DM risk factors?

A
  • 5-10% prevalence
  • younger
  • slimmer
  • white
  • insulin deficiency
51
Q

aim for type 1/type 2 diabetes?

A
  • 48mmol/mol (6.5%)
  • avoid pregnancy if HbA1c above 86 (10%)
  • stop ACEi, cholesterol lowering agents
  • determine macrovasc and microvasc complications
  • high dose folic acid 5mg!!! 3 months prior and up to 12 weeks

Reproduction and Sexual Health (29 decks)

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