Obs: conditions in pregnancy Flashcards
(75 cards)
1
Q
What are the risks of giving SSRIs in pregnancy?
A
- Sodium valproate: CI in women of childbearing age. NTD/ cleft palette
- Carbamazepine: cleft lip 0.1 %
- Lithium: cause fetal hypotonia, poor reflexes, arrythmia, Ebstein’s anomaly, neonatal goitre (thyroid)
- Lamotrigine: Steven Johnson syndrome
- Olanzepine: fetal macrosomia, GDM
- SSRI: pulmonary hypertension, Paroxetine in particular is associated with cardiac defects
2
Q
What is the difference between chronic HT and pregnancy induced HT?
A
- Chronic hypertension: is high BP that exists before 20 weeks gestation and is longstanding. This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia.
- Pregnancy-induced is hypertension occurring after 20 weeks gestation, without proteinuria.
3
Q
What is pre eclampsia?
A
- New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
- Proteinuria: quantified using the urine: protein creatinine + albumin: creatinine ration
- Other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
4
Q
What are some of the complications of preeclampsia?
A
- CNS: eclampsia, IC haemorrhage, stroke, cortical blindness
- Renal: RT necrosis (AKI)
- Resp: pulmonary oedema
- Liver: HELPP syndrome, liver capsule haemorrhage, liver rupture
- Haem: DIC, VTE (due to involvement of the liver)
- Placenta: placental abruption
5
Q
What are some of the high + moderate RFs fo pre eclampsia?
A
7
Q
What mx can be used for risk reduction in pre eclampsia?
A
- Aspirin 150mg from 12 weeks if one high RF or >1 moderate RF
- Dalteparin if anti phospholipid syndrome or other pro-coagulant disorders
8
Q
What are some of the sx of pre eclampsia?
A
-
↑ICP : headache, visual disturbance (papilloedema), N+V,
- Liver swelling -> abdo pain (RUQ), sudden ↑ in swelling, generally unwell, vomiting
- Reduced fetal movement
- Bleeding
- S**igns: hypertension, proteinuria, non-dependent oedema, hyperreflexia, clonus fetal growth restriction, oligohydramnios, abnormal fetal doppler
- Ask about: headache, flashing lights, epigastric, RUQ pain
9
Q
What are the fx of pre eclampsia?
A
- Features: asymptomatic (only detected at antenatal app): BP and urinalysis
- BP: hypertension: typically > 160/110 mmHg
- Proteinuria: dipstick ++/+++
10
Q
What Ix are used for pre eclampsia?
A
- Maternal: FBC, renal (UE, eGFR), LFT (transaminases), DIC (coag profile: PT, APTT), proteinuria (protein creatinine ratio, 24hr collection), raised serum uric acid
-
Monitoring: close BP monitoring every 48h
- Fetal:
- Every 2 weeks: growth velocity (fetal growth USS), fetal wellbeing (CTG, amniotic fluid volume, fetal Doppler),
- notching of uterine arteries on doppler, abnormal umbilical artery doppers
- NICE recommend placental GF testing (↓usually) on one occasion
11
Q
What monitoring scoring sx are used for pre eclampsia
A
- fullPIERS + PREP-S
12
Q
How is pre eclampsia mxd?
A
-
Gestational HT: Control BP
- Act: reduce BP of it is severely high (160/110) – admit and observe
- Offer offer treatment if BP is sustained >140/9
- Aim: for 135/85
- Review: review medication if BP stays below 110/70
-
Pre-eclampsia: Medication:
- Monitoring: Scoring systems: fullPIERS + PREP-S,
-
Oral treatment: 1st: labetalol
- 2nd: nifedipine
- 3rd: methyldopa
- Emergency: 1st: IV hydralazine
-
If severe of fulminating pre-eclampsia
- Prevent seizures (IV magnesium sulfate infusion during labour and post 24h)
- Give steroids for lung maturation if pre-term and considering delivery
- Strict fluid balance (prevent)
- IOL
-
Post delivery
- 1st: Enalapril (first-line)
- 2nd: CCB: Nifedipine or amlodipine (1st if black African or Caribbean patients)
- 3rd: Labetolol or atenolol
13
Q
How is fetal growth measured?
A
- Assessed routinely during antenatal care.
- >AFTER 24 weeks – useless before
- Methods: Clinical:
- Abdominal palpation of fundal height (sensitivity 20-30%)
- Symphysis-fundal height measurement using a measuring tape (sensitivity: 30-40%)
- Ultrasound assessment: key measurements (90-95% sensitivity)
- Head circumference (and Biparietal diameter)
- Abdominal Circumference
- Femur length
14
Q
What is considered SGA/ small for date?
A
- SMALL FOR DATES/SGA: describes anthropometric variables <10th population centile for GA
- Severe SGA: < 3rd centile for their gestational age.
- LBW: birth weight <2.5kg
15
Q
What Ix are used for pre eclampsia?
A
- Maternal: FBC, renal (UE, eGFR), LFT (transaminases), DIC (coag profile: PT, APTT), proteinuria (protein creatinine ratio, 24hr collection), raised serum uric acid
- Monitoring: close BP monitoring every 48h
Fetal:
- Every 2 weeks: growth velocity (fetal growth USS), fetal wellbeing (CTG, amniotic fluid volume, fetal Doppler),
- Notching of uterine arteries on doppler, abnormal umbilical artery doppler
NICE recommend placental GF testing (↓usually) on one occasion
16
Q
What is eclampsia?
A
- Defined as the development of seizures in association pre-eclampsia in pregnancy OR within 10 days of delivery
- At least two of the following features within 24h of seizure (tonic-clonic)
- Hypertension
- Proteinuria + plus or at least 0.3g/ 24h
- Thrombocytopenia less than 100,000 /il
- Raised transaminases
- At least two of the following features within 24h of seizure (tonic-clonic)
17
Q
How is eclampsia?
A
- Call for senior help: A-E management; IV access
- Bolus of 4g Magnesium Sulphate over 5-10 minutes then 1g/h for 24h IV infusion. Treat further fits with 2g bolus.
- Monitor: UO, reflexes, RR, 02 sats
- SE: resp. depression. Stop if RR<12/ reduced UO or lost reflexes. Mx 1st line: calcium gluconate
- Continue for 24h after last seizure or delivery
- Stop if RR <12/min, or reduced UO or reflexes lost: have IV calcium gluconate ready in case of MgSO4 toxicity
- Mx rpt seizures w/ diazepam and rule out IC haemorrhage
- Cathetarised for hourly UO
Antenatal – plan for delivery by most appropriate route.
- Monitor 3rd stage w oxytocin. CI Syntometrine + ergometrine - ↑ risk of stroke 2nd to HT
- Other: fetal HR monitoring with CTG, fluid balance (to avoid overload)
18
Q
How is eclampsia/ pre eclampsia mxd post natally?
A
- May require antihypertensive treatment for 6-12 wks post natally
- Increased risk of VTE particularly in severe proteinuria
- Severe PET may require follow up bloods
- Post-natal hypertension where appropriate
- Discuss contraception + implications for future pregnancy before discharge
- Write to GP with details of delivery and treatment etc
19
Q
What is HELPP syndrome?
A
Combination of features that occurs as a complication of pre-eclampsia and eclampsia
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
20
Q
What are some of the risks of diabetes in pregnancy?
A
- Miscarriage
- 4x congenital anomalies
- Macrosomia
- Large for date fetus
- Pre-eclampsia
- Polyhydramnios
- Pre-term birth
- C-delivery
- Short and long term morbidity
- Obesity and diabetes later in life
- Shoulder dystocia
21
Q
What pre pregnancy care is provided for pre existing DM?
A
- Use contraception until blood glucose controlled: aim for <48mmol HBA1c and BMI <27
- Retinal assessment via digital imaging: attempted before attempting glycaemic control associated with worsening retinopathy (treat retinopathy pre pregnancy)
- Kidneys: micro albuminuria measures before stopping contraception, creatinine + eGFR checked – women w poorly controlled HT are at risk of permanent kidney damage e.g. ESKD.
22
Q
How is pre existing DM mxd?
A
- Weight loss for women BMI >27kg/m2
- LMWH for VTE prophylaxis depending on risk stratification
- Stop oral hypoglycaemics statins and ACEi and A2a (use other hypertensives)
- Can continue Metformin but other oral hypoglycaemics to be substituted with insulin
- Folic acid 5mg OD until 12 weeks gestation + aspirin 75mg from 1st trimester (reduce pre eclampsia risk)
- Tight glycaemic control: Blood glucose targets
- Fasting : 5.3
- > 1h: 7.8
- >2h: 6.4
-
USS scans: dating by 12 weeks, detailed cardiac 18-22 weeks, fetal growth and liquor volume: 28, 32, 36
- Anomaly scan: 20 weeks. Including cardiac: detailed four chamber view of the heart and outflow tracts
- ANC: 1-2 weekly
- Repeat retinopathy screen at 28 weeks
- Planned delivery 37-38+6): NICE 2015
- IOL: 37-38 weeks
- Elective CS: 38-39 weeks
- Intra partum +T1DM: insulin sliding scale: insulin + dextrose during labour
- If preterm: give corticosteroids for fetal lung maturity
23
Q
What are some RFs for GDM?
A
- BMI of > 30 kg/m²
- Previous macrosomic baby > 4.5 kg
- Previous gestational diabetes
- First-degree relative with diabetes
- Ethnic minority with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
24
Q
What happens with high risk of GDM?
A
- Any women with RFs (above) or previous GD to be offered screening: OGTT (2h 75g load rapilose gel),
- 16-18 weeks (soon after booking)
- 24-28 weeks if 1st test is normal - not HbA1c due to short duration of pregnancy
- Also screen if there are fx of GD:
- Large for dates fetus
- Polyhydramnios (increased amniotic fluid)
- Glucose on urine dipstick
- Diagnosis: # STEPS 5678! Fasting >5.6mmol/ 2h OR BG > 7.8mmol
- Frequent follow up, ANC with GDM trained healthcare provider, self monitoring blood glucose for all women with diabetes.
- Fetal sonographic assessment to help determine size of the baby and diagnose fetal macrosomia
25
Q
What is the Management of Gestational Diabetes?
A
- Monitoring: Scans: dating scan 12 weeks, detailed scan 20 weeks, growth + LV 2 weeks > 26 weeks
- 1st: Conservative/ lifestyle: if fasting glucose <7: Weight loss, nutrition counselling and physical activity (30 mins per day)
- Pharmacological: if fasting glucose >7: stop oral hypoglycaemics but metformin 1g BD (if targets not met in 1-2 wks) and + insulin
- Insulin commencement: if macrosomia or polyhydramnios – 4 weekly scans from 28 weeks or if fasting blood glucose is >7mmol/L
- Folic acid 5mg OD till 12 weeks
- Aspirin 75mg OD from 12 weeks till delivery
- Planning delivery: 39 – 40+6
- IOL: 39-40
- Elective CS 39-40
26
How is GDM mxd post natally? ?
* Stop all treatment + BG monitoring at delivery
* Check for resolution of hyperglycaemia via Fasting BG 6-13 weeks post-partum
* HbA1 at 13 weeks + yearly thereafter (risk of T2DM)
* Lifestyle advice
* Contraception and need for pre-conception care in future
* Encourage breast feeding (insulin, metformin, glibenclamide), discuss contraception, retinopathy
27
What are some of the risks to the baby PN for GDM?
* Blood: Neonatal hypoglycaemia (Mx: close monitoring, frequent feeds, maintain blood sugar \>2mmol/l, if less MX: IV dextrose + NGT)
* Polycythaemia, Jaundice
* Heart: Congenital heart disease; Cardiomyopathy
28
What are some of the sx of **obstetric cholestasis?**
* **pruritus** - may be intense - typical worse palms, soles and abdomen
* intense at night causing insomnia and malaise; no rash
* clinically detectable **jaundice** occurs in around 20% of patients
* **raised bilirubin** is seen in \> 90% of cases
29
What IX are used for obs cholestasis?
* **LFT + bile acids:** ↑ bilirubin
* **Viral screen:** hep ABC, EBV, CMV
* **Liver autoimmune screen:** chronic active hepatitis, PBC, anti-smooth muscle and AMA abs
* USS abdomen – liver + gall stones
* Diagnosis of exclusion:
* ↑ transminases
* ALP
* ↑ GGT
* Mild ↑ in bilirubin (in 90% cases)
* Primary bile acids increased up to x100
30
How is obstetric cholestasis mxd?
* Drug treatment to reduce pruritis: ursodeoxycholic acid (reduces pruritis and abnormal LFTs, antihistamine, calamine
* **IOL at 37-38 weeks** is common practice but may not be evidence based
* **Ursodeoxycholic acid** - again widely used but evidence base not clear
* **Vitamin K** supplementation
31
32
What are the risks of thromboembolism?
* Pregnancy increases risk of **VTE x4-6**
* Puerperium **↑risk x5** compared to pregnancy - Absolute risk peaked in the first 3 weeks PP
33
What are some of the RFs for VTE?
* **Pre-existing:** obesity BMI \> 30, age \> 35, parity \> 3, smoking, grow varicose veins, paraplegia, medical comorbidities, thrombophilia, previous VTE
* **Obstetrics:** multiple pregnancy, PET, CS, prolonged labour \> 24h, mid cavity or rotational operative delivery, still birth, preterm birth, PPH \>1L, IVF
* **New onset reversible:** bone fracture, surgical procedure in pregnancy + puerperium, hyperemesis, dehydration, OHSS/ ART, immobile for \> 3 days, long-haul travel \> 4h, current systemic infection
34
35
How is VTE in pregnancy Ixd + mxd?
* Gold standard: **venography + fetal shield**
* **Dopper USS of leg veins** – good alternative, less risk to baby, direct image of clot and lack of compressibility of veins
* Mx: if 4 of \>4 RFs: **commence LMWH till 6 weeks post-natal**
* If dx of DVT is made shortly before delivery: continue anticoagulation treatment for at least 3 month
36
How are DVTs/ PEs mxd?
* Conservative: TEDs, Leg care , Advice re need for future prophylaxis for: pregnancy, surgery, flying etc.
* Medical: **Full anticoagulation with LMWH** e.g. dalteparin or enoxaparin
* High risk cases: **vena cava filters**
37
What psychiatric drugs can be prescribed during pregnancy?
* **SSRIs** – wait till **2nd trimester** till prescribing. Fine.
* Avoid: paroxetine: **CHD**
* High concentration: fluoxetine + citalopam
* Low conc.: sert racine, paroxetine, imipramine, motriptyline
* **Mood stabilised AEDs**
* NO: sodium valproate,lamotrigine carbamazepine – high malformation. **Craniofacial abnormalities ans neurodevelopental problems**
* Lithium – NO. **Teratogenicity**. Same as warfarin
* Benzodiazepines- NO. **Cleft palette**
38
What is PPH?
What is primary vs 2ndary?
* Blood loss of **\>500m**l from the genital tract **within 24h delivery**
* Minor **500-1000ml**
* Major **\> 1L**
* Moderate **1L-2L**
* Massive **\>2L OR 250 mL/min**
* **Primary PPH – within 24h**
* **Secondary PPH – from 24h to 12 weeks** after birth
39
What are some of the RFs for APH, intra partum + PPH?
40
What are the causes of PPH?
Tone
Tissue
Thrombin
Trauma
41
What are the RFs for uterine atony?
* **Maternal profile:** Age \>40, BMI \> 35, asian ethnicity
* **Uterine over-distension** – multiple pregnancy, polyhydramnios, fetal macrosomia.
* **Labour** – induction, prolonged (\>12 hours).
* **Placental problems** – placenta praevia, placental abruption, previous PPH.
42
What other RFs (the 3 other Ts) increased your risk of PPH?
* **Tissue** - retention of placental tissue –prevents the uterus from contracting (2nd most common cause) -\> 2ndary PPH (endometritis)
* **Trauma** - damage to reproductive tract during delivery (e.g. vaginal/cervical tears).
* RFs: Instrumental vaginal deliveries (forceps or ventouse), episiotomy, c section
* **Thrombin**
* **Vascular** – Placental abruption, hypertension, pre-eclampsia.
* **Coagulopathies** – vWB, haemophilia A/B, ITP or acquired coagulopathy i.e. DIC, HELLP.
43
How is PPH mxd specifically?
* Uterine atony
* **Conservative**: bimanual compression to stimulate uterine contraction, give birth on an empty bladder
* Pharmacological: **IV tranexamic acid**, **recombinant factor VII.** Cell salvage
* Surgical
* **Uterine tamponade** - intrauterine balloon (bakri balloon), uterine haemostatic suture, suture around uterus
* **Bilateral uterine or internal iliac ligation**
* **Hysterectomy** – haemostatic drugs
* **Trauma** - repair of laceration, if uterine rupture – laparotomy or repair of hysterectomy
* **Tissue** – **IV oxytocin,** manual removal of placenta + prophylactic abx
* **Thrombin** – correct any anti coagulation problems, haemocue and teg
44
How would you mx PPH?
A-E approach
Ix: FBC, GS, cross match 4-6L of blood, coagulation, UE, LFT, 2 wide bore cannulaes, warmed IV fluids + blood resuscitation, oxygen, FFP (for clotting abnormalities), keep her flat
**Activate major haemorrhage protocol**: 4 units 0-ve blood
Mx: mechanical, medical, surgical
* Mechanical: rub uterus, cathetarisation
* Medical: **oxytocin** (40u in 500ml) + **tranexamic acid** + those below
* Surgical
* Balloon tamponade
* B lynch suture
* Uterine artery ligation
* Hysterectomy – last resort
45
How do you prevent PPH?
* Active management of the **3rd stage of labour** reduces PPH risk by **60%: oxytocin**
* Vaginal delivery: **5-10 units of IM Oxytocin** prophylactically.
* C-section: **5 units of IV Oxytocin**
46
What are the main differentials for APH?
Placenta praevia, vasa praevia, placental abruption, cervical polyps, vaginitis and vulval varicosities
47
What are the fx of placenta praevia?
* Painless bleeding!
* Shock in proportion to visible loss
* No pain and uterine tenderness
* Lie and presentation may be abnormal
* Fetal heart usually normal – fetus unaffected unless a massive obstructive haemorrhage
* Coagulation problems rare
* Small bleeds before large
48
What Ix are used for placenta praevia?
Do not examine!
FBC, clotting, **Kleihauer test,** G+S, crossmatch, U+E, LFT,
* CTG –\> 26 weeks
* Imaging: USS – usually picked up routinely on 20-week anomaly USS
* TVS
49
* Placenta praevia minor – repeat scan at **36 weeks,**
* Placenta praevia major – a repeat scan at 32 weeks + a plan for delivery
* Confirmed placenta praevia: delivery via **elective C-section at 38 weeks.**
* **APH** all: give **anti-D** within **72h** of bleeding if rh-ve
* **Corticosteroids**: fetal lung maturity if pre term
If actively bleeding: admit, A-E, emergency C section
50
What is vasa praevia?
Where fetal blood vessels run near the internal cervical os (so are exposed and prone to bleeding during labour + birth)
Characterised by a triad of
* Vaginal bleeding
* Rupture of membranes
* Fetal compromise.
51
* Painful vaginal bleeding + absent FM (HB absent/ distressed)
* Tense tender abdomen + uterus
* Coagulopathy PPT
* Woody uterus (couvelair uterus)
* Normal lie/ presentation
* Beware: pre-eclampsia, DIC, anuria
52
How is placental abruption mxd?
* **Fetus alive** and **\< 36 weeks**
* fetal distress: immediate caesarean
* no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
* **Fetus aliv**e and **\> 36 weeks**
* Fetal distress: immediate caesarean
* No fetal distress: deliver vaginally
* **Fetus dead:** induce vaginal delivery
53
What are the RFs for placental abruption?
Abruption (PMH)
BP (HT/ pre eclampsia)
Rupture membrane
Uterine injury
Polyhydramnios
Twins
Infection
O
Narcotics
54
What is considered prematurity?
* \<37 wks gestation
* Extremely preterm - \<28 weeks
* Very preterm 28-32 weeks
* Moderate to late preterm 32-36+6 week
55
What are the risks to the foetus for prematurity?
* Neonatal death
* Respiratory distress syndrome
* Chronic lung disease
* Intraventricular hemorrhage
* NEC
* Sepsis
* Retinopathy of prematurity
* \< 28 weeks: physical/ learning disabilities, behavioural problems, visual and hearing problems
56
What are the causes / RFs of prematurity?
* APH (25%)
* cervical incompetence
* Chorioamnionitis
* Uterine abnormalities
* Diabetes
* Polyhydramnios
* Pyelonephritis or other infections.
* Abnormal genital colonization: BV, ureaplasma, mycoplasma hominis
* RFs: previous preterm birth, multiparity, cervical surgery (LLETZ, cone biopsy), uterine abnormalities, pre existing medical conditions, pre eclampsia, IUGR, abnormal genital tract colonisation
57
What are some of the complications of PPROM?
* fetal: prematurity, infection, pulmonary hypoplasia, sepsis, cord prolapse
* maternal: chorioamnionitis
58
59
What is PPROM?
* Water breaks when amniotic sack ruptures
* \<37 weeks and pre-labour
60
What is the hx of
* Gush of fluid from vagina
* Leaking vaginal fluid
* Increased watery discharge
* Concern or uncertainty about urinary incontinence
61
How is PPROM ixd?
* Avoid digital vaginal examination – can re-introduce bacteria up and pre-dispose to infection
* **Gold standard: Sterile speculum examination**
* Pool of fluid -\> Confirmed
* No fluid seen -\> test (different brands) – bedside swab tests detecting markers not usually present in vagina
* **AmniSure**
* **ActimPROM:** based on highly specific monoclonal abs for IGFBP-1 (insulin like growth factor binding protein-1)
* Sample posterior fornix
* High vaginal swab
* Bloods: FBC (WCC), CRP, HVS
62
How is PPROM mxd?
* Admit + observe 48h - chorioamnionitis
* GBS – early delivery preferred. Give prophylactic abx benzylpenicillin
* Erythromycin – for 10 days till labour - delays delivery and allows time for steroids to take effect
* Corticosteroid - FL maturity
63
What is pre term labour?
* Labour/regular contractions resulting in changes in cervix **\<37/40** (**effacement/ shortening OR dilation**)
* Threatened – **up to 4cm**
* Established – **after 4cm** (same as in term labour)
64
Who is at risk from pre term labour?
* Spontaneous preterm birth
* Mid-trimester loss (16+)
* PPROM
* Cervical trauma
65
How are women at risk of pre term labour mxd?
* TV USS cervical length
* HVS: BV
66
How does pre term labour present
* Menstrual-like cramping
* Mild, irregular contraction
* Low back ache
* Pressure sensation in the vagina or pelvis
* Vaginal discharge of mucus, which may be clear, pink, or slightly bloody (ie, mucus plug, bloody show)
* Spotting, light bleeding
67
How is preterm labour ixd?
* **USS**: Gold standard. **TVS for cervical length:**
* **\>15mm** – unlikely PTL – discuss risks/ benefits of going home vs in hospital monitoring
* **\< 15mm** – confirmed PTL and offer treatment
* **Fetal fibronectin** – (NICE recommended)
* Alternatives: **Actim partus, partosure**
68
How is pre term labour mxd?
* **Admit**
* **Tocolysis**: **atosiban** + **nifedipine**
* **Corticosteroids** (\<34 w)
* **Rescue cerclage** - if dilated cervix + exposed FM, \< 28 weeks, no PPROM/ infections/ contractions
* IN LABOUR - **MgS04** (neuroprotection), abx, continuous monitoring
69
How fetal growth is assessed in the antenatal period?
\>AFTER 24 weeks – useless before
* Methods: Clinical:
* Abdominal palpation of fundal height (sensitivity 20-30%)
* Symphysis-fundal height measurement using a measuring tape (sensitivity: 30-40%)
* Ultrasound assessment: key measurements (90-95% sensitivity)
* Head circumference (and Biparietal diameter)
* Abdominal Circumference
* Femur length
70
What are the definitions for
SMALL FOR DATES/SGA: describes anthropometric variables \<**10th population centile for GA**
o Severe SGA: **\< 3rd centil**e for their gestational age.
o LBW: birth weight **\<2.5kg**
LARGE FOR DATES/LGA: describes anthropometric variables **\>95th** population centile for GA
71
What are some RFs for FGR?
72
What are some signs of FGR?
Reduced amniotic fluid volume
Abnormal Doppler studies
Reduced fetal movements
Abnormal CTG
73
What are some complications of FGR
74
What are some of the causes of FGR
**Placenta mediated growth restriction**: Idiopathic, Pre-eclampsia, Maternal smoking, Maternal alcohol, Anaemia, Malnutrition, Infection, Maternal health condition
**Non-placenta mediated growth restriction:**
* Genetic/ structural
* Fetal infection
* Errors of metabolism
75
How are SFH monitored?
Low-risk women: SFH monitoring at every AN app \>24 weeks onwards to identify potential SGA
If SFH \<10th centile, women are booked for serial growth scans with umbilical artery doppler.
Women are booked for serial growth scans with **umbilical artery doppler** if they have:
* \> 3 RFS minor RFs
* \>+1 major RFs
* Issues with measuring the SFH (e.g. large fibroids or BMI \> 35)
Women at risk or with SGA are monitored closely with serial ultrasound scans measuring:
* Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity
* Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery
* Amniotic fluid volume
76
How are SGA foetuses mxd?
* Identifying those at risk of SGA
* **Aspirin** is given to those at risk of pre-eclampsia
* **Treating modifiable risk factor**s (e.g. stop smoking)
* **Serial growth scans** to monitor growth
* **Early delivery** where growth is static, or there are other concerns
* **NORMAL umbilical artery Doppler:** delay delivery until at **least 37 weeks** (+ satisfactory additional assessment)
* With Absent or reversed end-diastolic flow in the umbilical artery (AREDF) + Normal additional assessment: **\>34/40**
* Abnormal additional assessment (BPP/ CTG abnormal, or other Doppler parameters are abnormal (MCA, umbilical vein): **deliver**
