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Large for Dates Flashcards

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1
Q

What is meant by being large for dates?

A
  • SFH >2cm for the gestational age

- bby at 35 weeks measures at 37 weeks

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2
Q

Reasons for being Large for Dates ?

A
  • wrong dates
  • fetal Macrosomia
  • Polyhydramnios
  • Diabetes
  • Multiple pregnancy
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3
Q

Why may wrong dates occur in some cases?

A
  • concealed pregnancy
  • socially vulnerable women
  • transfer of care
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4
Q

How to diagnose LFD?

A
  • USS EFW >90th centile
  • AC>95th Centile
  • generic popn and customised growth (ehthnicity, BMI, parity)
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5
Q

Risks of LFD?

A
  • clinican & maternal anxiety
  • Labour dystocia (difficulty)
  • Shoulder dystocia
    (more with diabetes)
    -PPH
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6
Q

A 26 week fetus is found to be LFD.

What is the course of action now?

A
  1. Exclude diabetes
  2. Reassure the mom
  3. Plan pregnancy:
    Conservative vs IOL (induction of labour) vs C/S delivery

—-estimate of bby being more than 4.5kg: c-section must be done

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7
Q

What is polyhydramnios?

A
  • Excess amniotic fluid
  • —-deepest pool (in cord-free area) >8cm
  • —-AFI of >25cm
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8
Q

Maternal causes of polyhydramnios?

A
  • diabetes
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9
Q

Fetal etiology of Polyhydramnios?

A
  • ANOMALY: GI atesia, cardiac, tumors,
  • monochorionic TWIN pregnancy
  • hydrops fetalis: fluid accumulation in 2 or more compartments (Rh isoimmunisation)
  • viral infection (CMV, toxoplasmosis, EBV 19)
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10
Q

What is seen on examination for suspected polyhydramnios?

A
  • LFD
  • Malpresentation
  • tense shiny abdomen
  • inability to feel fetal parts
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11
Q

Management of polyhydramnios?

A

Patient information- complications
Serial USS- to monitor growth, LV, presentation
IOL by 40 weeks —-associated perinatal mortality

Neonatal examination

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12
Q

How is Polyhydramnios diagnosed?

A

Ultrasound Confirmation
AFI (amniotic fluid index) >25
DVP(deep vertical pocket) >8cm

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13
Q

What are symptoms of Polyhydramnios?

A
  • Abdominal discomfort
  • Pre-labour rupture of membranes
  • Preterm labour
  • Cord prolapse
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14
Q

Why may multiple pregnancies occur?

A
  • assisted conception (IVF-UK limits to 1 embryo, clomid)
  • Race (African)
  • geography (1 in 25 births in Nigeria are twins vs 1 in 500 in Japan)
  • family hx
  • increased maternal AGE
  • increased parity
  • Tall women> short women
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15
Q

Why is there a geographical discrepancy with twin gestation?

A
  • evolution; nature gives you a better chance to survival
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16
Q

Split in day 1-3?

A

DCDA

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17
Q

When does the splitting of the embryo occur for conjoined twins to result? Why?

A

Days 13-15
—-late: time for the embryonic disc form

e

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18
Q

How to determine chorionicity?

A

Ultrasound

  • –Shape of membrane and THICKNESS of membrane (twin peak at 11-13+6 weeks)
  • -placental masses
    • Lambda sign (membrane thickness, appearance of membrane attachment)

—Fetal Sex

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19
Q

Symptoms of Multiple pregnancy?

A

Exaggerated pregnancy symptoms e.g. excessive sickness/ hyperemesis gravidarum

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20
Q

SIgns of multiple pregn?

A
  • High AFP
  • Large for dates uterus
  • Mutiple fetal poles
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21
Q

When can multiple pregnancies be confirmed?

A
  • USS confirmation at 12 weeks
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22
Q

WHat are the complications for the mother from multiple pregnancie?

A
  • Hyperemesis Gravidarum
  • Anaemia
  • Pre eclampsia
  • Antepartum haemorrhage- abruption, placenta praevia
  • Preterm Labour
  • Caesarean section
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23
Q

Fetal complications of multiple pregnancies?

A

Perinatal mortality is 6x HIGHER compared to Singleton pregnancy….
- Congenital anomalies (acardiac twin)
- IUD ( single/both)
- Pre term birth
- Growth restriction- both /discordant
- Cerebral Palsy-(twins 8X higher, triplets 47X higher)
Twin to twin transfusion- oligohydramnios & polyhydramnios

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24
Q

Diff. in clinical appointments between MC and DC twins?

A

MC: every 2 weeks (monochorionic)

DC every 4 weeks

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25
Medications for multiple preg. mom?
Fe supplementation Low Dose Aspirin Folic Acid
26
What is the risk of single intra-uterine death to the survivor?
- 26% risk of neurological abnormality | - 15 % risk of survivor death (IUD)
27
Twin-twin transfusion syndrome?
- smaller one baby - arteriovenous anastomosis -----donor twin perfuses the recipient twin - ----rare after 26 weeks gestation
28
What is the risk of MCMA?
- Risk for cord entanglement - Higher Risk of Fetal Death - Deliver by C/Section 32-34+0 weeks
29
When should MCDA and DCDA twins be delivered?
- DCDA: deliver at 37-38 weeks | - MCDA: deliver after 36+0 weeks with steroids
30
Mode of delivery for multiple pregnancy?
- C-section: triplets and MCMA | - do Vaginal delivery if one is in Cephalic
31
What is the intertwin delivery time?
<30 mins each
32
Types of Pregestattional diabetes?
- MODY (mature onset of diabetes of the young) | - Type 1, 2
33
Always tell a sexually active diabetic to ______
- use contraception ! | - --high risk pregnancy; should be prepared for it
34
Complications common to PRE-existing and gestational diabetes in pregnancy?
- Pre eclampsia - Polyhydramnios - Macrosomia - Shoulder dystocia - Neonatal hypoglycaemia
35
At what hba1c level should the pregnancy not be done?
HBA1C ABOVE 86mmol/mol
36
How to manage TYPE 1 AND 2 diabtes in preg.?
- folic acid 5mg - Low dose aspirin from 12 weeks - INSULIN AND METFORMIN (type2) - continous glucose monitoring - growth scans (4 weekly) - counsel about SHOULDER dystocia - deliver at 38 weeks (earlier with complications) - ----fetal anomaly scan at 18-20 weeks - eye check ups for retinopathy - early booking in diabetic ANC
37
OGTT dx of GDM?
Fasting >=5.6 mmol/l | 2 hour >= 7.8 mmol/l
38
Mainstay rx for GDM?
- mainstay exercise and diet control
39
RIsks of lack of GDM control?
- Macrosomia | - Neonatal Hypoglycemia
40
Educating the patient of what risks regarding GDM?
- importance (measure glucose 4 times a week) - premeals------measure POST-PRANDIAL BG - transient morbidity in baby - risk of obesity and diabetes - increased risk of type 2 diabetes
41
WHy is insulin administration NOT enough for diabetes control?
- insulin without exercise = WEIGHT gain; sugar build up in fat
42
What is the % risk of shoulder dystocia?
- 9-10% risk
43
POSTNATAL - management?
= FBS at 6-8wks
44
DOSE OF FOLIC ACID Administration in diabetic mother ?
- 5mg!!!
45
What occurs in shoulder dystocia?
- baby's anterior shoulder gets stuck underneath the mother's pubic bone==> MAY damage the brachial plexus
46
How accurate is the USS for predicting the bby's weight?
- USS EFW is commonly OVERESTIMATED (compared to actual weight) - margin of error up to 10% - ---more accurate <38 weeks !
47
What is NICE recommendation on IOL?
- should NOT be carried out simply because a healthcare professional suspects a baby is LFD
48
What investigations are done for suspected polyhydramnios?
- OGTT (oral glucose tolerance tests) - serology (CMV, Parvovirus, toxoplasmosis) - Antibody screen - USS (fetal survey: lips and stomach)
49
How is polyhramnios managed?
1. make pt aware of complications that MAY arise 2. Serial USS (growth, LV, presentation) 3. IOL by 40 weeks - risk of pre-term labour (serial check ups!) - risk of cord prolapse/ PPH - risk malpresentation
50
What are the 2 types of Zygosity?
- Monozygotic: splitting of a SINGLE fertilized egg (30%) | - Dizygotic: fertilization of 2 ova by 2 sperms (70%)
51
What is meant by chorionicity?
1 placenta/2placentas - ----DIZYGOUS: DCDA - ----MONOZYGOUS: MCMA, MCDA, DCDA, conjoined
52
Cleavage of the blastocyst at day 4-8?
MCDA
53
Cleavage of implanted blastocyst at days 8-13?
MCMA
54
When are monochorionic pregnancies likely to occur?
- Days 4-7 and 8-14
55
What chorionicty is at a higher risk of pregnancy complications?
- Monochorionic/ Monozygous twins - ----clinical appointments are evry 2 WEEKS (DC: 4Wks)
56
How does the Lambda sign appear?
- a triangle appearance of the chorion insinuating layers of the intertwin pregnancies
57
What is told to the mother during maternal education for multiple pregnancy?
- pre-term labour and risks - support - TAMBA
58
What is the managment of multiple pregnancies?
Meds: Fe supplementation/ Folic Acid/ Low dose aspirin USS: MC (2x wkly)/ Anomaly USS (18-20 wks)
59
Why are MC twins asked to come in more frequently for their USS scans?
- Huge risk of complications including: 1. Single fetal death 2. Selective growth restriction 3. Twin-to-twin Transfusion syndrome (TTTS) 4. Twin anemia-Polycythemia Sequence (TAPS) 5. Absent EDV (AEDV) or Reversed (REDV)
60
What is EDV?
- indicated through an umbilical artery Doppler assessment | - placental insufficiency (seen in MC) may result in Absent EDV (End diastolic flow) or Reversed EDV (REDV)
61
What ivx to follow after singleton death?
- MRI of cofetal brain 4 wks post IUD! | - MCA PSV to check for fetal anemia (middle cerebral arterial, peak systolic velocity)
62
What is meant by EFW discordance?
- growth discordance means a significant wgt differences between the 2 fetuses >20% is a.w INCR. PERINATAL risks
63
When may TAPS (Twin Anemia- Polycythemia Sequence occur)? What should be checked for?
- after a small surgical procedure to resolve TTTS (twin-transfusion $) -- FETOSCOPIC laser ablation for TTTS - abnormal vessel connections are sealed off - MCA PSV - absent/ reversed EDV to be checked for!
64
How is TTTS dx?
- findings of polyhydramnios in one sac and oligohydramnios in the other sac
65
What are the complications of TTTS?
- mortality >90% with no rx | - neurological morbidity of 37% and HIGH in surviving twin if IUD
66
RX for TTTS?
- fetoscopic laser ablation (before 26wks) - Amnioreduction/septosomy >26wks - deliver 34-36 wks
67
Multiple pregnancy labour holds high risk. What are some precautions that should be taken?
- 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)
68
Define GDM.
- carbohydrate intolerance resulting in HYPERGLYCEMIA of variable severity with onset or first recognition during pregnancy
69
Complications specific to pre-existing diabetes in pregnancy?
- congenital anomalies (depends on HBA1C levels) - miscarriage - IUD - worsening diabetic complications
70
What would be expected of a Type 1 diabetic vs a type 2?
- Tpe 1: slimmer/ 5-10% prevalence/insulin def./white | - type 2: overweight/older/ non-caucasian
71
Why is it important to be well-prepared prior to conceiving a child when diabetic?
- aim for HBA1C of 48 mmol./mol (6.5%) - to stop embryopathic meds (ACE inhibitors, cholestrol lowering agents) - determine macrovascular and microvascular complications - ----start on HIGH dose FOLIC ACID 3 months before conception (5mg) - ----advise on hypglycemia - contraception if not wanting to concieve
72
What are risk factors of GDM?
- - previous - BMI >31 - Family hx - Asian, Caribbean, Middle eastern - previous /current BIG baby - polyhydramnios - glycosuria (1+ on >1 times)
73
What is HpL known to do? Its consequence?
- during late pregnancy increases up to 30 fold ; inducing huge insulin release ! > cause insulin resistance ----overgrowth of insulin sensitive tissues ----hyopxaemic state in utero ....metabolic changes to baby (obesity, diabetes)
74
WHat happens if OGTT in 1st trimester is NORMAL?
- repeat in 24-28 weeks
75
What does OGTT involve?
- venous FBS > given a 75g Glucose solution> 2hr venous glucose reading is obtained (minimal activity to avoid false +)
76
Advs of oral hypoglycemics agents over insulin?
- less weight gain | - less administration info
77
What is problem with insuling use for the fetus?
- risk of hypoglycemia | - ---does not cross the placenta
78
How is the delivery timing diff. for timing of delivery for GDM pts on metformin vs diet alone?
- diet alone: 40-41 weeks - Metformin: 39-40 ----insulin rx: 38-39 weeks
79
When should the baby be delivered early with diabetic pts?
- if fetus has macrosomia/ IUGR/ PET earlier delivery
80
What is the % risk of the Type 2 diabetes developing later in the mom ?
- 70% | - ----main risks: obesity/insulin use/ ethnic gr.
81
Risks during labour in polyhydramnios?
- Risk malpresentation - Risk of cord prolapse - Risk of Preterm Labour - Risk of PPH (postpartum hemorrh.)
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