1 / 45

Size and date discrepancy of pregnancy

Size and date discrepancy of pregnancy. Facilitator: Pawin Puapornpong. Size < date. Inaccurate menstrual period Fetal growth restriction oligohydramnios. Size > date. Elevation of the uterus by a distended bladder Multifetal pregnancy

gjimenes
Download Presentation

Size and date discrepancy of pregnancy

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Size and date discrepancy of pregnancy Facilitator: Pawin Puapornpong

  2. Size < date • Inaccurate menstrual period • Fetal growth restriction • oligohydramnios

  3. Size > date • Elevation of the uterus by a distended bladder • Multifetal pregnancy • 􀁺 Inaccurate menstrual history • 􀁺 Hydramnios • 􀁺 Hydatidiform mole • 􀁺 Uterine myomas • 􀁺 A closely attached adnexal mass • 􀁺 Fetal macrosomia (late in pregnancy, DM)

  4. Oligohydramnios • Normally, 1L by 36 wks. • Only 100 to 200 mL (postterm) • Diminished volume : oligohydramnios • Amniotic fluid index ( AFI) < 5 cm. • Risk of cord compression, fetal distress

  5. AFI

  6. Early onset oligohydramnios • Obstruction of urinary tract or renal agenesis • Preterm delivery and neonatal death • Adhesions between amnion and fetal parts : deformities (amputation) • Pressure to fetus, muscle, skeletal deformities: clubfoot • Pulmonary hypoplasia 15% • Impaired lung growth and development

  7. Oligohydramnios in late pregnancy • Variable deceleration • c/s for fetal distress • 5-minute apgar score < 7 • Amnioinfusion during labor, prevent cord compression

  8. Hydramnios • > 2 L • AFI > 25 cm. • CNS or GI malformation • Anencephaly and esophageal atresia • First half of pregnancy : transfer water and small molecules across amnion and fetal skin • Second trimester : fetus urinate, swallow and inspire amnionic fluid • Maternal diabetes : fetal hyperglycemia, osmotic diuresis, excess amnionic fluid

  9. Symptoms • Overdistended uterus • Dyspnea • Edema : compression of venous system ( lower extremieties, vulva) • Diagnosis : uterine enlargement with difficulty in palpating fetal parts • Differential diagnosis : ascites or a large ovarian cyst by U/S

  10. Pregnancy outcome • Fetal malformation • Preterm delivery • Umbilical cord prolapse • Placental abruption • Uterine dysfunction • PPH • Abnormal fetal presentation

  11. Management • Minor degrees : no Px • Dyspnea or abdominal pain : hospitalization • Bed rest, diuretics and water-salt restriction : ineffective

  12. Therapeutic amniocentesis : relieve maternal distress (only transient) • Membranes rupture : cord prolapse, placental abruption • Indomethacin : impair lung liquid production, enhances absorption, fetal urine production potential for closure of fetal ductus arteriosus

  13. Fetal growth restriction • 3 to 10 % of infants • Small-for-gestational age (SGA) : intrauterine growth retardation • Avoid “retardation” : fetal growth restriction now preferred

  14. definition • SGA : below 10th percentile for their GA • Some are small because of constitutional factors, not pathologically growth restricted. • Others define by +2 SD with normal limits SGA < 3rd percentile, most of them are poor outcomes.

  15. Mortality and morbidity • Fetal demise, birth asphyxia, meconium aspiration, neonatal hypoglycemia and hypothermia • Growth restriction due to congenital, viral, chromosomal or maternal constitutional factors remains small throughout life. • but due to placental insufficiency will often catch-up growth after birth.

  16. Symmetrical VS asymmetrical fetal growth restriction

  17. symmetrical • Early insult : chemical exposure, viral infection, aneuploidy : proportionate reduction in both head and body.

  18. asymmetrical • Late insult : placental insufficiency from hypertension, diminished glucose transfer and hepatic storage • Fetal abdominal circumference (liver size) is reduced. • Shunting of oxygen and nutrients to the brain : normal brain and head growth. • Increase relative brain size compared with small liver.

  19. Risk factors • Constitutional small mothers • Fetal infections • Rubella and CMV • Hepatitis A and B • Listeriosis, TB, syphilis • Congenital malformations • karyotype abnormalities : trisomy 18, 13 • Not in trisomy 21, Turner and Klinefelter

  20. Chemical teratogens • Cigarette, alcohol, cocaine • Maternal medical complications • Chronic vascular disease • Preeclampsia • Renal disease • High altitude residence • Placental and cord abnormalities • Multiple fetuses

  21. diagnosis • Early confirmation of GA • Maternal weight gain • Uterine fundal growth • Identification of risk factors • Serial sonography • Doppler velocimetry • NST • Biophysical profile

  22. management • Near term : prompt delivery • Remote from term : growth remains normal, expectant until maturity, interval U/S of 2 to 3 wks. • Labor : monitor for evidence of compromise, insufficient placental function aggravated by labor. • Newborn : meconium aspiration, hypothermia, hypoglycemia and polycythemia

  23. Twin pregnancy

  24. Definition(Multi-fetal Gestation) -Twins (two babies) -Monozygotic(Division of 1 ova fertilized by the same sperm) -Dizygotic(Fertilization of 2 ova by 2 sperm) -Triplets (three babies) -Quadruplets (four babies)

  25. Incidence • Twins - 1 in 100 births • African Americans: 1 in 70 • Caucasians: 1 in 88 • Japanese: 1 in 150 • Chinese: 1 in 300 • Triplets are about 1 in 7,500 births • Quadruplets are about 1 in 65,000 births

  26. Causes of Multiple Gestation • Spontaneously • In Vitro fertilization • Intrauterine insemination • Assisted Hatching • GIFT, ZIFT • Frozen Embryo Transfer, Blastocyte Embryo Transfer • Fertility Drugs • Clomiphene citrate (clomid, serrophene) • Gonadotropins

  27. Dizygotic twins (66% ) Dichorionic – separate chorion (placenta) Diamniotic – separate amnion (amniotic sac) Monozygotic twin(33%) Ova division: < 72 hours: Dichorionic, diamniotic 4-8 days:Monchorionic, diamniotic 8-13 days: Monochorionic, monoamniotic > 13 days:conjoined twins

  28. Average age of gestation Number of babiesWeeks of Gestation 1 40 weeks 2 35 1/2 weeks 3 33 weeks 4 29 ½ weeks

  29. Zygosity & Chorionicity • Zygosity refers to the type of conception whereas chorionicity denotes the type of placentation. • Two thirds of all twins are dizygotic. • Approximately 25% of monozygotic twins are dichorionic. • Chorionicity rather than zygosity determines outcome.

  30. Diagnosis of multiple fetuses

  31. HistoryPatient profile: • Etiological factors; with positive pasthistory and family history speciallymaternal (advanced maternal age, highparity, large maternal size) ART • Early pregnancy:Hyperemesis, abnormal bleeding

  32. Mid-pregnancy: Greater weight gain than expected abdominal size > period of amenorrhea, early PIH symptoms. • Late pregnancy: Pressure symptoms (dyspnea, dyspepsia)

  33. Examination • Abdominal: Size > Date especially in midpregnancy • exclude other causes. • Palpation: Multiple fetal parts • Auscultation of FHS: 2 different recordings by 2 observers and a difference > 10 bpm

  34. Ultrasonography • Detect multifetal gestation 99% before 26 weeks. • Confirm fetal number [ 2 sacs or 2 fetal heads in 2 perpendicular planes]. • Confirm fetal lives • Diagnosis of vanishing twin syndrome. • Diagnose type

  35. Complication

  36. Conjoined twins or Siamese twins • *Anterior (thoracopagus) • *Posterior (pygopagus) • *Cephalic (craniopagus) • *Caudal (ischiopagus)

  37. Discordant twins • Diagnosis1. US anatomical.2.Fetal weight difference.* wt. of the larger - wt.of smaller wt.of the larger twin >15-25% poor outcome* • Abd circumferences differ >20 mm.

  38. Twin-TwinTransfusionSyndrome • Incidence : 4 - 20% of MC twins􀁺 It is characterised by an imbalance of bloodflow between the twins􀁺 The former criterion of > 20% discordance is no longer used in the diagnosis

  39. Twin-TwinTransfusionSyndrome • Monochorionicity. Marked discordance in amniotic fluid volume between the twins. • Discordance in size with the larger twin in the polyhydramniotic sac. • Fetal anomalies are excluded.

  40. Suggested treatment in TTTS • Serial amnioreduction • Amniotic septostomy • Laser ablation • Selective fetocide

  41. Antenatal care protocol First visit • Routine growth scan & AFI • 􀁺 Chorionicity determination • 􀁺 Placental localization • 􀁺 Cord insertions • 􀁺 Doppler study of UA/UV in each • 􀁺 Inspection of chorionic plate for anastomotic vessels

  42. Subsequent visit • As the first visit • Prenatal diagnosis as indicated • No agreement on the ideal frequency of ultrasound examinations in twins. DC : 4 weekly from 24 weeks MC : 2 weekly from 18 weeks • Note any change in anastomotic flow patterns

  43. Delivery bed with lithotomy stirrups • Obstetric forceps (Piper’s forceps if breech delivery planned) or vacuum apparatus • Premixed oxytocin infusion • Methergine, 15-methyl PGF2 , or both • Immediate availability of blood • Capabilities and staff for emergency cesarean section

  44. Uterine overdistension causes hypotonic uterine dysfunction. • Increased risk of postpartum hemorrhage due to uterine atony. • multifetal gestation is not a contraindication to labor induction, but is a condition that warrants special attention.

  45. Thank you for your attention

More Related