Transcript Gynae History Taking

WHEN THE UTERUS IS
LARGE OR SMALL FOR
DATES....
Max Brinsmead MB BS PhD
May 2015
When the uterus is LFD or SFD you first need to know…
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What is normal
SFH = Weeks of gestation is valid only between 20
and 30 weeks
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Thereafter the mean runs off to 37 cm at 40 weeks
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This should be validated in each population
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And the 95% confidence limits are not less than +/3 cm
When the uterus is LFD or SFD you also need to know
DATES accurately…
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Menstrual history is unreliable when…
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The patient is uncertain
She has a good reason to tell lies
Cycles are irregular
Ovulation was delayed >14 days by
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Quickening is unreliable when…
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The patient is uncertain
The placenta is on the anterior uterine wall
The patient is obese
There is something wrong with the fetus or fluid
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It is done by a non expert or with poor equipment
It is done late in pregnancy
There is something wrong with the fetus e.g. microcephaly
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Miscarriage
Breast feeding
Hormonal contraception
Ultrasound is unreliable when…
If the uterus is LFD think of…
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Wrong dates
Hydatidiform mole
Multiple pregnancy
 Many
small parts
 Three poles
 Lots of fluid and difficult to feel the baby
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Polyhydramnios
Uterus lifted up by
 Previous
CS
 Tumours e.g. Fibroids, Ovarian cyst
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A Large Baby
If the uterus is LFD then…
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Ultrasound is useful because it readily diagnoses:
 Hydatidiform
mole
 Multiple pregnancy
 Polyhydramnios
 Fibroids and tumours
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But ultrasound is poor at:
 Diagnosing
fetal abnormalities
 Estimating fetal weight
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If there is a large baby:
 Check
for maternal diabetes
 But macrosomia more commonly due to maternal obesity
 +/- Excessive weight gain in pregnancy
If there is fetal macrosomia then…
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There is a risk of intrauterine death
 If
the mother is diabetic
 And it is poorly controlled
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There may be birth difficulties
 Cephalopelvic
disproportion
 Shoulder dystocia
 Maternal birth injury and PPH
 Vaginal breech birth may not be wise
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There may be neonatal problems
 From
hypoglycaemia
 From birth injuries
Management of suspected fetal macrosomia…
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Exclude maternal diabetes or…
Control maternal blood sugars before and during
birth if diabetic
Refer to a place where expert assistance is
available
Consider induction of labour but only when it is
safe to do so
Watch progress in labour and prepare for
complications
Have someone expert standby for the delivery
If the uterus is SFD think of…
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Wrong dates
Oligohydramnios
 Premature
rupture of membranes
 Abnormality of the fetal renal tract
 Intrauterine growth retardation (IUGR)
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Intra uterine growth retardation
 There
are two major categories
 Symmetrical = head, trunk and body reduced
proportionaely
 Asymmetrical = head-sparing growth restriction
Causes of Symmetrical IUGR
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Constitutional smallness
 Consider
maternal size
 Ethnic origin
 Paternal influence less important
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Fetal Infections
 TORCH
= Toxoplasmosis, Other, Rubella, Cytomegalovirus
and Herpes
 Remember Syphilis and HIV
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Fetal Abnormalities
 Especially
13&16
chromosomal abnormalities such as Trisomy 21,
Causes of Asymmetrical IUGR
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Anything that reduces Maternal-Uterine-Placental
to Fetus transfer of oxygen and nutrients
 Maternal
smoking and malnutrition
 Severe maternal anaemia
 Chronic maternal disease
 Maternal hypertension especially pre eclampsia
 Uterine malformations
 Some placental diseases
 Maternal thrombophilias congenital or acquired
 Recurrent antepartum haemorrhage
 An idiopathic group
A SFD uterus is more serious when…
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The mother was underweight to begin with
She has not gained weight appropriately
There is a past history of IUGR or pregnancy loss
A condition known to be associated with IUGR is
also diagnosed
 Pre
eclampsia
 Recurrent APH
 Chronic maternal disease or anaemia
Management of the SFD baby
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Accurate diagnosis
Is the baby salvageable?
 Mother at risk?
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Steps that improve M-U-P-Fetal transfer of oxygen
and nutrients
Stop maternal smoking
 Bed rest
 Correct anaemia
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Monitor fetal growth and well being
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There is little point in ultrasound at less than 2w intervals
Timely delivery
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Must weigh up the risks of induced delivery against the risk of
remaining in utero
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