Fetal abnormalities Flashcards
what is breech presentation ?
types (3)
Babies that are breech b4 9 months often turn spontaneously, so no intervention is advised.
is when the fetus presents buttocks or feet first (rather than head first – a cephalic presentation).
FRANK is most commonest!
Risk factors for Breech
IDIOPATHIC 85%
Large uterus: multiparity, Polyhydramnios–> unstable LIE
somthing there that stops baby from moving: Placenta previa, fibroids, uterine septum
Managment options in Breech presentation? (3)
- External Cephalic Version : technique in attempt to turn a fetus from the breech to a cephalic position using pressure on the abdomen.
- C- Section
- Vaginal Breech Birth
NOT in footling breech, as the feet and legs can slip through a non-fully dilated cervix, and the shoulders or head can then become trapped.
ALL BABIES where born breech must have USS in 6 weeks to check for hip DDH
complication of External Cephalic Version? (4)
contraindication? (4)
- failure and even if successful in the short-term, may return back to breech presentation
- discomfort/ pain
- transient fetal heart abnormalities
- placental abruption
ContraX:
- recent antepartum haemorrhage
- ruptured membranes
- uterine abnormalities
- previous C-section.
How is Vaginal Breech Birth performed?
if baby does not deliver what r some specific manoeuvres you can do?
The most important advice when conducting a vaginal breech delivery is “hand off the breech”. This is because putting traction on the baby during delivery can cause the fetal head to extend & then trapped during delivery. The fetal sacrum does need to be maintained anteriorly, which can be done by holding the fetal pelvis.
Occasionally the baby does not deliver spontaneously, and some specific manoeuvres are required:
- Flexing the fetal knees to enable delivery of the legs.
- Lovsett’s manoeuvre to rotate the body and deliver the shoulders.
- Mauriceau-Smellie-Veit (MSV) manoeuvre to deliver the head by flexion.
The delivery of the aftercoming head can be challenging, but if MSV fails forceps can be used.
when is normal fetal movements supposed to be detected?
causes of reduced fetal movements? (8)
assessment? (2)
Most women are aware of fetal movements by
18-20 weeks
Cx–> divide into mum causes vs fetus
- Sedating drugs that cross the placenta (benzos,
- Smoking & alchohol
- Fetal malformations
- Fetal position : Anterior fetal position means movements are less noticeable
- Administration of corticosteroids to enhance fetal lung maturation
- abnormalities of CNS, muscular dysfunction or
- Oligohydramnios and polyhydramnios can cause reduction in fetal movements
- mum is too busy to even realize or she’s fatso
Assessment
- Maternal perception
- hand -held Doppler (Fetal HR) or real-time USS
What should be included in the clinical history? (3)
referrals
If movements still not felt by 24 wks, onward referral to _maternal fetal medicine unit._
The initial goal of antenatal fetal surveillance in cases of RFM is to exclude fetal death.
Hx
- Duration of RFM? Absence of FM?
- Is it the first occasion the woman has RFM.
- The history must include stillbirth risk evaluation, & RF of stillbirth, known FGR, hypertension, diabetes, extremes of maternal age, primiparity, smoking, placental insufficiency, congenital malformation, obesity, racial/ethnic factors, poor past obstetric history (e.g. FGR and stillbirth), genetic factors and issues
investigation of RFM in
- at 24+ weeks of gestation?
- referrels
- If a woman presents with RFM prior to 6mnths :*
- Auscultation with a Doppler handheld device >> to confirm presence of a fetal heartbeat
►if doppler shows fetal HR–> CTG for 20 mins to monitor
►if doppler shows NO fetal HR–>IMMEDIATE USS
- If NEVER felt by 24 weeks >> referral to a specialist fetal medicine centre > to look for evidence of fetal neuromuscular conditions.
- Examination: BP, fundal height chart
- Antenatal Foetal Surveillance (referred to MAU)
- Doppler–> fetal HR
- CTG/non-stress test–> monitor fetal HR
- USS
what are some abnormal patterns of fetal growth? (4)
Assessment of foetal growth?
causes?
- Small for gestational age (SGA)
- Large for gestational age (LGA)
- Fetal growth restriction (FGR)
- Low birth weight refers
investigations of Abnormal fetal growth?
SGA
causes?
Rf?
divided into
- Constitutionally small–>mum is small too
- Fetal growth restriction (FGR)
- Placenta mediated GR (Abnormal trophoblast invasion ex: pre-eclampsia, infarction, abruption)
- Non-placenta mediated GR (due to a genetic or structural abnormality)
fetal surveillance of SGA/monitoring
Once a fetus is confirmed as SGA…
if umbilical artery Dopplers NORMAL…..
repeat every 2 wks
If doppler still normal : aim for IOL at 37 wks.
if umbilical artery Dopplers ABNORMAL + preterm,
==> present end–diastolic velocities : repeat 2x wkly ==> absent end–diastolic velocities : DAILY
Corticosteroids (24 and 35+6 )
Check amniotic fluid volume
MCA (middle cerebral artery) doppler: Abnormal suggests IUGR
Ductus venosus (DV) doppler (if umbilibal A is abnormal)
When identified as SGA, what investigations we do to find out underlying cause? :
Uterine A. doppler: tells us about b. flow from placenta to baby
Detailed fetal anatomy scan by FETAL MEDICINE
Karyotyping for chromosomal abnormalities
Serological screening for congenital (CMV) and toxoplasmosis infection
Testing for syphilis and malaria
Prevention of SGA
If high risk pre-eclampsia: Antiplatelet b4 4 months
Smoking cessation
Antithrombotic therapy goals for preventing delivery of a SGA infant in high-risk women
Delivering SGA
and fetus care after birth
If delivery is considered btw 24 and 35+6 weeks, give single course of antenatal steroids
- After birth, temp regulation (hypothermia) may be an issue, encourage skin-to-skin contact w/ mother.
- Neonates have little stored glycogen so are prone to hypoglycaemia. Feed within 2h of birth
- ARDS (lungs poorly developed) & NEC (bowel poorly developed)
what are some amniotic fluid problems that can occur? (4)
Polyhydramnios
Oligohydramnios
amniotic fluid embolism
Chorioamnionitis
what is amniotic fluid?
how is it produced?
recycled?
when does it stop producing?
The amniotic fluid is the protective liquid that cushions the fetus and involved of exchange of nutrients from mama to baby
increases steadily until 33 weeks of gestation. plateaus from 33-38 weeks, and then declines to 500ml at birth
made of fetal urine, and shway from the placenta and some fetal secretions (e.g. respiratory, oral).
recycled by the fetus swallowing it or breathing it
Causes of Oligohydramnios vs polyhyramnios
- PPROM
- Placental insufficiency – results in the blood flow being redistributed to the fetal brain rather than the abdomen and kidneys. This causes poor urine output.
- Renal agenesis (Potter’s syndrome)
- Non-functional fetal kidneys (bilateral multicystic dysplastic kidneys)
- Obstructive uropathy
Causes of Polyhydramnios (4)
idiopathic in 50-60% of cases
- Congenital anomaly (Any condition that prevents the fetus from swallowing – e.g. oesophageal atresia,)
- Gestational diabetes
- Twin-to-twin transfusion syndrome*
- Macrosomia – larger babies produce more urine.
*a complication of a disproportionate BS in twin pregnancies.
Investigations and management of polyhydramnios
USS
Amniotic fluid index (AFI) calculated by measuring maximum cord-free vertical pocket of fluid in 4 quadrants of the uterus and adding them together.
Maximum pool depth is the vertical measurement in any area.
managment
what is chorioamniontis?
infection and inflammation of the AF and chorioamniotic membrane
Amniotic Fluid Embolism
clinical features?
rare but severe condition where the AF passes into the mums blood, AF contain immune factors causing a immune reaction to mum
CF similar to anaphylactic shock!
- SOB
- tachycardic
- shock, pale
- hypotension
- confusion
- Seizures
- DIC (may be 1st sign in some cases but nearly all patients will develop this w/in 4 hrs)
Management AF embolism
CALL FOR HELP
- The 1st priority is to prevent death from respiratory failure. Give Oxygen mask and call an anaesthetist urgently.
- Set up IVI in case DIC should supervene.
- CVS collapse is due to LVF
- DIC and haemorrhage then usually follow.
Treatment is essentially SUPPORTIVE
Cardiopulmonary resus
Give highest available O2, If unconscious, ventilate and use 100% inspired O2 >>> This is to prevent neurological sequelae from hypoxia. Monitor for fetal distress.
If hypotensive, give fluids rapidly IVI to increase preload. If still hypotensive consider inotropes: dobutamine
Pulmonary artery catheterization (Swan–Ganz catheter if available) helps guide haemodynamic management.
After initial hypotension is corrected, give only maintenance requirements of fluid to avoid pulmonary edema from ARDS!
Transfer to ICU asap
Treat DIC with fresh whole blood or packed cells and fresh frozen plasma.
what is Stillbirth (IUD)
causes?
defined as the birth of a dead fetus after 24 weeks gestation.
Mx and Ix of Stillbirth
Investigation: Real time USS – foetal heart beat
Tests to establish the cause? (maternal and fetus)
Maternal tests:
- Kleihauer: test you do to find fetal Hb in mother’s blood – ALL mums but impx for RH- mums
- FBC, CRP, LFT, TFT, HbA1c, glucose,
- blood culture, viral screen (TORCH (Toxoplasmosis, Other, Rubella, CMV, Herpes)
- Coagulation stuff: thrombophilia screen
- immunological: antibodies (antiphospholipid, antcardiolipin, anti- red cell, anti-Ro, anti-La, alloimmune antiplatelet)
- Urine: MSU, urine for cocaine
- cervical swabs
Fetus testing:
- Fetal and placental swabs–>infection
- Fetal and placental tissue–>karyotyping
- Cord blood in lithium heparin tube for infection
- May also do a postmortem exam
Support for parents post stillbirth (5)
- Give parents a follow-up appointment to discuss causes found by the tests described
- Genetic counselling
- Support group
- Appointed bereavement officers
- Arrange a follow-up appointment with the obstetrician to discuss implications for future pregnancy
- statutory maternity pay and the maternity allowance and social fund maternity payments are payable after stillbirth.
