fetal complications part 2 Flashcards
freq of fetal death
1% of preg in second half
diagnosing fetal death
- symptoms: regression of size, lack of FM
- absence of HR on doppler or US
- US: skull collapse, retracted brain, empty bladder + aorta
causes of fetal death
maternal:
- DM, HTN, pre-eclampsia
- septicemia
Fetal:
- malformation
- infection
- immune hemolytic
- cord accident, prolapse, amniotic band strangulation, compression
- metabolic
placental:
- dysfunction, IUGR, post-mature
- abruption
- previa
- twin-twin transfusion
- mat-fet hemorrhage
work-up for fetal death
tests:
- HbA1c, fasting glucose
- platelets, fibrinogen, coombs
- TORCH
- CBC, antibody screen
- Betke Keihaur
- APA, ANA, thrombophilia
fetal
- karyotype / microarray
- AF cluture for CMV, parvo, herpes, bacteria (+ repeat at delivery)
- tot body x ray
- post mortem pathology inc placenta
management of fetal death
- <15 wks D+C
- 16-20 wks D+E or induce /w miso
- > 20 induce
- or wait, usually labour /w in 3 weeks
if >20 wks can have coagulopathy if undelivered for >4 wks, fibrinogen falls (consumed)
only dangerous if <100
platelets also fall
early vs late neonatal deaths
early: <7 days
late: 8-29 days
main causes of maternal mortality
- thromboembolism
- HTN
- hemorrhage
- ectopic
- infection
- abortion related
- anesthesia
- stroke
neonatal death causes
- prematurity
- hypoxic injury
- congenital anomalies
Rh primary immunization process + secondary exposure
- slow, 8-9 weeks after exposure
- IgM anti-D, cannot cross placenta
- second response is fast, IgG that crosses placenta
Rh sensitization effects
- destruction of RBCs
- anemia
- bone marrow can’t keep up, hepatosplenomegally
- hyperdynamic state + fetal hydrops
- macrophage mediated, lyses cells
- can cause bilirubinemia, anemia, jaundice, kernicterus, hydrops
- if ABO incompatible less likely to have sensitization
when to give Rhogam
if Rh neg, unimmunized
- after birth of +ve baby
- SA, TA, ectopic
- amnio or CVS
- at 28 weeks + repeat screen
- vag bleeding
- after massive hemorrhage of fetal blood
Rhogam dose + delivery management
- 300mcg
- lasts 12 weeks
- protects against 25ml of fetal RBC
- cord blood for ABO, Rh, and coombs
- maternal bood for betke-kleihaur
predicting hemolytic disease in Rh sensitized
- hx of fetus /w Rh disease = strong predictor
- maternal Rh antibody titre - can’t predict severity only risk of dx
- amniotic fluid optical density (amniocentesis) - old technique, shows amount of bilirubin in fluid + predicts severity
- US: doppler MCA PSV for anemia, liver, spleen + placenta size, ascites, effusions (hydrops), use to guide intrauterine transfusion
delivery for Rh sensitized
- if mild or unaffected based on dopplers: term
- if need intrauterine transfusions: at 36wks (lung maturity)
- neonate: phototherapy, blood transfusion/exchange
mono vs di twins & diagnosis
- dizigotic: always di/di
- monozygotic: di/di, di/mono, mono/mono, conjoined depending on time of separation
- US at 10-14 wks: lambda = dichorionic, T = monochorionic (not seen in 2nd trimester)
maternal risks with multiples
- anemia
- hydramnios
- ureter dilatation and obstruction (rare)
- HTN
- GDM
- premature labour
- PPH / atony
- instrumental + CS delivery
- perineal trauma
fetal risks /w mulitples
- SA
- malpresentation
- previa
- PPROM
- PTL
- cord prolapse
- IUGR
- discordant growth
- congenital anomalies
- conjoined
- velamentous cord insertion
- twin-twin transfusion
- perinatal morbidity/moretality (stillbirth, trauma, asphyxia, etc)
twin-twin transfusion syndrome
- monochorionic
- anastamosis
- blood goes from 1 to other twin
- donor: hypovolemia, hypotension, anemia, IUGR, oligo
- recipient: hypervolemia, viscosity, thrombosis, HTN, cardiomegaly, polycythemic, edema, CHF, polyhyrdamnios, neonatal kernicterus/jaundice
OR: circulation reversed + gets little O2, and then malformations, embolization from trophoblastic tissue entering
antepartum care ofr twins
- visits q2wks from mid preg, to q1wk from third trimester
- increased Ca, Fe, folic acid, calories
- earlier check for GDM
- US at 10-14 wks for zygosity and chorionicity
- genetic screen at earlier age b/c higher risk that 1 will have down’s (age 32=35)
delivery of twins
vertex/vertex
- SVD
- cut 1 cord, clamp
- VE for twin B position
- cont if vertex, monitor
- oxytocin to increase contractions
- when low AROM, wait for cervix to dilate again, and deliver
- optimal time <20min between, otherwise get less blood to baby B b/c decreased uterine vol
- can wait longer if reassuring HR and not a lot of bleeding
- after both delivered obtain cord samples, deliver placentas
vertex/breech or vertex/transverse
- can do C/S
- or can do vag birth and breech extraction
twin A breech
- CS
when to induce twins
Most end up with PTB (spont or medically indicated)
Induce at:
di/di & uncomplicated = 38wks
mono/di = 36 wks
di/di = 32 - 34
