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MBBS VI: O&G > Fetal medicine > Flashcards

Fetal medicine Flashcards

1
Q

Define small for gestational age and intrauterine growth restriction

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2
Q

What is the classification of IUGR?

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3
Q

Compare SGA and IUGR in history taking, PE< growth velocty, cardiotocography (CTG), amniotic fluid volume, umbilical artery doppler, middle cerebral artery doppler

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4
Q

What is the etiology of intrauterine growth restriction?

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5
Q

What is the pathophysiology of IUGR?

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6
Q

What is the clinical manifestation of IUGR (antenatal, intapartum and postpartum complications)?

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7
Q

What is the workup of IUGR?

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8
Q

What is the ambulatory monitoring of IUGR?

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Serial USG evaluation of the following is key fetla assessments and helps to identify fetuses that are at highest risk of in utero demise and neonatal morbidity who may benefit from preterm delivery
* Fetal growth velocity: calculated and plotted on a population based growth curve to determine whether estimated fetal weight <10th percentile and to monitor growth velocity.
* Biophysical profile (BPP) including non stress test (NST): 5 parameters included with USG and NST: fetal breathing, fetal movement, fetal tone, fetal heart rate by NST, amniotic fluid volume (chronic placental insufficiency leads to both IUGR and oigohydramnios)
* Amniotic fluid volume: chronic placental insufficiency leads to both IUGR and oligohydramnios
* Doppler velocimetry (impedence to blood flow in fetal arterial and venous vessels):
Umbilical artery: reflects fetal haemodynamic changes due to placental vascular changes. Primary surveillance tool for monitoring when IUGR is suspected. Useful for fetal assessment in IUGR when etiology is placental dysfunction related to progressive obliteration of villus vasculature.
Placental vascular changes in IUGR: defective trophoblast invasion of vessels leads to increased placental vascular resistance. Decreased forward flow in umbilical artery leadsto decreased end diastolic flow.
Middle cerebral artery: gives information about the haemodynamic status of the fetus. Changes in the venous circulation in the growth restricted fetus including absent or reversed flow in the ductus venosus or pulsatile umbilical venous flow.

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9
Q

What is the timing and mode of delivery in IUGR?

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10
Q

What is the neonatal management of IUGR?

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11
Q

What is the prevention of recurrence and management of subsequent pregnancies of IUGR?

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12
Q

What are the different types of fetal presentation?

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13
Q

What is transverse/oblique/unstable lie?
What is management?

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14
Q

What is management of breech delivery?

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15
Q

What are indications and contraindications for external cephalic version?
What is preprocedural prep?

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ECV performed at >37 weeks

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16
Q

What is the post procedural assessment of ECV for malpresentation?

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17
Q

What are the risk and complications of ECV for malpresentation?

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18
Q

When is elective C-section considered for malpresentation?

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19
Q

What is the selection criteria for vaginal breech delivery in malpresentation? What are the indications?
What does the procedure involve?

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20
Q

What are the complications of vaginal breech delivery in malpresentation?

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21
Q

Define zygosity, chorionicity and amniocity

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22
Q

What are the different types of twins?

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23
Q

What are the causes of twins?

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24
Q

What are the maternal complications of twins?

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25
Q

What are the fetal complications for all twins?

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26
Q

What are the complications of monochorionic twins?

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  • Twin twin transfusion sydnrome (TTTS)
  • Twin reversed arterial perfusion sequence (TRAP)
  • Twin anemia polycythemia sequence (TAPS)
  • Conjoined twins (MCMA only)
  • Cord entanglement (MCMA only)
27
Q

What is the presentation of twin-twin transfusion syndrome (TTTS)? When does it occur?
What is the underlying pathophysiology?
What is the treatment?

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  • occurs in the 2nd trimester
  • Vascular connections (anastomosis) frequently occurs within monochorionic pregnancy which share a common placenta
  • Results from unbalanced blood flow through vascular artery to vein anastomosis which are present in the placenta of majority of monochorionic pregnnacy
  • Donor = anemic, hypoxic, malnutrition and hypotension resulting in growth retardation and oligohydramnios. Bladder may not be seen at all. Severe oligohramnios can lead to adherence of the donor twin to the uterine wall (stuck twin)
  • Recipient = volume overload with hyperviscosity of the blood (polycythemia) result in in high output heart failure, hydrops fetalis and polyhydramnios. The recipient twin typically has a large umbilical cord, abdominal circumference, kidneys and bladder.
  • Dx by discordance of growth and oligohydramnios in 1 amniotic sac and polyhydramnios in the other sac
  • Treated by repeated amnioreduction and devascularization of anastomosis with laser

Neonatal management
* IV access for volume expansion to treat hypotension, correct hypoglycemia and transfuse RBC in donor twin
* Partial exchange transfusion to treat polycythemia in recipient twin

28
Q

What is the underlying pathophysiology for twin reversed arterial perfusion sequence (TRAP)?
What is the consequence?
What is the treatment?

A
  • Results from artery to artery anastomosis which leads to severe abnormalities when perfusion pressure of one twin overtakes the other resulting in reversed arterial blood flow
  • Blood from donor twin enters recipients iliac vessels so that lower part of the boyd is perfused more than the upper part which causes acardius fetal malformation, resulting in lack of functioning heart in recipient twin
    Consequence:
  • donor/pump twin = added circulatory burn leads to cardiomegaly and heart failure that may progress to hydrops fetalis
  • Recipient twin/acardiac twin = lethal
  • Selective termination using RFA or cord occlusion
29
Q

What is the underlying pathophysiology for twin anemia-polycythemia sequence (TAPS)?

A
  • A variant of TTTS (twin twin transfusion syndrome) in which one twin is anemic and the other twin is polycythemic but without amniotic fluid volume discordance
  • Anastomotic vessels at the periphery of the placenta
30
Q

What is the underlying pathophysiology for conjoined twins (MCMA only)?
What is the classification?
What is the management?

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Rare form of MCMA pregnancy resulting when MZ twins fail to separate into 2 individuals as division occurs at or after day 13 post fertilization

Classificied according to the dominant site of interfetal body part connection into 5 ventral unions and 3 dorsal unions
* Cephalopagus = 11%
* Thoracopagus: thorax = 19%
* Ischiopagus = 11%
* Parapagus: pelvis and variable trunk = 28%
* Craniopagus: head = 5%
* Rachiopagus: vertebral column = 2%
* Pyopagus: sacrum = 6%

  • Conjoint twins are suspected under USG when fetuses are facing each other with same lie and presentation with no membranes separating them
  • Poor prognosis with half of them resulting in intrauterine deaths and 1/3 of remaining livebirths having severe defects for which surgery is not possible
  • Elective termination is advised when there is a cardiac or cerebral fusion since separation is rarely successul
  • Elective C/S after lung maturation with surgical separation after delivery
31
Q

What PE and biochemical tests for twins?

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32
Q

What are signs to be assessed in twins for USG abdomen in the 1st and 2nd trimester?
What parameters are assessed?

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33
Q

What are the general principles of managing twin pregnancy?

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34
Q

What is the timing of delivery of twins?

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35
Q

What is the mode of delivery for twins?

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Malpresentation is common in twin pregnancy: 75% of cases of Twin 1 presents by vertex
* Vaginal delivery is an appropriate mode of delivery for uncomplicated twin pregnancy with the 1st twin in cephalic presentation
* C-Section indicated when the 1st twin is non-cephalic: potential risk of vaginal breech delivery of 1st twin. Risk mainly lies in the 2nd twin in general. Possibility of locked twins though exceedingly rare but high mortality

Other indications for C-section
Emergency C/S: either twin shows signs of persistent compromise
Elective C/S:
* Placental previa
* Malpresentation
* Gross disparity in fetal size
* MCMA twins
* Higher order of multiple pregnancy

36
Q

What is the intrapartum management of twins?

A
  • Pain relief with epidural analgesics is recommended: good pain relief, does not cause neonatal depression and is a suitable anesthetic if uterine manipulation (e.g. version) or operative delivery (e.g. forceps, C/S) becomes necessary
  • Fetal monitoring: both fetus should be monitored with continuous cardiotocography (CTG), 1st twin is monitored with a fetal scalp electrode. 2nd twin is monitored with external doppler apparatus
37
Q

What is the 3rd stage management of delivering twins?

A
  • Give syntometrine
  • IV Syntocinon (oxytocin) infusion in a single bolus followed by infusion to prevent uterine atony
  • Check placenta and membranes for chorioamnionicity
38
Q

What are the types of fetal reduction in triplets or higher orders of pregnancy?
What methods?

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39
Q

What types of cephalic presentation cannot do vaginal delivery?

A
  • Brow presentation: head is moderately extended (verticomental –> 13cm engaging diameter)
  • Face presentation that is mentum posterior/mentum transverse (baby cannot bend its neck any further to fit the curvature of pelvic canal) –> can deliver vaginally if head is a mentum anterior position
40
Q

What are the 3 indications for external cephalic version?

A
  • Breech at 36 weeks
  • Stabilization induction for other malpresentation
  • Non cephalic presentation of 2nd twin

MBBS VI: O&G (109 decks)

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