MFM

Question 1

CRITO: hydrops

Answer 1

Condition: excess fluid in 2 or more compartments; includes polyhydramnios and placentomegaly.

DDx (CAUSTIC):

• Chromosomal
• Anaemia (HDFN, feto-maternal haemorrhage), Parvo, alpha thalassaemia)
• Unknown
• Structural (thoracic, other organs)
• Twins
• Infections
• Cardiac (arrhythmia, fx, structural)

Risks:

• Maternal: mirror syndrome/PET
• Fetal: fetal loss, PTB, neurological injury.

Investigations:

• Referral to MFM
• Tertiary scan and fetal ECHO
  
  • MCA-PSV
• Maternal blood group/antibody screen
• Maternal TORCH screen
• Maternal FBC/haemoglobinopathy screen
• Kleihauer
• Amnio: TORCH PCR, karyotype, microarray +/- cordocentesis FBC

Treatment:

• Option of TOP
• Treat reversible causes.

Ongoing management:

• Option of neonatal palliation
• Option of active management: steroids, CTG/BPP, delivery at tertiary unit.
• Aim delivery 36-37 weeks.

Question 2

Increased nuchal translucency

Answer 2

Explanation of increased NT: accumulation of fluid behind the fetal neck in the first trimester. In the second trimester this is called a cystic hygroma.

Normal NT <3.5mm

Risk:

• NT >3.5 mm adverse outcome 30-80%
• Isolated increased NT <3.5mm with normal karyotype: 90% normal
• Fetal: miscarriage, perinatal death

DDx:

• Chromosomal esp T21/18
• Cardiac failure
• Venous congestion
• Altered ECM
• Abnormal lymphatics
• Infection
• Anaemia

Investigations:

• MSS-1 bloods.
• If high risk combined first trimester screen:
  
  • Refer to MFM for IPT.
  • Early anatomy scan 16/40 if CVS performed
  • Tertiary anatomy scan + ECHO 20/40
  • TORCH screen
• Normal karyotype and no anomalies seen: serial growth scans in 3rd trimester

Question 3

Omphalocoele CRITO

Answer 3

• Condition: congenital midline abdominal wall defect at the umbilicus allowing the baby’s internal organs to protrude out into the amniotic sac but is contained by a membranous sac and the umbilical cord inserts at the apex of the sac.
• Risks: IUGR, PTB, SB and NND (40%).
  
  • Association with aneuploidy and other structural abnormalities
• Investigations:
  
  • DDx: gastroschisis, urachal cyst, amniotic band.
  • Tertiary anatomy scan
  • Fetal ECHO.
  • Amniocentesis for karyotype and microarray.
• Treatment:
  
  • Referral to MFM and paediatric MDM.
  • Paediatric surgeon consultation.
  • Option for TOP.
  • Serial USS and review.
• Ongoing management:
  
  • Delivery in hospital with paediatric surgeons.
  • Consider IOL at 39 weeks.
  • CEFM
  • May need CS if very large defect.
  • Wrap omphalocoele in plastic at delivery; early NGT and IVL.
  • Surgery to repair (one or multi-stage.

Question 4

Gastroschisis CRITO

Answer 4

• Conditions: paraumbilical abdominal wall defect allowing the bowel and abdominal organs to protrude out fo the abdomen.
• Risks: IUGR, PTB, SB.
  
  • NOT associated with aneuploidy.
• Investigations:
  
  • Tertiary anatomy scan.
  • Serum aFP raised
• Treatment:
  
  • Referral to MFM.
  • Paediatric surgeon consultation
• Ongoing management:
  
  • Serial growth USS.
  • Consider IOL by 37-38 weeks.
  • Delivery in a hospital with paediatric surgical services.