MFM and neonates Flashcards

1
Q

DCDA twin delivery

A

Induce 37-38 weeks aiming for vaginal birth providing the following criteria are met:
- Twins diamniotic
- Twin 1 is cephalic
- Twin 2 is not >500g bigger than twin 1
- Neither twin has any evidence of fetal
compromise requiring c-section
Twin birth study (2013) RCT of planned c-section vs vaginal delivery for twin pregnancy.
c-section delivery after 32 weeks did not significantly decrease or increase the risk of neonatal or fetal death or serious morbidity as compared with planned vaginal birth.
Cochrane review (2015) With planned vaginal delivery 30-40% risk of emergency c-section. No evidence of lower maternal or fetal morbidity having c-section. C-section for 2nd twin occurs in 10% of cases.

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2
Q

Risks with DCDA twins

A

▪ Antenatal: growth scans, anatomy scan, GTT, PET screening, vigilance re: FM, sleep on side, 28/40 bloods, anaesthetic discussion
▪ Intrapartum: MOD depending on T1, deliver ~ 37/40, IVL, CEFM, hospital, personnel at delivery, early epidural delivery of T2
▪ Postpartum: PND, breastfeeding support, VTE prophylaxis

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3
Q

Complications in MC twins

A

Twin to Twin Transfusion (TTTS) 10-15%
One twin receives more blood supply than the other due to unidirectional flow along a large arterio-venous anastomoses deep in the placenta. This leads to oligohydramnios, poor growth and abnormal umPI in the donor and polyhydramnios progressing to cardiac dysfunction and cardiac failure in recipient

Twin Anaemia Polycythaemia Syndrome (TAPS) 5%
A small arterio-venous anastomoses on the placenta leads to unidirectional blood supply from one twin to the other but this is a very slow transfusion leading to one twin becoming anaemic and the other polycythaemic.

Twin reversal arterial perfusion sequence (TRAPS) <5% Presence of a live twin and an acardiac twin. The live twin pumps blood through both twins and this leads to high out-put heart failure.

Selective IUGR 10-15%
Due to unequal sharing of placental mass leading to growth restriction in one twin. Can be contributed by marginal/velamentous cord insertion of smaller twin .

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4
Q

Management in MC twins

A

Counsel woman regarding complications related to MCDA twins
· Inform woman with written and verbal information regarding model of care for MCDA twins.
· This should include what symptoms to be aware of e.g. sudden increase in abdominal girth and SOB could indicate polyhydramnios due to TTTS. PET symptoms.

Early anatomy scan ~ 18 weeks
Aneuploidy screening is less sensitive in twin pregnancy. MC twins have a higher rate of congenital abnormalities and an increase risks of congenital heart disease so a fetal ECHO may be required

Fortnightly growth scans from 16 weeks at a centre with sufficient experience to recognise these complications Scans should include
· growth -discordance >20% suggest sIUGR
· liquor volume, bladder and stomach filling- screening for TTTS
· umbilical artery doppler

Scan for MCA PSV from 20 weeks
To look for fetal anaemia (TAPS)

Refer for obstetrician care or multiple pregnancy clinic MC twins are high risks pregnancies. Should be managed by a MDT team including senior MW and obstetricians

Prompt referral to fetal medicine if any concerns regarding twin related complications
Prompt review to allow optimal treatment before onset of severe disease e.g. laser ablation for TTTS

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5
Q

Ambiguous Genitalia
Whether we develop into a male or female gender depends on the presence of our chromosomes, hormones, and hormone receptors. Chromosomes are the genetic building blocks that make up who we are. Male gender is typically associated with XY and female XX. However we also need the presence the corresponding male or female sex hormone, and the ability of our body to process and recognise this. Ambiguous genitalia can result from a range of conditions affecting our chromosomes, our production or sex hormones, or our ability to recognise these sex hormones.

A

history:
History - drugs in pregnancy, consanguinity, or family hx of ambiguous genitalia, IUD/NND, hyperandrogenism, congenital abnormalities
Exam”
vital signs, evidence of dehydration (fontanelles), head to toe examination, genital examination looking a urethral meatus / vagina / labial folds / clitoris / gonads / phallus / groin
CAUSES:
• CAH (AR),
• 5 alpha reductase deficiency (AR - conversion testosterone to DHT),
• tumours,
• maternal hormones in pregnancy,
• androgen insensitivity syndrome (AR)
Investigations:
FBC, UEC, LFT, karyotype, SRY gene (FISH specific probes), AMH, 17 OHP, testosterone, DHEAS, androstenedione, cortisol, dihydrotestosterone, FSH, LH, USS abdomen and pelvis
MDT approach:
paediatrician, psychologist, endocrinologist, paediatric surgeon, social work.
?genetic referral

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6
Q

Echogenic bowel

A

Echogenic bowel associated with CF, perinatal infections such as CMV and toxoplasmosis, and aneuploidy, as well as rarely intrauterine bleeding, bowel malformation, fetal alcohol syndrome and mesenteric ischaemia
Refer to MFM.
Investigations:
1. Detailed USS assessment of anatomy to check for markers of aneuploidy or infection
• Usually focal and mass-like in the lower abdomen – CF and aneuploidy tend towards multifocal, whereas CMV tends to be focal.
• Assess for amniotic fluid volume
• Detailed review of growth and placenta
• Check for markers of aneuploidy – nuchal thickening, hypoplastic/absent nasal bone, major structural anomalies, intracardiac echogenic foci, shortened femur
• Check for markers of fetal infection – microcephaly, ventriculomegaly, cerebral calcification, hydrops, SGA
2. Fetal genetic assessment
• Usually recommend amniocentesis for karyotype, virology PCR and DNA analysis (CF)
• Could also do CFDNA maternal bloods (but would then need diagnostic test if +ve)
3. Maternal virology screen for toxoplasma and CMV (TORCH).
4. Parental Cystic Fibrosis Carrier Status Screening (80% detection rate)
Follow up:
• Prognosis usually good, but will depend on above assessment
• Monthly growth scans should be initiated as there is an association with IUGR and death.

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7
Q

CMV in pregnancy

A

o Transmitted in body fluids/saliva
o Self limiting flu like illness or asymptomatic in mother
o Risk of transmission for primary infection is 30 to 40% in the first and second trimesters, and 40 to 70% in the third trimester.
10% risk of long term harm.
Risks:
o Fetal risks include neurological disability, hearing loss, chorioretinitis, stillbirth, seizures, microcephaly, cerebral palsy
o Amniocentesis tells us the baby has been exposed to infection but does not predict long term effects – most babies are normal. Decisions about termination are difficult because of this.
Plan:
o Referral to MFM
o Serial growth USS
o MRI brain
o If normal USS and MRI prognosis good
o Give hygiene advice to prevent future infections

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8
Q

Neonatal CMV

A

• Thorough physical exam at birth -90% are healthy at birth and have normal development
• Encourage breastfeeding
Investigations:
o Should be done <3 weeks old
o CMV IgM
o CMV PCR (urine, saliva, blood)
o FBC, LFTs
o Also do testing in those with abnormal hearing screen without known maternal history.
• If positive
o Do an ophthalmology and radiological exam
• Head USS –> Hydrocephalus
• MRI –> intracranial calcification, atrophy, ventriculomegaly, migrational or white matter abnormalities
Asymptomatic: 3-6monthly review including hearing and neurodevelopmental assessment

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9
Q

MUTANISM for MFM

A
M- MFM referral
U - USS tertiary 
T - Torch
A - Amnio
N - Neonatal review
T - TOP consider
I - information
S - Support
M - Management specific to the condition
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10
Q

Omphalocele

A

Explain issues :
 Congenital abdominal wall defect related to base of umbilicus, abdominal viscera contained within membranous sac. Thought due to failure of midgut to return to abdomen after 10 weeks gestation

Differential:
 Amniotic band
Urachal cyst
Gastroschisis

Risks:  
 Strong association with other anomaly 
70% association with aneuploidy  
Mortality 40% 
IUGR/PTB 

Plan :
Tertiary anatomy scan esp for cardiac defects and other GI abnormalities eg malrotation, atresia, volvulus
MFM
Amniocentesis for karyotype
Support groups/condolences
Offer termination vs conservative management with ongoing growth surveiullance
Involve paeds surg, deliver at tertiary centre, NVD except where defect super large prior to delivery, CFM in labour etc.

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11
Q

Parvovirus

A

IgG + IgM positive recent infection
High risk groups: Mother’s of children, teachers amd childcare workers
Risk to fetus only if infected within the first 20 weeks
- 10% excess fetal loss
- 3% hydrops (33% resolve, 33% need IUT & 33% IUFD)
Management: USS 1 - 2 weeks intervals for 12 weeks and MCA PSV

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12
Q

Listeria

A

Found in soil and water - wash all fruit and veg
Symptoms fever, malaise, N+V and diarrohoea
Transmission highest 3rd trimester
Overall mortality 50%
Risks: PTB, neonatal meningitis and IUFD
Treat: Ampicillin and Gentamicin IV 10-14 days

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13
Q

CMV

A

Frequent close contact with children who tend to shed virus from nasal secretions and salvia
IgM + IgG positive IgG avidity low recent primary infection
Trimester 1 - adverse outcome 10%
Amnio >20 weeks/ 6 weeks post infection if -ve reassure and if positive 1:4
Fetal MRI 28 + 32 weeks
Leading cause of non genetic sensorineural hearing loss.
Also causes IUGR and hydrops

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14
Q

CMV prevention

A

Do not share food, drinks or utensils used by children < 3 years old
Do not put a child’s dummy in your mouth
Attention to hand hygiene when in touch with your young child’s bodily fluids.

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15
Q

Toxoplasmosis

A

IgM can remain +ve for months/years check antenatal serum
Low avidity more specific for recent
Amnio 18 - 20 weeks or > 4 weeks after maternal infection
1st - Risk low 5-15% infection high risk fetal damage
2nd - Risks 25-45 infection with 20-30% risk of fetal damage
3rd - risk transmission 33-70% but risk fetal damage low 5-15%
Treatpyrimethamine sulfadiazene and folinic acid if +ve PCR
4 weekly USS for fetal infection
Baby needs bloods after delivery and full examination neurological, hearing and occular examinations

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16
Q

Food safety advice listeria

A

Avoid high risk foods such as pate, deli meats and soft cheeses
Wash fruit and veg to get rid of soil
Only drink pasturised milk
Do not reheat leftovers

17
Q

A - H of food safety

A
Avoid undercooked meats and soft cheese
Buy fresh produce and meats
Cook meats and wash vegetables thoroughly
Don't kiss baby on the mouth
Excercise good hand hyigene
Forego pre-pared salads and foods
Heat until piping hot 
Toxo cat litter or feaces
18
Q

Chicken Pox

A

Infective 48 hours prior to rash and until it has crusted over ~ 5 days
Significant exposure is >1 hour in same room
Transmission:
<12 weeks <0.55%
12-28 weeks 1.4%
>28 weeks 0%
Treatment:
Aimed at reducing maternal morbidity and mortality e.g. hepatitis, encephalitis and pneumonia 4-13% mortality.
<96 hours VZIG and acyclovir
>96 hours acyclovir
Baby congenital varicella syndrome lesions can affect the skin, limbs. autonomic nervous system and growth retardation mortality is high
Neonatal VZIG if infection wihtin 7 days of delviery or 2 days after

19
Q

HSV

A

Primary >35 weeks transmission rate high 50%
Commence aciclovir 400mg QID for 7 days suppressive theraphy from 36 weeks
Delivery examine perineumand vagina for active lesions
If onne risk of transmission low <0.5%
Active lesions transmission ~3%offer c section within 4 hours

20
Q

Early onset IUGR

A
Needs uterine artery dopplers
Karyotype
NIPT/ amnio, check PAPP-A
TORCH screen, check syphilis
PET screen
Kleihauer
21
Q

Fetal thyrotoxicosis

A

without treatment mortality 25%
● MFM review, MDT management – paeds endocrine, endocrine, MFM, obs
● Consider FBS for TFTs - risk to baby with this
● Treat the mother – carbimazole + thyroxine, consider
beta blocker
● Cord blood and neonatal TFTs + continue carbomazole for a few weeks until maternal
antibodies have disappear

22
Q

Talipes

A

50% bilateral, increased in Maori and PI, confirm diagnosis only once born (10% false pos diagnosis)

Positional (uterine anomaly, oligo), syndromic, congenital

May be genetic (Fhx)

Most common congenital assoc is NTD

Good prognosis esp if isolated

Management:
MFM
-tertiary USS
-offer of amnio esp if additional abnormalities
-MDT geneticist/paed/paed ortho/midwife may be needed PN
-Need for treatment difficult to predict
-Treatment PT/cast/surgery
-Long term prognosis excellent, most walk normally

23
Q

Critical titres of blood

A

Refer >1:16
Anti-D
Anti-CD
Anti-c

Any titre
Anti-K

Refer>1:32
Most others

MFM
Check paternal blood group or cfDNA
Tertiary USS looking for hydrops 
MCA PSV
\+/- IUT
24
Q

Syphillis risk of congenital infection

A
Primary untreated 80-100%
Risk of infection 1-2% if untreated
Secondary 60%
Early latent 40%
Late 10%
Long acting penecillin very effect 98%
Low risk not adequate therefore maternal and neonatal follow up and congenital infection ruled out
Syphillis screening at booking 28 weeks and birth
25
Q

Presentation primary syphillis

A

Painless genital tract ulcers (chancre) vagina, cervix, anal skin
Flu-like illness
RPR test and TPPA both positive confirmed infection. IF one positive could be past treated or very early repeat in 2 weeks

26
Q

What to do with a +ve syphillis

A

MDT: sexual health, obs and MFM
Full STI screen
Fetal USS to look for signs of infection e.g. poly, hydrops IUGR or placentomegaly
Treat 2.4 million units IM Benzathine penecillin G
Monthly RPR titre beginning on day 1 of treatement. Looking for it to reduce >4 fold or become negative
Peads review postnatal
Vaginal birth not contraindicated
Placental histology
Breastfeeding safe as long as no lesions on the breast
Staff appropriate PPE
Continue sexual hea;th follow up repeat test at 6 weeks PP
Contact tracing
Notifiable disease

27
Q

Cervical length screening

A

Previous spontaneous preterm birth before 36 weeks
Previous second trimester loss 16-23 weeks
LLETZ depth >10mm
A CONE, trachlectomy or 2x LLETZ
A known uterine anomaly
This will take place 2 weekly from 16-24 weeks
Short cervix <25mm
If short do swabs, urine culture and start PV progesterone
Consider cerclage <15mm
Consider steroids from 22+5 d/w NICU

28
Q

Raised NT

A
NT is sonographic appearance of subcutaneous accumulation of fluid behind the fetal neck in 1st trimester
Cut off 3.5mm
Differentials if rasied:
T21 or T18
Cardiovascular defects 
Structural defects e.g. omphalocele, diaphragmatic hernia 
Congenital infection
Metabolic and heamatological disorders
Syndromes CAH or Noonan
If normal karyoptype ~70% will be normal
Management:
- Early anatomy at 16 weeks
- CVS or amnio for karyotype 
- Fetal echo
- Virology screen 
- Serial growth scans
29
Q

Cleft lip or palate

A
0.15% of all live births 
80% have both
Can be associated with T13/T18
Unilateral 10%
Management:
- Detailed anatomy 
- Amnio 
- MDT plastics ENT, dentist, SALT
- Repair lip 2-3 months and palate 9-18 months
- May cause issues feeding
30
Q

Congenital diaphragmatic hernia

A

1-4:10,000
Abdominal content herniate into the chest. Can be corrected surgically after delivery.
Can cause pulmonary hypoplasia and pulmonary hypertension
Chromosomal anomalies in 10-20% of acses
Can be a/w cardiac defects, poly and hydrops
Postnatal may have chronic lung disease persistent pulmonary hypertension, GORD, feeding issues or thoracic abnormalities
Delivery by 40 weeks not an indication for c-section

31
Q

Echogenic bowel

A

Prevalence 1% in 2nd trimester
Fetal bowel with homogenous areas of echogenicity equal or greater than surrounding bone
Benign condition vast majority of fetuses are normal and no evidence of long term bowel problems
35% underlying pathology:
- Aneuploidy T21, 13+18
- CF
- Intra-amniotic bleeding
- Malformations of bowel e.g. Hirschsprung’s
- Infection CMV, Toxoplasmosis
- Fetal alcohol syndrome
Management:
- Amnio
- Virology screen
- Paternal CF carrier screening status
- Monthly growth scans as at risk of IUGR
- Monitor movements as increased risk of IUFD

32
Q

Gastroschisis

A

Full thickness anterior abdominal wall defect with bowel protruding not covered by membrane
Survival rate 90%
Risks factors: young age, smoking and use of vasoactive drugs
Management:
Refer to MFM and Peads surg
No amnio if isolated defect
4 weekly USS from diagnosis till 32 weeks
Weekly surveillance 32-37 weeks
Consider elective delivery 37-38 weeks