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THE FETUS AT RISK Max Brinsmead PhD FRANZCOG July 2010.

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Presentation on theme: "THE FETUS AT RISK Max Brinsmead PhD FRANZCOG July 2010."— Presentation transcript:

1 THE FETUS AT RISK Max Brinsmead PhD FRANZCOG July 2010

2 The fetus is unique because...  He or she cannot signal his or health by way of any history  And we can only examine through his or her mother  We can only...  Document size and growth  Evaluate his or her movements  Listen to his or her heart  Evaluate the fluid around him or her  Assess his or her reaction to stimuli

3 This talk will concentrate on fetal problems unrelated to any obvious maternal disease  Too big  Too small  Born too early  In utero for too long  “Not lying straight”  Poor relatives

4 When the uterus is LFD or SFD you first need to know…  What is normal  SFH = Weeks of gestation is valid only between 20 and 32 weeks  Thereafter the mean runs off to 37 cm at 40 weeks  This should be validated in each population  And the 95% confidence limits are not less than +/- 3 cm

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6 When the uterus is LFD or SFD you also need to know DATES accurately…  Menstrual history is unreliable when… ▪ The patient is uncertain ▪ She has a good reason to tell lies ▪ Cycles are irregular ▪ Ovulation was delayed >14 days by ▪ Miscarriage ▪ Breast feeding ▪ Hormonal contraception  Quickening is unreliable when… ▪ The patient is uncertain ▪ The placenta is on the anterior uterine wall ▪ The patient is obese ▪ There is something wrong with the fetus or fluid  Ultrasound is unreliable when…  It is done by a non expert or with poor equipment  It is done late in pregnancy  There is something wrong with the fetus e.g. microcephaly

7 If the uterus is LFD think of…  Wrong dates  Hydatidiform mole  Multiple pregnancy Many small parts Three poles Lots of fluid and difficult to feel the baby  Polyhydramnios  Uterus lifted up by Previous CS Tumours e.g. Fibroids, Ovarian cyst  A Large Baby

8 If the uterus is LFD then…  Ultrasound is useful because it readily diagnoses: Hydatidiform mole Multiple pregnancy Polyhydramnios Fibroids and tumours  But ultrasound is poor at: Diagnosing fetal abnormalities Estimating fetal weight  If there is a large baby: Check for maternal diabetes But macrosomia more commonly due to maternal obesity +/- Excessive weight gain in pregnancy

9 If there is fetal macrosomia then…  There is a risk of intrauterine death If the mother is diabetic And it is poorly controlled  There may be birth difficulties Cephalopelvic disproportion Shoulder dystocia Maternal birth injury and PPH Vaginal breech birth may not be wise  There may be neonatal problems From hypoglycaemia From birth injuries

10 Management of suspected fetal macrosomia…  Exclude maternal diabetes or…  Control maternal blood sugars before and during birth if diabetic  Refer to a place where expert assistance is available  Consider induction of labour but only when it is safe to do so  Watch progress in labour and prepare for complications  Have someone expert stand by for the delivery

11 If the uterus is SFD think of…  Wrong dates  Oligohydramnios Premature rupture of membranes Abnormality of the fetal renal tract Intrauterine growth retardation (IUGR)  Intra uterine growth retardation There are two major categories Symmetrical = head, trunk and body reduced proportionaely Asymmetrical = head-sparing growth restriction

12 Causes of Symmetrical IUGR  Constitutional smallness Consider maternal size Ethnic origin Paternal influence less important  Fetal Infections TORCH = Toxoplasmosis, Other, Rubella, Cytomegalovirus and Herpes Remember Syphilis, HIV and Malaria  Fetal Abnormalities Especially chromosomal abnormalities such as Trisomy 21, 13&16

13 Causes of Asymmetrical IUGR  Anything that reduces Maternal-Uterine-Placental to Fetus transfer of oxygen and nutrients Maternal smoking and malnutrition Severe maternal anaemia Chronic maternal disease Maternal hypertension especially pre eclampsia Uterine malformations Some placental diseases Maternal thrombophilias congenital or acquired Recurrent antepartum haemorrhage An idiopathic group

14 A SFD uterus is more serious when…  The mother was underweight to begin with  She has not gained weight appropriately  There is a past history of IUGR or pregnancy loss  A condition known to be associated with IUGR is also diagnosed Pre eclampsia Recurrent APH Chronic maternal disease or anaemia

15 Management of the SFD baby  Accurate diagnosis Is the baby salvageable? Mother at risk?  Steps that improve M-U-P-Fetal transfer of oxygen and nutrients Stop maternal smoking Bed rest Correct anaemia Improve nutrition  Monitor fetal growth and well being There is little point in ultrasound at less than 2w intervals  Timely delivery Must weigh up the risks of induced delivery against the risk of remaining in utero

16 Born too Early  Premature delivery a major cause of perinatal loss  Delivery before 30w almost 100% fatal without neonatal intensive care  Also known as neonatal expensive care  You cannot diagnose threatened preterm delivery unless you know the dates  And diagnosis of labour is difficult  It is a diagnosis in retrospect  To diagnose labour you need to document uterine contractions and find cervical change

17 Causes of Premature Labour  Overdistension of the uterus  Polyhydramnios  Twins  Premature rupture of membranes  Genital tract infection  Antepartum haemorrhage  Cervical incompetence  Maternal diseases like preeclampsia  An idiopathic group  Studies of the mechanism of birth in humans suggest that the fetus and or its placenta determine when labour starts

18 Management of Premature Labour  Is the mother OK?  Is the baby better off in or out?  There is a role for tocolysis  Drugs that relax the uterus  Although studies do not confirm significant prolongation of pregnancy  Administration of high dose corticosteroids to the mother significantly improves neonatal survival  Dexamethasone 6mg Q12H for 2 days  And the few hours bought by tocolysis may allow in utero transfer to a place of optimal birth

19 In Utero too Long  Epidemiological studies show that perinatal mortality begins to rise post term  Beyond 42w completed gestation from LMP  May be earlier in some ethnic/racial groups  But the vast majority of babies (>99%) are still okay  So you need to induce labour in some 450 women to save one baby  We need to identify the fetus at risk. He or she will…  Be not growing well  Not moving well  Surrounded by little fluid (oligohydramnios)  In utero in an unhealthy mother  Weigh up the risks of induction of labour  And always check the dates

20 Babies that do not “Lie Straight”  Breech presentation occurs in 4% women at term  Perinatal mortality is increased 3 – 4 fold  The largest part of the baby is coming last  Risk of hypoxia and trauma is increased  But risk of death or damage from congenital causes are also increased  And 96% of babies born by the breech will be ok  It is desirable to identify breech babies after 36w  Check the dates!  External cephalic version (ECV) shown in RCT’s to reduce the need for Caesarean birth  Consider the need for Caesarean birth

21 Babies that do not “Lie Straight” (2)  Transverse lie occurs in 1-2% women at term  First ask why is the baby lying transverse or oblique  Wrong dates  Placenta previa  Twins or polyhydramnios  Tumour occupying the pelvis  There is a risk of cord prolapse and labour obstruction  So admit to hospital at 37 – 38w and observe  Most will be okay when labour starts  Consider a stabilising induction of labour

22 Babies with Poor Relatives  If there is a history of previous stillbirth or neonatal death  Is there a recurrent cause?  Deal with maternal anxiety  The precious baby  The Previously Infertile Mother  The Poor Obstetric Performer  Previous pre term delivery  The recurrence risk is 30% after one  And 60% after two  Previous low birth weight babies  Risk of meconium and SGA again  The Fetus who is one of Twins (or more)


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