fetal growth and well-being. dating scan sac from5wks fetal pole6wks fetal heart7 wks limb buds8 wks...
TRANSCRIPT
Fetal growth and well-being
DATING SCAN
SAC FROM 5WKS
FETAL POLE 6WKS
FETAL HEART 7 WKS
LIMB BUDS 8 WKS
HEAD 12WKS
NT 11 TO 14 WKS
FULL ANOMALY 18-20 WKS
BPDHCFACFEMUR LENGTH
CROWN RUMPLENGTH
ANOMALIES – ULTRASOUND 18 TO 20 WEEKS
Spina BifidaAnencephalyCardiacRenalDiaphragmatic hernialimbs FacialChromosomal
Late > 20/40
RenalMicrocephalyHydrocephalusUreteral valves
aFP
ULTRASOUND GUIDANCE
AMNIOCENTESIS, L/S RATIO
CVS
CORDOCENTESIS, TRANSFUSION
PARACENTESIS
SHUNTS bladder, asciteskidney, head
LIVER BIOPSY, SKIN
FETAL REDUCTION
OTHER OBSTET
Estimated fetal weight
Twins discordance
Behavioural states ( B.P.S. )
Presentation
Placenta ( previa, RPC’S)
DEFINITION OF I.U.G.R
Less than 2500 grams
SGA vs AGA
Less than 5 centile for GA
Approx. 4 - 7 % of all infants are IUGR
Appropriate screening tests in an early,
uncomplicated pregnancy include all of
the following except:
a) repeat human chorionic gonadotropin
b) hemoglobin
c) syphillis serology
d) cervical cytology
e) blood type and Rh factor
CAUSES OF I.U.G.R
MATERNAL FACTORS
• Malnutrition• Drugs• Substance Abuse• Diseases• Infections
CAUSES OF I.U.G.R
FETAL CAUSES
- Chromosomal Abnor mality
- Congenital Abnor mality
- Multiple Gestation
- Congenital Infection
CAUSES OF I.U.G.R
PLACENTAL FACTORS
Placental Perfusion
Placental Abnormalities
- Abnormal Cord Insertion- Abruption- Circumvallate placentation- Placental Memangioma- Placental Infection- Twin to Twin Transfusion
CAUSES OF FETAL OVERGROWTH
Maternal Diabetes
Maternal Obesity
Excessive Maternal Weight Gain
IMMEDIATE NEONATAL MORBIDITY IN IUGR
Birth asphyxiaMeconium aspirationHypoglycemiaHypocalcemiaHypothermiaPolycythemia, hyperviscosityThrombocytopeniaPulmonary hemorrhageMalformationsSepsis
CLINICAL TESTSFundal heightMaternal weightFetal Kicks
BIOCHEMICAL TESTSaFPHPLoestriolcrf
CARDIOTOCOGRAPHYStress testsNon stress tests
ULTRASOUNDGrowth parametersFetal weightAmniotic fluid volumeBiophysical profile score
DOPPLER
FUNDAL HEIGHTS - F HEIGHT IN cms + 2 = no of weeks
Sensitivity 60 %
Use of S - F charts
MATERNAL WEIGHTwks gain
0 - 20 4 kg21 - 28 4 kg29 - 40 4 kg Average 12 kg
Not very reliable guideBig mother
BIOPHYSICAL PROFILECTG 0 - 2MOVEMENTTONELIQUOR VOLUMEBREATHING
MAX. 10
DOPPLERWhat is it?Uteroplacental waveformsUmbilical arteryCarotid arteryDescending aorta
FETAL ACTIVITY
Cardiff “count to ten “ chart
towards term
10 movements in 12 hours
Randomized study
CARDIOTOCOGRAPHYMaybe as good as BPP
Non - stress movement
uterine activity
Stress testsSyntocinon infusion
nipple stimulation
Features of the normal CTG
rate 120 - 160BTB variation 5 - 15Accelerations presentNo decelerations
The perinatal mortality rate is defined as :
a) the number of neonatal deaths that occurper 1000 live births
b) the number of still births that occur per1000 births
c) the number of fetal deaths within the firstweek after birth
d) the number of still births and neonataldeaths per 1000 live births
WHY FETAL ASSESSMENT ?1. To prevent damage (asphyxia)
2. To deter unnecessary intervention ( prematurityoperative deliveries )
WHICH FETUSES SHOULD BE ASSESSEDALL FETUSES ?
small for gestational : age v postdates
maternal hypertension, Diabetes
antepartum hemorrhage
FM’ s etc.....
The “high risk” pregnancy
WHAT IS TEST LOOKING FOR ?
FETAL HYPOXIA BEFORE ASPHYXIA
PLACENTAL FAILURE
Poor growth
movmt, liquor
Poor CTG
The essential characteristics of asphyxia (hypoxic acidemia) are:
• umbilical cord arterial pH < 7.0
• base deficit > 16
• Apgar score 0 – 3 for > 5 minutes
• neonatal neurologic sequelae (e.g.,seizures, hypotnia, coma)
• evidence of multiorgan system dysfunction in the immediate
neonatal period.
FETAL HEART RATE IN LABOUR
Baseline 120 - 160 b.p.m
Variability > 5 b.p.m
Accelerations present
DECELERATIONS EARLYVARIABLELATE
pH sampling normal > 7.25borderline 7.25 - 7.2deliver < 7.2
NORMAL TRACE
Early decels
Early decelerations
Late decelerations
Variable decals
Reduced variability
Tachycardia
Percentage distribution of acidity states in different groups of cardio-tocographical findings according to the HAMMACHER score.
Effect on: Odds Ratio (95% CI)Treatment: Control
All caesarean sectionsCaesareans for fetal distressCaesareans for failure to progressOperative vaginal deliveriesApgar score <7 at one minuteApgar score <4 at one minuteAdmission to special care nurseryNeonatal seizuresAll perinatal deathsIntrapartum deathsAll operative deliveriesGeneral anaesthesiaCerebral palsyCerebral palsy after neonatal seizureLow Bayley mental development indexLow Bayley psychomotor index
1 2 4 100.1 0.3 0.5
EFM + scalp sampling vs intermittent auscultation in labour (6 trials reviewed)
Treatment better Treatment worse
..
...
.
AN IDEAL TEST ?
1. A simple screening test performed in early pregnancy to see whether or not a risk exists.
2. Low rate of false positives and false negatives
3. Cheap
4. Safe
5. Painless
6. Not anxiety inducing for mom
7. Fully assessed
OTHER TESTS
CORDOCENTESIS
FETAL ECG
INFRA RED
CONTINUOUS pH
ARE TESTS ANY USE ?
Need randomized trials but poor oucomes are infrequent
Usually a normal test will result in a favourable outcome
Characteristics or associated findings with latedecelerations include all of the following except:
a) they may be seen in patients with pre-eclampsia
b) they may be associated with respiratory alkalosis
c) they are associated with a decreased uteroplacental blood flow
d) they often are accompanied by decreased PO2
e) they usually are accompanied by an increased PCO2