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Gynae History Taking

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					THE FETUS AT RISK




        Max Brinsmead PhD FRANZCOG
                            July 2010
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
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
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
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
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
       PreviousCS
       Tumours e.g. Fibroids, Ovarian cyst

   A Large Baby
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
If there is fetal macrosomia then…
   There is a risk of intrauterine death
       Ifthe 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
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
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
       Thereare two major categories
       Symmetrical = head, trunk and body reduced
        proportionaely
       Asymmetrical = head-sparing growth restriction
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
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
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
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
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
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
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
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
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
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
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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