Transcript Gynae History Taking

THE FETUS AT RISK
Max Brinsmead MB BS PhD
May 2015
The fetus is unique because...
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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
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When the uterus is LFD or SFD you first need to know…
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What is normal
SFH = Weeks of gestation is valid only between 20
and 32 weeks
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Thereafter the mean runs off to 37 cm at 40 weeks
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This should be validated in each population
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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…
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Menstrual history is unreliable when…
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The patient is uncertain
She has a good reason to tell lies
Cycles are irregular
Ovulation was delayed >14 days by
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Quickening is unreliable when…
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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
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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
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Miscarriage
Breast feeding
Hormonal contraception
Ultrasound is unreliable when…
If the uterus is LFD think of…
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Wrong dates
Hydatidiform mole
Multiple pregnancy
 Many
small parts
 Three poles
 Lots of fluid and difficult to feel the baby
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Polyhydramnios
Uterus lifted up by
 Previous
CS
 Tumours e.g. Fibroids, Ovarian cyst
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A Large Baby
If the uterus is LFD then…
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Ultrasound is useful because it readily diagnoses:
 Hydatidiform
mole
 Multiple pregnancy
 Polyhydramnios
 Fibroids and tumours
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But ultrasound is poor at:
 Diagnosing
fetal abnormalities
 Estimating fetal weight
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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…
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There is a risk of intrauterine death
 If
the mother is diabetic
 And it is poorly controlled
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There may be birth difficulties
 Cephalopelvic
disproportion
 Shoulder dystocia
 Maternal birth injury and PPH
 Vaginal breech birth may not be wise
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There may be neonatal problems
 From
hypoglycaemia
 From birth injuries
Management of suspected fetal macrosomia…
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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…
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Wrong dates
Oligohydramnios
 Premature
rupture of membranes
 Abnormality of the fetal renal tract
 Intrauterine growth retardation (IUGR)
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Intra uterine growth retardation
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are two major categories
 Symmetrical = head, trunk and body reduced
proportionaely
 Asymmetrical = head-sparing growth restriction
Causes of Symmetrical IUGR
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Constitutional smallness
 Consider
maternal size
 Ethnic origin
 Paternal influence less important
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Fetal Infections
 TORCH
= Toxoplasmosis, Other, Rubella, Cytomegalovirus
and Herpes
 Remember Syphilis, HIV and Malaria
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Fetal Abnormalities
 Especially
13&16
chromosomal abnormalities such as Trisomy 21,
Causes of Asymmetrical IUGR
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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…
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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
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Accurate diagnosis
Is the baby salvageable?
 Mother at risk?
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Steps that improve M-U-P-Fetal transfer of oxygen
and nutrients
Stop maternal smoking
 Bed rest
 Correct anaemia
 Improve nutrition
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Monitor fetal growth and well being
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There is little point in ultrasound at less than 2w intervals
Timely delivery
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Must weigh up the risks of induced delivery against the risk of
remaining in utero
Born too Early
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Premature delivery a major cause of perinatal loss
Delivery before 30w almost 100% fatal without
neonatal intensive care
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You cannot diagnose threatened preterm delivery
unless you know the dates
And diagnosis of labour is difficult
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Also known as neonatal expensive care
It is a diagnosis in retrospect
To diagnose labour you need to document uterine
contractions and find cervical change
Causes of Premature Labour
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Overdistension of the uterus
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Polyhydramnios
Twins
Premature rupture of membranes
Genital tract infection
Antepartum haemorrhage
Cervical incompetence
Maternal diseases like preeclampsia
An idiopathic group
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Studies of the mechanism of birth in humans suggest that the
fetus and or its placenta determine when labour starts
Management of Premature Labour
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Is the mother OK?
Is the baby better off in or out?
There is a role for tocolysis
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Administration of high dose corticosteroids to the
mother significantly improves neonatal survival
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Drugs that relax the uterus
Although studies do not confirm significant prolongation of
pregnancy
Betamethasone chronodose
And the few hours bought by tocolysis may allow in
utero transfer to a place of optimal birth
In Utero too Long
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Epidemiological studies show that perinatal mortality
begins to rise post term
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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…
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Beyond 42w completed gestation from LMP
May be earlier in some ethnic/racial groups
But the vast majority of babies (>99%) are still okay
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”
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Breech presentation occurs in 4% women at term
Perinatal mortality is increased 3 – 4 fold
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It is desirable to identify breech babies after 36w
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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
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)
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Transverse lie occurs in 1-2% women at term
First ask why is the baby lying transverse or
oblique
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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
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If there is a history of previous stillbirth or neonatal
death
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The Previously Infertile Mother
The Poor Obstetric Performer
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Previous pre term delivery
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The recurrence risk is 30% after one
And 60% after two
Previous low birth weight babies
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Is there a recurrent cause?
Deal with maternal anxiety
The precious baby
Risk of meconium and SGA again
The Fetus who is one of Twins (or more)
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