Transcript Gynae History Taking
INTRAUTERINE GROWTH RESTRICTION
Max Brinsmead MB BS PhD August 2014
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
When the uterus is 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 SFD you also need to know DATES accurately…
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 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
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
Asymmetrical Growth Restriction
Occurs because the hypoxic baby will redistribute its cardiac output
From glycogen storage (liver size)
From the kidneys (oligohydramnios)
From the trunk and limbs
From the bowel (meconium)
And it does this to maintain blood flow to the head, brain and heart
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
Diagnosis of IUGR
Only 30 – 50% will be detected by measuring SFH Serial measures more valuable than a single one We need to have a high index of suspicion in a fetus at risk Hypertensive disorders Recurrent APH Poor obstetric history Multiple pregnancy And use ultrasound selectively to confirm or exclude the diagnosis
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
Umbilical Artery Doppler Study
Upper panel represents peak (systolic) and trough (diastolic) flow often expressed as S/D ratio Lower panel is constant flow through a uterine vein UA Doppler reflects downstream placental resistance Is the 1 st change to occur with placental disease
Umbilical Artery Doppler changes with Gestation
Abnormal UA Doppler Flows
When flow ceases in the diastolic phase (AEDF) the S/D ratio is very high ( ∞) Flow may even reverse in the diastolic phase (RDF) as shown opposite
Uterine Artery Dopplers…
▪ ▪ ▪
Are of limited use when…
▪ ▪ ▪ The fetus is very premature (<30 weeks) Pregnancy is prolonged (>40 weeks) It is a low risk pregnancy ▪ 5% will be high but normal
Are useful in High Risk Pregnancies
▪
May be used to prolong pregnancy with immature fetus and apparent IUGR
Have a high negative predictive value for fetal death
Will change 4 – 7 days before other changes in
fetal wellbeing e.g. Biophysical Profile
Other Pregnancy Doppler Studies
Fetal Middle Cerebral Artery
Resistance falls as brain-sparing IUGR begins Strong correlation with fetal HB Of particular use in monitoring intrauterine haemolysis
Fetal Ductus Venosus
Resistance rises as the placenta deteriorates
Maternal Uterine Arteries
Increased resistance with bilateral notching at 12 – 24w predicts early (but not late) onset pre eclampsia with ≈ 60% sensitivity
Uterine Artery Doppler
Fetal Biophysical Profile
Ultrasound for…
Fetal Breathing Fetal Movements Fetal Tone Amniotic Fluid Volume
Non Stress CTG
Looking at fetal heart short term variability and accelerations
Assigns a score of 0,1,2 to each of these five measures as with the Apgar Score
Scores ≤ 6 are abnormal
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