1
Q
What mode of birth is recommended for planned preterm delivery of breech fetus >25 weeks?
A
caesarean
2
Q
With preterm delivery of breech baby 22+0 -24+6 what mode of birth is safest?
A
no clear benefit to caesarean section, usually nenonatal oucome is determined by other factors, no CS not routinely recommended
3
Q
When should ECV be offered in multips?
A
from 37 weeks - as higher chance of spontaneous version (compared to 36 weeks in nullips)
4
Q
What are the absolute contraindications to ECV?
A
CS needed for another reason, rhesus isoimmunisation, PPROM, APH in lat 7 days, abnormal CTG, multiple pregnancy
5
Q
What are the relative CI to ECV?
A
IUGR, PET, oligohydramanios, major fetal anomalies, uterine anomalies.
6
Q
What is the maximum attempts and time frame for ECV atempt?
A
4 attempts, 10 minutes total
7
Q
What are the prognostic factors which make ECV less likley to work?
A
nulliparous, engaged rumb, extended breech, anterior placenta, oligohydramnios, BMI >30
8
Q
What are the complications of ECV?
A
1/200 will need emergency CS - abruption, cord prolapse, acute fetal compromised
4.3% mild complications - ROM, small APH, transient CTG abnormality
3% will revert back to breech
slightly increased risk of instrumental or CS in labour
9
Q
What are the contraindications to breech vaginal birth?
A
SGA <10%
macrosomia >3.8kg
hyperextension of fetal neck on USS
cord presentation
non extended or flexed position
fetal compromise
fetal anomaly incompatible with vaginal delivery
10
Q
When is augmentation or IOL of breech recommended? why?
A
never
normal progress may be the best marker of adequate fetopelvic proportions
11
Q
When should breech be visible on perineum in second stage of labour?
A
2 hours. if not, recommend CS
12
Q
When should you offer intervention to expedite breech vaginal delivery in 2nd stage?
A
poor fetal tone
delay of >5 minutes between delivery of buttocks and head
Delay of >3 minutes between delivery of umbilicus and head
13
Q
what are the assisted techniques for breech vaginal birth?
A
keep spine anterior, avoid traction
when scapulae visible deliver arms by hooking elbows down or lovsets maneuvre
delivery achieved with forceps, SP pressure for flexion or Mauriceau-Smellie-Viet
14
Q
Describe Mauriceau-Smellie-Viet?
A
baby’s body resting on your forearm
one hand reaches into vagina and one finger on each cheek bone to flex head
other hand on the babys shoulder.
additional person give suprapubic pressure
15
Q
What is lovsets maneuvre?
A
rotating the baby’s body 90-180 degrees to bring anterior shoulde rorut from pubic bone
16
Q
What is the risk of head entrapment in 24-27 week breech vaginal birth?
how should it be managed
A
9%, incision on cervix at 2,and 10 oclock, consider 6 if needed
consider tocolysis
17
Q
If suspected breech presentation antenatally in late T3 what should be done?
A
a form USS to assess position, growth, LV cause for breech eg fetal anomaly or placenta praevia, or maternal finding. hyper extension of the next or fetal cord
18
Q
What percentage of babies will be breech beyond 37 weeks?
A
3-4%
19
Q
How many breech CS are needed to be performed to avoid one fetal death?
A
175
20
Q
What is the mortality in planned breech vaginal birth vs planned CS found in the 2016 MA?
A
1 in 333 vs 1 in 2000
21
Q
What medications should be considered with ECV?
A
anti D
tocolysis
22
Q
Do you need to fast or have IVL in for ECV?
A
no as risk of emergency CS is less than those in labour
23
Q
Why should you offer elective CS prior to 40 weeks for breech?
A
Breech is a significant risk factor of IUFD
24
Q
What infrastructure must be available for planned breech vaginal birth?
A
CTG
skilled staff - obs, anaesthetics, paeds resus, including for shift change over
access to immediate CS
25
When do the chorion and amnion fuse?
14 weeks
The two membranes that form the amniotic sac
26
What needs to be done prior to 14 weeks in MC twins on USS?
confirm chorionicitiy, check CRL, early anatomy
27
When should ultrasound monitoring for TTTS start?
16 weeks, fortnightly
28
When should you start doing UAPI and MCA dopplers?
20 weeks but can be earlier if concerns about abnormalities
29
What is the treatment for TTTS?
- laser ablation - organise as early as possible as to allow treatment prior to severe disease or cervical shortening.
- selective feticide
- TOP
- mild disease or late disease >26 weeks, may be possible to treat with serial amnioreduction or expectant management +/- preterm delivery
- cord ligation if one twin has an anomaly
30
What are the complications unique to MC twin pregnancies?
TTTS - 15% MCDA twins pregnancies
Selective IUGR - unequal placental sharing or velamentous cord
death of one twin
TRAPS - twin reversal arterial perfusion sequence
31
What symptoms do you warn parents to look for for TTTS?
rapidly increasing abdominal girth and SOB (poly)
32
What information should be provided to parents with MC twins about aneuploidy screening?
For aneuploidy have a lower detection rate in twin pregnancies than in singletons
NIPT can be useful, sensitivity for T21 99% and 85% for T18
Most study data is from DCDA twins so unclear if detection is different
33
What can be early signs that increase the risk of TTTS later?
disconcordant CRL or NT
34
What are the two forms that TTTS can take?
TOPS - twin oligo/polyhydramnios sequence
TAPS - twin anaemia/polycythaemia sequence
35
When is TOPS usually seen? and how frequently?
in the mid-trimesters, 10% of MC twins pregnancies
36
What are the signs of TOPS you would see on USS?
donor twin - oligo, abnormal UAPI, poor growth
recipient twin - polyhydramnios progressing to cardiac dysfunction then failure
37
What is TAPS?
A very slow transfusion of blood between a A_V anastamoses <1mm from the donor twin to the recipient twin 5-15ml/24 hours.
38
what do you see on USS in TAPS?
significant disconcordance in MCA PSV. one >1.5Mom and one <1.0
You do not see differences in LV or cardiac dysfunction.
Usually presents later in pregnancy or at birth it is noted that there is an Hb discrepancy >80g/L
This is the reason MCA PSV should be done with fortnightly scans from 20 weels
39
What proportion of MC twins have TAPS?
2% of MC twins
13% of twins that undergo laser therapy for TTTS
40
What is the definition of selective growth restriction for MC twins? what is it's prevalence?
one twin <10% and a >25% discrepancy between the twins.
occurs 10-15% of MC twins
41
When is selective growth restriction of one twin usually diagnosed?
Typically 20-24 weeks for Type II or III
42
What are the types of selective growth restriction for MC twins?
Type I - forward flow in UAPI
Type II - absence or reversal of forward flow UAPI
Type III - cyclical reversal AND absence of UAPI
43
What can occur in the event of the death of one twin in MC pregnancies?
you can get neurological disability or death of surviving twin. You get agonal hypotension in the surviving twin either from the blood vulme being transfused into the body of the dead twin or from thromboplastin release from the dead twin into the shared circulation
Laser ablation can help to reduce this risk
can also get renal lesions.
44
What should you do if one twin dies?
delivery will not improve the neurologic outcome of the surgviing twin unless there is CTG abnormalities or significant fetal anemia.
do fetal brain MRI after 4 weeks to check extent of damage. monitor MCA PSV and transfuse if anemic.
45
What is TRAP sequence in MC pregnancies?
twin reversed arterial perfusion sequence. One twin is structually normal 'pump twin' and one is 'acardiac' eg just lower limbs or
can occur when death of one twin occurs in T1.
you can get the surviving twin continuing to perfuse the other twin body via large placenta A-A anastamosis and candevelop cardiac failure
46
When and how should you deliver MCDA twins?
by 37+0 and can have vaginal birth if otherwise safe
47
What is assessed on USS for MC twins each scan
fetal biometry
bladder filling
from 20 weeks or if signs of TTTS UAPI, MCA PSV
48
What are the quintero stages of TTTS?
Stage 1 - <20 weeks twin 1 DVP <2cm and twin 2 >8cm
>20 weeks Twin 2 DVP >10cm
Stage 2 absent bladder with oligohydrmanios one twin
stage 3 critically abnormal doppler (R or absent EDF)
Stage 4 hydrops
49
What USS finding shows DCDA twins pregnancy?
lamda sign from the placenta tissue extending into the inter twin membrane
50
What USS finding shows MCDA twins pregnancy?
Tau sign
51
Why is oral low dose miso preferred way of prostaglandin IOL?
in terms of hyperstimulation, time to delivery, rate of vaginal delivery and costs, in comparisons to other methods
52
What is the advised time frame after PG prior to starting oxytocin?
4-6 hours
53
What should be taken into account for IUFD IOL?
gestation, use of mife, previous CS. Shouldn't use if previous CS and >28 weeks
54
What is the rate of uterine rupture if previous CS and use of miso?
1.4-2.45%
55
What are ways to reduce pregnancy>42 weeks?
accurate dating
membrane sweeps
IOL from 41 weeks
56
If a woman is declining IOL after 42 weeks what should you advise her about monitoring?
- only tells us how this baby is doing right now so may help them decide about options for birth, but cannot predict what will happen after the monitoring ends.
- cannot predict adervse events on the baby and when these might occur. Can't be prevented with monitoring
- suggest twice weekly CTG and DVP
57
What is the cut-off for ARM and oxytocin with bishops score
If over 6
58
What are the three reasons that breech CS has a lower mortality rate than vaginal birth?
1. still birth is reduced after 39 weeks
2. you avoid the intrapartum risks
3. The risks of breech vaginal birth
59
What are the risks of perinatal mortality with breech CS, breech vaginal birth and cephalic vainal birth?
breech CS 0.5/1000
breech vaginal 2/1000
cphalic vaginal 1/1000
60
What are the risks of breech vgainal birth?
increased risk in short term risks such as low apgars and serious short term complications but thereis no nicreaased on risk of long term morbidity.
61
What is the risk of emergency breech CS in labour for planned breech birth?
40%
62
GTG recomend that augmentation of a breech vaginal birth could be considered in one situation what is it?
UA has slowed in context of an epidural
63
What should be done in a woman presents in labour with breech?
if circumstances permit should attempt visualising fetal legs, neck, estimating weight
64
What should women be advised about:
epidural in breech vaginal birth
CTG in breech vaginal birth?
epidural - unclear effect on birth but likely to increase intervention
CTG - lacking evidence but likely to lead to improved outcomes for neonate
65
What are the three essential components for planned breech vaginal birth?
strict protocol, appropriate case selection and availability of skilled operators.
66
What positions in GTG are advised for breech delivery?
semi recumbent or all fours
67
What are the principles of management of active second stage for breech birth?
assistance without traction is required if there is evidence of delay or poor fetal condition
68
If twins present in labour with the first twin breech what should be done?
routine emergency cs is not recommended. Decision should be made based on clinical situation.
69
What are the criticism of the term breech trial?
Case selection and intrapartum management
* 31% had no USS in labour to exclude fetal neck extension
* FGR babies were included
* A few women were randomised in violation of the protocol and included in ITT analysis
* Senior obs absent from 31% of births
* And any obstetrician was absent from 13% of births
* Serious neonatal morbidity included some benign conditions
* Found higher perinatal mortality and morbidity than other previous studies
70
What was the PREMODA study and what did it show?
Observational study
Outcomes of 8105 31% planned breech vaginal births compared to 69% planned caesarean section in France and Belgium
Strict criteria included pelvimetry, CTG in labour and routine USS
IOL and augmentation was allowed.
Did passive second stage 18% for 60 minutes of longer (higher than TBT)
In planned vaginal group, 71% delivered vaginally.
significant difference in perinatal death or morbidity
Vaginal group had more neonates with apgars of <7 at 5 minutes and fetal injuries (haematoma or fractures)
No difference in NICU admission or composite of serious mortality or morbidity
USED CUT OF FOR EF 3.8KG
71
What is the risk of PAS after one CS?
0.3%
72
Why is CTG recomended in breech vaginal birth?
cord prolapse risk
head compression risk
if hypoxic, lose tone and the delivery is very challenging
73
Is FBS in breech recommended?
no
74
How long would of passive descent of breech fetus would you give prior to precomended CS?
2 hours
75
With planned vaginal birth for twins what is the emergency CS rate?
44%
76
How many babies are breech at 28 weeks?
20%
77
How many babies are breech at 32 weeks?
16%
78
What proportion of breech babies in nulliparous women will spontaneously turn after 36 weeks?
10%
79
What are the maternal risk factors for breech presentation
* Multiparity
* Congenital uterine anomalies
* Fibroids
* Cephalo-pelvic disproportion
* Previous breech presentation
* Placenta previa
80
What are the fetal risk factors for breech presentation?
* Preterm birth
* Polyhydramnios
* Oligohydramnios
* Fetal macrosomia
* Multiple pregnancy
* Fetal anomalies: anencephaly, hydrocephaly
81
What is the most common and second most common type of breech presentation?
1. extended breech/frank breech 65%
2. Footling breech 10-40%
82
What is another name for complete breech?
flexed
83
What is another name for frank breech?
extended breech
84
What are the risks with breech vaginal brith?
maternal birth canal trauma
neurological conditions - torticollis, palsy, paralysis
fetal joint dislocation
fracture of fetal long bones
cord prolapse - most common with footling or flexed breech
85
What is the risk of cord prolapse with footling breech?
15%
86
What is the risk of cord prolapse with flexed breech?
5%
87
How do you counsel women about breech presentation?
- ECV is no CI
- CS has lower mortality and morbidity in short term for fetus but increased short term risk for mum
- long term fetal outcomes are similar
- make informed decision
- spontaneous labour ,don't induce
- counsel and document risks
- if presents in advanced breech labour may counsel for breech vaginal birth
88
WHat did the cochrane reveiw from 2015 show for breech birth?
3 tirals 2396 women
planned CS reduced perinatal and neonatal mortality and composite of morbidity and death
no difference in death or delay at 2 years
increase in maternal morbidity for CS
89
How do you manage fetal head in entrapment?
emergency bell
mcroberts
MSV trial and suprapubic pressure
turn baby to transverse
give tocolysis
trial forceps
cervical incisions
CS if baby still alive
symphysiotomy
90
Management of breech vaginal delivery?
senior obs
empty badder
consider episiotomy
avoid handling or traction fetus
ensure enough UA
delay pushing until breech distending introitus
When anus visible - lithotomy
sacrum anterior
maternal effort to umbilical levels
flex legs to deliver
maternal effort until scapula seen
lovsets manoeuvre
femoral pelvic grip - thumbs rest parallel to fetal spine lower back
passive until when babies nape of neck visible (to avoid neck ext)
- SP pressure, MSV, forceps (if MSV not working for 2-3 mins)
91
What kinds of forceps do you use for breech?
piper -> keillands -> NB not wrigleys
92
What is the still birth rate in NZ and aus?
7 per 1000
93
What are the USS signs of fetal demise on USS other than absent FHR?
spalding sign (overlapping skull bones), fetal skin oedema >5mm, echogenic amniotic fluid, intra fetal gas
94
What proportion of IUFD have RFM prior?
55%
95
In late IUFD when full investigation is undertaken including a post mortem what proportion will find a possible or probably cause of fetal death?
3/4
96
what is the highest yield in investigation for IUFD?
post mortem
97
When is a parental karyotype indicated for investigating IUFD?
if fetus has unbalance translocation or other aneuploidy. If genetic tetsing on fetus fails and abnormality suspected from post mortem
98
When would you do anti-red cell antibodies in investigating IUFD?
hydrops present indicating ?haemolytic disease
99
What is the risk of DIC in the first 4 weeks after an IUFD?
10%
100
What should you advise women who do not want an IOL for an IUFD?
they should have twice weekly DIC monitoring and that the post mirtem value will reduce with time due to appearance of baby
101
What proportion of women with an IUFD deliver within 24 hours of staring IOL?
90%
102
What proportion of women will spontaneously deliver within 3 weeks of an IUFD?
>85%
103
What is the recommended regime for IOL for IUFD?
mifepristone 200mg then PG 24 to 48 hours later. Vaginal has fewer side effects.
Foley can be considered but infection risk
104
What is the risk of uterine rupture using PG for IUFD after 1 and 2 CS?
0.47% and 2.5%
105
What post natal care should be offered to women after an IUFD?
counselling and support groups
lactation suppression - carbergoline
VTE prophylaxis
follow up of investigations and planning
risk of PND
Update GP
cancel any ANC appointments
106
What maternal positions can make feeling movements more difficult?
standing most, sitting also
107
After what gestation should women contact their LMC with FM concerns?
28 weeks
108
If women are unsure if their movements are abnormal. what does GTG suggest?
lie on side for 2 hours and count movements, if less than 10 in 2 hours should discuss with LMC
109
What risks are associated with recurrent RFM?
still birth, FGR and PTB
110
If absent FM by 24 weeks what should be done?
refer to MFM for ?neuromuscular condition
111
When are most women aware of fetal movements by?
20 weeks
112
When are babies usually the most active?
afternoon and evening
113
What is the longest period of time between movements as per GTG?
50-75 minutes (sleep cycles rarely exceed 90 minutes in a healthy fetus)
114
When do you see a 'plateau' in frequency of movements ?
32 weeks
115
What factors influence perception of fetal movements?
drugs- benzos, alcohol, morphine, methadone
maternal position eg standing
anterior placenta <28 weeks
fetal spine anterior
steroids reported
major fetal malformations
maternal smoking (less fetal breathing due to carbon dioxide)
116
What are risk factors for still birth?
FGR, HTN/PET, diabetes, smoking, extremes of age, primiparity, smoking obesity, racial/ethnic factors
117
When should USS be done for an RFM assessment?
Part of the preliminary investigations of a woman
presenting with RFM after 28+0 weeks of gestation if the perception of RFM persists despite a normal
CTG or if there are any additional risk factors for FGR/stillbirth
118
When and what should be looked at with USS for RFM?
AC/EFW AFI, fetal morphology if not previously done and mum consents.
within 24 hours
dopplers added may not provide additional information benefit
119
What is included in a biophysical profile?
fetal breathing, tone, AFI and movement
120
Whats proportion of women with a single episode of RFM are uncomplicated?
70%
121
What does GTG recommend for 24-28 weeks presenting with RFM?
handheld doppler
screen for FGR and investigate if suspected
122
What dose of misoprostol is given for 24-25 weeks, 25-28 weeks and >27+6?
400mcg 3 hourly
200mcg 4 hourly
25-50mcg hourly vaginally or 50-100mcg oral every 2 hours
123
What should women be advised if they have had more than two CS and have IUFD?
the safety of IOL is unknown
124
What general things are investigations for IUFD looking for?
Recommended to look for cause if fetal death, chance of recurrence and possible means of avoiding in future
125
Who should be offered cytogenetic testing of baby after IUFD?
all parents
126
What is the definition of late IUFD?
after 24+0 a baby with no signs of like in utero
127
What is the definition of still birth?
a baby delivered with no signs of life after 24 weeks
128
What is the UK occurrence of later IUFD?
1 in 250
129
What are non modifiable risk factors of IUFD?
Nulliparity, age >35, Age <20, non white women, previous still birth, previous adverse pregnancy outcomes, multiple pregnancies, GA >41+0, FGR or SGA, low education, RFM, thyroid disease, thrombophilia, malaria, COVID, cholestasis, SLE/APS, renal disease
130
What are possibly modifiable risk factors for IUFD?
HTN, BMI, smoking, alcohol use, illicit drug use, sleeping supine, living in deprived areas
131
When should you consider a foley with IUFD?
previous CS after 27+6, insufficient safety after this time for miso
132
What is the cabergoline dose?
1mg PO stat day one prior to lactation establishment
133
What tests should all women be offered with a late IUFD be offfered?
post mortem
genetic testing
placental pathology
134
When would maternal bacteriology (cervical and vaginal swabs,MSU, blood cultures) be indicated for IUFD investigations?
prolonged ROM, maternla fevers, flu symptoms, alnormal liquor.
bacteria without chorio is of doubtful significance
135
When are anti Ro and La antibodies indicated for investigating late IUFD?
hydrops, endomyocardial fibroelastosis or AV calcification on OM
136
When do you do APLS antibody screen for IUFD investigation?
can consider in all but especially if FGR or placental disease.
not until 6 weeks PP
137
What investigations for IUFD should always be offered as per green top guideline?
1. biochemistry - including CRP, bile salts, LFTs
2. Coags
3. Kleihauer
4. maternal serology - TORCH
5. random BSL
6. HbA1c
7. TFTs
8. Thrombophilisa screen
9. fetal and placental microbiology - fetal blood, swabs and placental swabs
10. fetal and placental cytogenetics
11. Postmortem
12. COVID 19 PCR
138
What IUFD investigations are only offered if certain situations?
1. Maternal toxicology
2. Parental karyotype
3. Maternal alloimmune antiplatelet antibodies
4. maternal anti Ro and La
5. anti red cell antibodies
6. Maternal bacteriology
7. Tropical infections
139
what are the post mortem aspects that can be offered?
external
autopsy
microscopy
xray
placenta and cord
USS and MRI
140
What is the rate of MC twins globally?
3-5 in 1000 live births
141
What is the rate of twins globally?
15.9/1000 live births
142
whats i the still birth rate for singletone vs twins?
5 in 1000 vs 12 in 1000 births
143
what are the maternal risks associated with twins?
PET, GDM, PPH, CS and
144
What are the fetal risks associated with twins?
cerebral palsy (8x), IUFD, PTB, FGR, TTTS, congenital anomalies.
145
What proportion of twins are DCDA?
2/3
146
What cleavage stage of a monozygote pregnancy would create a DCDA pregnancy?
day 3 25-30%
147
What cleavage stage of a monozygote pregnancy would create a MCDA pregnancy?
day 4-8 75%
148
What cleavage stage of a monozygote pregnancy would create a MCMA pregnancy?
day 8-13
149
how do you get MCDA twins from a cellular levels?
you get two inner cell masses after early splitting in blastocyst stage
150
When is the best time to determine chorioncity?
10-13 weeks. but can be seen at 6-8 weeks.
The lamda signs regresses at 16 weeks
151
Why do twins have a higher aneuploidy risk
due to maternal age association. MC and DC same level of risk
152
What is the false positive rate for MSS screening for MC and DC twins?
MC 10%
DC 5%
153
When should you start serial growth scans with twins?
24 weeks
154
What is the pathogensis behind TTTS?
there are deep placental A-V communications and superficial V-V and A-A communications, The superficial compensate for the deep. When this can't occur you get TTTS
155
What changes do you get from the donor twin in TTTS?
hypovolemia, activation of RAAS, ADH secretion --> vasoconstriction oligouria and FGR
156
What changes do you get in the recipient twin in TTTS?
hypervolemia --> release atrial natriuretic factor, polyuria, polyhydramnios, cardiac hypertrophy, fetal hydrops and death
157
What is quintero staging for MC twins stage 1 for TTTS
: oligo-polyhydramnios sequence with visible fetal bladder in donor twin
* Oligo: DVP <2cm
Poly: DVP>8cm at <20/40, or >10cm if >20/40
158
What is quintero staging for MC twins stage 2 for TTTS
fetal bladder not visible in donor twin
159
What is quintero staging for MC twins stage 3 for TTTS
abnormal doppler studies in either twin, typically raised UAPI in donor and abnormal DV in recipient
160
What is quintero staging for MC twins stage 4 for TTTS
: fetal hydrops in either twin (ascites, pericardial effusion, pleural effusion, skin oedema)
161
What is quintero staging for MC twins stage 5 for TTTS
death of one or both twins
162
What is the mortality rate if untreated of moderate to severe TTTS?
90%
163
How does laser ablation for twins work ?
all anastomoses of vessels between twins in placenta are ablated
164
What is the survival rate of one twin after laser ablation?
81%
165
What is the survival rate of both twin after laser ablation?
70%
166
What are the risks of laser ablation?
PPROM, infection miscarriage, PTB, recurrence of TTTS 14% and TAPS 13%
167
What is the mortality rate of the pump twin in TRAPS and why?
50% due to heart failure from out output required.
168
How common is selective FGR in MC twins?
15% in those without TTTS and 50% with TTTS
169
What is the difference between TTTS and SFGR in MC pregnancies?
SFGR there is no significant difference in AFIs
170
What % of MC twins are MCMA?
1%
171
Why are fetal losses in MCMA pregnancies common?
early losses from anomalies, conjoined twins and TRAPS
172
Why are congential malformations common in twins?
mainly due to monozygosity from midline defects eg NTDs, holoprosencepahly
and cardiac defects 9% in MC
commonly discordant anomalies between twins
173
Timing of birth for DCDA twins?
37 weeks
174
Timing of birth for MCMA/
32-34 weeks CS
175
Timing of birth for MCDA?
36 weeks
176
What is the normal advice for timing between twin delivery?
30 minutes due to increasing risk of fetal distress and acidosis but may be appropriate to delay if reassuring fetal status
177
If the second twin is cephalic, what should you do for the delivery?
fundal pressure, ARM, start oxytocin
178
If doing an ECV for twin 2 when should this be done?
prior to oxytocin so uterus is relaxed. 60-80% success rate
179
What are the CIs to IPV?
lack of consent, not fully dilated, inadequate analgesia, EFW >4kg, inexperience
180
What is the likelihood of CS for second twin?
3-5%
181
if large FMH when should you check kleihauer again to check negative/
48 hours
182
What is cytogenetics?
the study of chromosomes and inheritance.
includes karyotype, microarray, QF PCR
183
What solution should cytogenetics go into?
ringers lacte solution
184
What proprtion of IUFD will have cytogenetic abnormalty?
6-13%
185
What proportion of IUFD have a placental pathology identified?
65%
186
PM alone will find classification for death in what % of cases?
45
187
What are the placental findings of glucose dysmetabolism?
delayed villous maturity or fetal vascular malperfusion
188
When do you offer IOL for previous IUFD?
39+0
189
WHat proprtion of still births are from FMH?
4%
190
As per PSANZ what investigations should be offered to all women with IUFD?
comprehensive history
antenatal postmortem USS of fetus
kleihauer
external examination of baby
clinical photographs
autopsy
detailed macroscopic exam of placenta and cord
placenta histopathology
cytogenetics - ideally CMA
baby xray
191
As per PSANZ what investigations should be offered to selected women with IUFD?
LFTS and bile salts - itch
APLS - SGA or placental infarction of abruption
HbA1c - SGA or LGA
infectious screen - history of infection or SGA, hydrops, hepatosplenomegaly
blood group and antibodies - jaundice hydrops
toxicology
TFTs - clnical
192
What are the associated findings of CMV infection in IUFD?
severe FGR, petechiae, villitis
193
When is parvo virus most likely to cause anaemia and hydrops?
21-24 weeks when hepatic erythropoiesis os occurring
194
What are the PSANZ risk factors for still brith?
previous
FGR
APH
DM
HTN
parity 0 or >3
AMA >35
IVF
indigneous
BMI >25
smoking or drugs use
low SES
194
What investigations does PSANZ recomended rfm assessment >28 weeks?
hand held doppler FHR
CTG
consider USS within 24 hours
kleihauer
195
What is the definition of neonatal death as per PSANZ?
a live born baby who dies within 28 days of life (regardless of gestation or weight at birth).
Early - 1-7 days
Late 8-28 days
196
What is the definition of still birth as per PSANZ?
birth following the death of an unborn baby of 20 weeks or more completed weeks of gestation and 400g or more birth weight
197
What is perinatal death?
fetal or neonatal death
20 weeks to 7 days after birth
198
what are the PSANZ classification groups of perinatal death? (Causes)
1. Congenital abnormality - commonly CNS or cardiac
2. Perinatal infection - ecoli, GBS, CMV
3. Hypertension
4. APH
5. Maternal conditions - GDM,
6. Specific perinatal conditions - TTTS, FMH, allo immune
7. Hypoxic event - rupture,
8. FGR
9. Spontaneous PTB
10. Unexplained
No obstetric antecedent - SIDs
199
What is the still birth rate in Australasia per 1000?
7-8 per 1000 births 0.7-0.8%
200
What is perinatal related mortality? how is is reported?
fetal death after 20 weeks and neonatal death up to 28 days
deaths per 1000 births (alive or not)
201
What is a maternal death and how is it reported?
death of a person while pregnant or within 42 days of end of the pregnant from any cause related to or aggravated by the pregnancy or it's management.
per 100 000 live births
202
what is an infant death?
up to one year
203
What is the NZ MMR in 2021 report?
9.5 per 100 000 live births
204
What is the perinatal related death rate in 2021 report?
11.2 per 1000
(includes TOP)
205
Ellen's flashcards
flashcards
Decks in class (27)
# Cards
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Week 419
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Week 585
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Autoimmune medications and pregnancy11
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Landmark trials to date13
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Week 6253
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Week 7259
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Week 8232
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Week 9206
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Week 10364
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Week 258
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week 371
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Week one136
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Week 11237
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Week 12314
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Week 13381
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GONC 1395
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GONC 2259
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Week 16134
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Week 17410
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Week 18266
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Week 19347
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Week 20307
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Week 21430
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Week 22370
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Week 23298
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Week 24325
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Week 261
