fetal complications part 2

Question 1

freq of fetal death

Answer 1

1% of preg in second half

Question 2

diagnosing fetal death

Answer 2

• symptoms: regression of size, lack of FM
• absence of HR on doppler or US
• US: skull collapse, retracted brain, empty bladder + aorta

Question 3

causes of fetal death

Answer 3

maternal:

• DM, HTN, pre-eclampsia
• septicemia

Fetal:

• malformation
• infection
• immune hemolytic
• cord accident, prolapse, amniotic band strangulation, compression
• metabolic

placental:

• dysfunction, IUGR, post-mature
• abruption
• previa
• twin-twin transfusion
• mat-fet hemorrhage

Question 4

work-up for fetal death

Answer 4

tests:

• HbA1c, fasting glucose
• platelets, fibrinogen, coombs
• TORCH
• CBC, antibody screen
• Betke Keihaur
• APA, ANA, thrombophilia

fetal

• karyotype / microarray
• AF cluture for CMV, parvo, herpes, bacteria (+ repeat at delivery)
• tot body x ray
• post mortem pathology inc placenta

Question 5

management of fetal death

Answer 5

• <15 wks D+C
• 16-20 wks D+E or induce /w miso
• > 20 induce
• or wait, usually labour /w in 3 weeks

if >20 wks can have coagulopathy if undelivered for >4 wks, fibrinogen falls (consumed)

only dangerous if <100

platelets also fall

Question 6

early vs late neonatal deaths

Answer 6

early: <7 days
late: 8-29 days

Question 7

main causes of maternal mortality

Answer 7

• thromboembolism
• HTN
• hemorrhage
• ectopic
• infection
• abortion related
• anesthesia
• stroke

Question 8

neonatal death causes

Answer 8

• prematurity
• hypoxic injury
• congenital anomalies

Question 9

Rh primary immunization process + secondary exposure

Answer 9

• slow, 8-9 weeks after exposure
• IgM anti-D, cannot cross placenta
• second response is fast, IgG that crosses placenta

Question 10

Rh sensitization effects

Answer 10

• destruction of RBCs
• anemia
• bone marrow can’t keep up, hepatosplenomegally
• hyperdynamic state + fetal hydrops
• macrophage mediated, lyses cells
• can cause bilirubinemia, anemia, jaundice, kernicterus, hydrops
• if ABO incompatible less likely to have sensitization

Question 11

when to give Rhogam

Answer 11

if Rh neg, unimmunized

• after birth of +ve baby
• SA, TA, ectopic
• amnio or CVS
• at 28 weeks + repeat screen
• vag bleeding
• after massive hemorrhage of fetal blood

Question 12

Rhogam dose + delivery management

Answer 12

• 300mcg
• lasts 12 weeks
• protects against 25ml of fetal RBC
• cord blood for ABO, Rh, and coombs
• maternal bood for betke-kleihaur

Question 13

predicting hemolytic disease in Rh sensitized

Answer 13

• hx of fetus /w Rh disease = strong predictor
• maternal Rh antibody titre - can’t predict severity only risk of dx
• amniotic fluid optical density (amniocentesis) - old technique, shows amount of bilirubin in fluid + predicts severity
• US: doppler MCA PSV for anemia, liver, spleen + placenta size, ascites, effusions (hydrops), use to guide intrauterine transfusion

Question 14

delivery for Rh sensitized

Answer 14

• if mild or unaffected based on dopplers: term
• if need intrauterine transfusions: at 36wks (lung maturity)
• neonate: phototherapy, blood transfusion/exchange

Question 15

mono vs di twins & diagnosis

Answer 15

• dizigotic: always di/di
• monozygotic: di/di, di/mono, mono/mono, conjoined depending on time of separation
• US at 10-14 wks: lambda = dichorionic, T = monochorionic (not seen in 2nd trimester)

Question 16

maternal risks with multiples

Answer 16

• anemia
• hydramnios
• ureter dilatation and obstruction (rare)
• HTN
• GDM
• premature labour
• PPH / atony
• instrumental + CS delivery
• perineal trauma

Question 17

fetal risks /w mulitples

Answer 17

• SA
• malpresentation
• previa
• PPROM
• PTL
• cord prolapse
• IUGR
• discordant growth
• congenital anomalies
• conjoined
• velamentous cord insertion
• twin-twin transfusion
• perinatal morbidity/moretality (stillbirth, trauma, asphyxia, etc)

Question 18

twin-twin transfusion syndrome

Answer 18

• monochorionic
• anastamosis
• blood goes from 1 to other twin
• donor: hypovolemia, hypotension, anemia, IUGR, oligo
• recipient: hypervolemia, viscosity, thrombosis, HTN, cardiomegaly, polycythemic, edema, CHF, polyhyrdamnios, neonatal kernicterus/jaundice
  OR: circulation reversed + gets little O2, and then malformations, embolization from trophoblastic tissue entering

Question 19

antepartum care ofr twins

Answer 19

• visits q2wks from mid preg, to q1wk from third trimester
• increased Ca, Fe, folic acid, calories
• earlier check for GDM
• US at 10-14 wks for zygosity and chorionicity
• genetic screen at earlier age b/c higher risk that 1 will have down’s (age 32=35)

Question 20

delivery of twins

Answer 20

vertex/vertex

• SVD
• cut 1 cord, clamp
• VE for twin B position
• cont if vertex, monitor
• oxytocin to increase contractions
• when low AROM, wait for cervix to dilate again, and deliver
• optimal time <20min between, otherwise get less blood to baby B b/c decreased uterine vol
• can wait longer if reassuring HR and not a lot of bleeding
• after both delivered obtain cord samples, deliver placentas

vertex/breech or vertex/transverse

• can do C/S
• or can do vag birth and breech extraction

twin A breech
- CS

Question 21

when to induce twins

Answer 21

Most end up with PTB (spont or medically indicated)

Induce at:
di/di & uncomplicated = 38wks

mono/di = 36 wks

di/di = 32 - 34