Transcript Maternal Fetal Medicine

MATERNAL DEATHS
Deaths of women while pregnant or
within 42 days of the end of the
pregnancy, from any cause related to
or aggravated by the pregnancy or its
management, but not from accidental
or incidental causes
DIRECT
Deaths resulting from obstetric
complications of the pregnant state
(pregnancy, labour and puerperium),
from interventions, omissions,
incorrect treatment or from a chain of
events resulting from any of the above
INDIRECT
Deaths resulting from previous
existing disease, or disease that
developed during pregnancy and which
was not due to direct obstetric causes,
but which was aggravated by the
physiologic effects of pregnancy
LATE
Deaths occurring between 42 days
and 1 year after abortion, miscarriage
or delivery that are due to Direct or
Indirect maternal causes
COINCIDENTAL
(FORTUITOUS)
Deaths from unrelated causes which
happen to occur in pregnancy or the
puerperium
PREGNANCY-RELATED
DEATHS
Deaths occurring in women while
pregnant or within 42 days of
termination of pregnancy,
irrespective of the cause of the death
MBRACE 2011/13
Most Common Causes;
Direct deaths – Thrombo –embolic disease
Indirect deaths – Cardiac disease
MBRACE 2009/13
Most Common Causes of late deaths –
Malignant disease
MATERNAL DISEASES
• Hypertension
• Diabetes mellitus
• Epilepsy
• Thyroid disease
Women with Type 1 and Type 2 diabetes have
high risk pregnancies compared to the general
maternity population
Their babies are;
• five times as likely to be stillborn
• three times as likely to die in the first month of life
• twice as likely to have a major congenital anomaly
• five times as likely to be macrosomic (> 4kg) at birth
and 10 times as likely to have Erb’s palsy
Two-thirds of women with Type 1 and Type 2 diabetes are
delivered by caesarean section.
PERINATAL MORTALITY
AND MORBIDITY
PERINATAL MORTALITY RATE =
Number of stillbirths and first week
neonatal deaths per 1,000 total births
Perinatal Mortality Rate
Number of stillbirths and early week neonatal deaths
per 1,000 total births.
Stillbirths : a baby delivered without life after 24
completed weeks of pregnancy
Early neonatal deaths : death of a live born baby
less than 7 completed days from the time of birth.
BUT
Intrauterine fetal death delivered at 22 weeks is a late fetal
loss.
Live birth at 19 weeks, then death 2 hours later is on early
neonatal death and therefore a perinatal loss.
CAUSES OF PERINATAL LOSS
Preterm Labour
Fetal Abnormality
Rhesus Haemolytic Disease
Multiple Pregnancy
Intrapartum Trauma
Intrapartum Asphyxia
Infection
Gestational Proteinuric Hypertension
Antepartum Haemorrhage
Maternal Disease
Unexplained Intra-Uterine Death
Maternal Risk Factors for Perinatal Mortality
• Age ; less than 20 years
more than 40 years
• Obesity
• Social deprivation
• Ethnicity
Neonatal Risk Factors for Perinatal Mortality
• Birth weight < 1.5kg
• Prematurity
THE PURPOSES OF ANTENATAL CARE;
• To minimise maternal mortality and morbidity
• To minimise perinatal mortality and morbidity
• Offer informed choice
• To enhance the experience
LMP+9m+7d=CDC
• 28 days cycle for at least 3 cycles
• LMP – sure
• Nothing to interfere with ovulation
• USS – first trimester
28 DAY CYCLE
ovulation
Follicular phase
luteal phase
9m+7d
14
1
28
21 DAY CYCLE
1
7
21
9m
35 DAY CYCLE
1
21
9m+14d
35
INTERVENTIONS IN ANTENATAL CARE
•
•
•
•
•
Induction of Labour at 41 weeks
Prevention of Rhesus isoimmunisation
Use of steroids in Pre-Term Labour
Fetal abnormality
Umbilical artery doppler wave form analysis in
high risk pregnancy
• GBS
THE ANTENATAL BOOKING VISIT
•
•
•
•
Determination of pregnancy
Overall assessment
Triage
Screening; syphilis, hepatitis B, rubella,
H.I.V., anaemia, thalassaemia,
sickle cell disease,
fetal abnormality
ROLE OF ULTRASOUND IN PREGNANCY
• Diagnosis of pregnancy
• Molar, multiple, ectopic gestation
• Ongoing Pregnancy
• Placental site
• Fetal morphology
• Minor markers of chromosomal abnormality
ANTENATAL VISITS
Booking
ANSS – 16w.
USS – 19w.
20w.
28w.
32w.
36w.
38w.
40w.
41w.
ATTRIBUTES OF A SCREENING TEST;
•
•
•
•
•
•
•
•
•
•
Test must be available
Diagnosis must be available
Treatment must be available
Significant condition
Significant latent period
Sensitivity
Prevalence
Cost
Acceptability
Integration
Present
Absent
Screen positive
TP
FP
Screen negative
FN
TN
Prevalence
=
TP+ FN / TP+FN+FP+TN
Sensitivity
=
TP / TP+FN
Specificity
=
TN / TN+FP
Positive Predictive Value =
TP / TP+FP
Number
µ = mean
б = SD
- 1б
µ
Measurement
+ 1б
Number
3400
- 1б
Total = 10,000
3400
µ
Measurement
+ 1б
Number
4,750
4,750
- 1.96 б
Total = 10,000
+ 1.96 б
Measurement
Number
1 in 3
1 in 3
1 in 2,000
- 3.26 б
- 2.57 б - 1.96 б - 1б
1 in 2,000
µ
+ 1б + 1.96 б +2.57 б + 3.26 б
Observation
Assuming normal distribution,
probability of a sample chosen at random
falling within certain ranges.
Fetal medicine: team
• Parents
• Fetal medicine specialist
• Specialist teams eg clefts,
cardiac teams,
orthopaedic surgeons etc
• Specialist midwife
• Neonatologist
• Geneticist
• Paediatric surgeon
• ? Radiologist: fetal MRI
MEDICAL MANAGEMENT OF LABOUR
• Monitoring
- School of thought
- Level of acceptability
• Interventional
- IVD
- CS
• Emergencies
• Catastrophes
Suicide profile
•
•
•
•
•
White, older, married, comfortable
Second or subsequent pregnancy
PMH: psychiatric illness, 50% admitted
Baby < 3months
Dies violently
Domestic Violence
Occurrence
Detection
Awareness of risks
Management
EFFECTS OF IONISING
RADIATION ON THE FETUS
Dependent on → Gestation
→ Radiosensitivity
→ Dose of radiation
Dose>200 cGy during 1st trimester
consistently produces fetal anomalies
EFFECTS OF IONISING
RADIATION ON THE FETUS
Day 1
All or None
Day 10
Day 56
4 cGy – CNS
1UGR
100cGy – 100% rate of FA in survivors
50cGy – microcephaly
– microcephaly
Day 140
Haematologic
Skin
AEXTENDED MATCHING QUESTIONS (EMQs)
Author
Theme
Domain
Mr S J Duthie
Antenatal care
Pre-natal diagnosis
Options
A
B
C
D
E
F
G
H
1%
2%
15%
25%
50%
60%
75%
100%
Each of the clinical scenarios described below refers to a pregnant woman who is consulting you for
antenatal care having delivered a previous child with Down’s syndrome (trisomy 21). Unless
otherwise stated the patient is 20 years old and has been in good health. For each of the clinical
scenarios described below choose the option which shows the patient’s risk of having another child
with Down’s syndrome in this pregnancy. Each option may be used once, more than once or not at all.
ITEM 4
ITEM 1
The patient has a normal karyo-type and her partner
Both the patient and her partner have normal karyo-types.
has a balanced 14/21 translocation.
ANSWER
ANSWER
A 1%
A 1%
ITEM 2
ITEM 5
The patient is 40 years old and both herself and her
The patient has a balanced 21/21 translocation and her
partner have normal karyo-types.
partner’s karyo-type is normal.
ANSWER
ANSWER
B 2%
H (100%)
ITEM 3
The pregnant woman has a 14/21 balanced
translocation, and her partner has a normal karyo-type.
ANSWER
C 15%
ITEM 6
The patient has a normal karyo-type and her partner
has a balanced 21/21 translocation.
ANSWER
H (100%)
The 11 auditable conditions and detection rates
Anencephaly
98%
Open spina bifida
90%
Cleft lip
75%
NHS Fetal Anomaly Screening Programme 2010
The 11 auditable conditions and detection rates
Diaphragmatic hernia
60%
Gastroschisis
98%
Exomphalos
80%
NHS Fetal Anomaly Screening Programme 2010
The 11 auditable conditions and detection rates
Serious cardiac abnormalities
50%
Bilateral renal agenesis
84%
Lethal skeletal dysplasia
60%
NHS Fetal Anomaly Screening Programme 2010
The 11 auditable conditions and detection rates
Edward’ syndrome (Trisomy 18) 95%
Patau’s syndrome (Trisomy 13)
95%
NHS Fetal Anomaly Screening Programme 2010
EXTENDED MATCHING QUESTIONS (EMQs)
Author Mr S J Duthie
Theme IT CG and R
Domain Coefficient of Variation
Options
A
B
C
D
E
F
G
H
I
J
K
L
Analysis of range
Analysis of variance
Average
Inter observer coefficient of variability
Intra observer coefficient of variability
Inter observer standard error
Inter observer standard error of the mean
Median
Mode
Standard error of the mean
Variance
Zero error
ITEM 1
The Head of Department in a Maternity Unit introduced a quality control
initiative in respect of measurement of the fundal height in pregnant women.
One hundred Doctors and Midwives working in the same unit were required to
measure the fundal height in a single pregnant woman who volunteered. The
woman was 28 weeks pregnant with a single baby and there were no
complications. All the measurements were taken in the same afternoon.
The Head of Department studied the measurements and discovered that they
had a normal distribution with a mean of 28 cm. The standard deviation was
calculated and the quantity standard deviation/ mean was measured. Select the
single most correct term for standard deviation/mean in this setting from the list
of options.
ANSWER
D
ITEM 2
The Head of Department in a Maternity Unit introduced a quality control
initiative in respect of measurement of the fundal height in pregnant women
by individual clinicians. Each Doctor and Midwife working in the same unit
was required to measure the fundal height in 100 pregnant women who
volunteered. All the women were 28 weeks pregnant with a single baby and
there were no complications. All the measurements were taken in the same
afternoon.
The Head of Department studied the measurements taken by individual
clinicians and discovered that each set of measurements had a normal
distribution with a mean of 28 cm. The standard deviation was calculated and
the quantity standard deviation/ mean was measured for each clinician.
Select the single most correct term for standard deviation/mean in this setting
from the list of options.
ANSWER
E
EXTENDED MATCHING QUESTIONS
(EMQs)
Author Mr S J Duthie
Theme Maternal medicine
Domain Phaeochromocytoma 1
Options
A
B
C
D
E
F
G
H
I
J
K
L
M
N
Atropine
Dantrolene
Dexamethasone
Diazepam
Hydralazine
Magnesium
Methyl-DOPA
Pethidine
Phenoxybenzamine
Phentermine
Phenylephrine
Phenytoin
Prednisolone
Propranolol
ITEM 1
A 35 year old woman was pregnant for the first time, had booked for antenatal care, classified as
low risk apart from concerns related to maternal age and ultrasound examination findings at both
12 weeks and 20 weeks were reassuring. The pregnancy reached a gestation of 30 weeks and
the Community Midwife raised an alert as the woman’s blood pressure was 150/100 mm Hg and
the fundal height was 26 cm. The fetal heart was detected, no proteinuria and other observations
were reassuring.
The woman was seen in the Day Assessment Unit on the same day. The blood pressure at the
time of antenatal booking at 11 weeks was 100/65 mm Hg. After checking the blood pressure the
Midwife called you immediately as the reading was 200/100 mm Hg. You arrange emergency
admission, the blood pressure settles to 140/90 mm Hg, no proteinuria, serum urea and
electrolytes are normal and the serum uric acid is also normal. The woman is very anxious and
complains of palpitations. There is no clonus and knee jerks are normal.
Ultrasound examination shows that there is an ongoing intrauterine pregnancy with a single live
baby presenting by the head. The amount of amniotic fluid is reduced and the estimated weight of
the baby is 1.0 Kg.
You arrange for various tests and the salient results are as follows;
Elevated serum noradrenaline and adrenaline.
Elevated 24hour urinary level of vanillylmandelic acid (VMA).
The Midwife calls you to the ward as the blood pressure is 210/125 mm Hg,
pulse rate 124/min.
Select the drug which you would provide immediately from the list of options.
ANSWER
I
SINGLE BEST ANSWER QUESTIONS
(SBAs)
Author Mr S J Duthie
Theme Maternal medicine
Domain Cholestasis
ITEM 1
Cholestasis of pregnancy is related to a specific defect in an ATP binding cassette
transporter. The substrate of the transporter is which one of the following?
Options
A
B
C
D
E
Bile salts
Bilirubin
Iron
Long chain phosphatidyl choline
Peptide transporter
ANSWER
D
SINGLE BEST ANSWER QUESTIONS
(SBAs)
Author Mr S J Duthie
Theme Antenatal care
Domain Free fetal DNA 1
ITEM 1
Free fetal DNA is a portion of total free DNA in maternal circulation. The level of
free fetal DNA is altered by which one of the following?
Options
A
B
C
D
E
Maternal age
Maternal body mass index
Maternal cigarette consumption
Mode of conception
Placental volume
ANSWER
B
The End
Thank you very much.
S. J. Duthie