Transcript MULTIFETAL GESTATION

Perinatology.
Risk factors in perinatal
period.
 By Korda I.
Anatomy of a normal placenta:
The placenta provides the fetus with oxygen and nutrients and takes away waste such
as carbon dioxide via the umbilical cord.
Indicators of High Risk Pregnancy
 Maternal age <16 or >35
 Chronic disease – hypertension, diabetes, cardiovascular or
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renal disease, thyroid disorder
Preeclampsia- abn hypertension during pregnancy
Rh isoimmunization- neg and pos in blood  coagulation
History of stillbirth
IUGR- baby is smaller than needs to be; Growth Retardation
Postterm pregnancy – 2wks past the due date
Multiple gestation
History of preterm labor
Previous cervical incompetence
Maternal Assessment of Fetal
Activity
 Fetal movement
 Vigorous activity reassuring
 Decreased activity requires immediate follow-up
 Factors affecting activity
 Sound
 Drugs
 Sleep
 Smoking
 Blood glucose level
Ultrasound
 High frequency sound waves (Real time scanning)
 Advantages - early detection of fetal anomalies,
accurate determination of gestation, noninvasive and
painless, no known harmful effects, use at any time
during pregnancy
 Types
 Transabdominal US- need full bladder, if not full drink 3-4
8oz glasses and rescan
 Endovaginal US- probe is inserted into vagina (closer to
structures) same preparation. Lithotomy position.
Clinical Applications
1st trimester
• Early identification of pregnancy
• Observation of FHR and breathing movements
• Measurements – biparietal “side bones of head” diameter
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of fetal head, crown to rump, fetal femur length, birth
weight
Detection of anomalies
Identification of amniotic fluid index
Location of placenta and grading; to check whether there’s
proper profusion. Lower the number the better.
Detection of fetal death
Determination of fetal position and presentation
Accompanying procedures (ex: Amniocentesis
Doppler Blood Flow Studies
Not same as Doppler fetal hrt tones
 Evaluates blood flow in fetus and mother
 Assesses placental function
 Helpful in managing pregnancies with maternal
diabetes, IUGR “term for slowed growth of the fetus during
pregnancy”, preterm labor, prolonged pregnancies, and
multiple gestation
Nonstress Test
 Evaluate fetal heart rate with fetal activity
 Reassuring if accelerations occur with fetal
movement
 Interpretation
 Reactive – 2 or more FHR accelerations of at least 15 bpm
with a duration of at least 15 seconds in a 20 minute
interval (desired)
 Nonreactive – reactive criteria not met within 30 minutes
 If decelerations are noted- phys notified- for further
evalutaion
incr of about 15 bmp lasting 15 sec desired
Fetal Movement
Figure 14–5 Example of a reactive nonstress test (NST). Accelerations of 15 bpm lasting 15 seconds with each fetal
movement (FM). Top of strip shows FHR; bottom of strip shows uterine activity tracing. Note that FHR increases (above the
baseline) at least 15 beats and remains at that rate for at least 15 seconds before returning to the former baseline.
Ex: Nonreactive NST. Poss sleep or
hypoglycemic. Poss treat w/ juice.
Figure 14–6 Example of a nonreactive NST. There are no accelerations of FHR with FM.
Baseline FHR is 130 bpm. The tracing of uterine activity is on the bottom of the strip.
Biophysical Profile
 Assessment of 5 biophysical variables
1) Fetal breathing movement (US to determine)
2) Fetal movement of body or limbs
3) Fetal tone (extension and flexion of extremities)
4) Amniotic fluid volume
5) Reactive NST with activity
 Scoring (2 or 0, no in-between) Between 8-10 is
good/desired
 2 is given for normal
 0 is given for an abnormal finding
Contraction Stress Test
 Evaluates the Respiratory function of the placenta
 Does it get O2 to the baby? Test to check if the placenta has the reserves
needed during contractions.
 Records FHR response to stress of uterine contractions
 Compress arteries to placenta
 Uterine Contractions induced by nipple stimulation or Oxytocin
(Caution: may cause pt to go into labor!)
 Interpretation
 Negative – 3 good contractions lasting 40 seconds in 10 minute interval with no
late decelerations
 Positive – persistent late decelerations with more than 50% of the contractions
(NOT THE DESIRED RESULTS)
CST “Contraction Stress Test”
Postive CST- baseline about 150,
HR drops w/ contractions
Another example of positive CST.
Figure 14–8 Example of a positive contraction stress test (CST). Repetitive late decelerations
occur with each contraction. Note that there are no accelerations of FHR with three fetal
movements (FM). The baseline FHR is 120 bpm. Uterine contractions (bottom half of strip)
occurred four times in 12 minutes.
Amniocentesis
 Amniotic fluid obtained by inserting a needle through the abdominal
and uterine walls
 Purpose
 Genetics - Abnormal AFP
 Fetal lung maturity
 Risks
 Infection (Sterile tech req’d)
 Pregnancy loss
 Tests
 Triple tests – AFP, hCG, and UE3 (unconjugated estriol/estrogen)
 L/S ratio- “Lecithin/Sphingomyelin” test for fetal lung maturation; 2:1
 Fetal maturity index
 Phosphatidylglycerol- another phospholipid surfactant
Amniocentesis
Figure 14–9 Amniocentesis. The woman is scanned by ultrasound to determine the placental site
and to locate a pocket of amniotic fluid. Then the needle is inserted into the uterine cavity to
withdraw amniotic fluid.
Other Fetal Diagnostic Tests
 Chorionic Villus Sampling – performed at 10 – 12 weeks, off
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the placenta
Percutaneous Umbilical Blood SamplingComputed Tomography- obtain maternal pelvic and fetal
diameters
Magnetic Resonance Imaging- confirm anamolies, placental
assessment for location and size
Fetal Echocardiography- identify cardiac anomalies- during 2nd
and 3rd trimester
Changes in Fundal Height
Fetal Monitoring
 Fetal heart sounds
 Auscultate between 16 and 40 wks by stethoscope,
fetoscope, or Doppler
 Benefits of fetal monitoring
 Procedure
 Normal fetal heart rate: 120-160 bpm
Fetoscope
Doppler
Sites for Auscultation of
Fetal Heart Tones
Placental
insufficiency
 It is the failure of the placenta to supply nutrients
to the fetus and remove toxic wastes.
 When the placenta fails to develop or function
properly, the fetus cannot grow and develop
normally. The earlier in the pregnancy that this
occurs, the more severe the problems. If placental
insufficiency occurs for a long time during the
pregnancy, it may lead to intrauterine growth
retardation (IUGR).
Fetal distress
Fetal distress is defined as depletion of oxygen and
accumulation of carbon dioxide,leading to a state of
“hypoxia and acidosis ” during intra-uterine life.
 Decreased movement felt by the mother
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or Fetal hyperactivity
Meconium in the amniotic fluid
Cardiotocography signs
increased or decreased fetal heart rate
(tachycardia and bradycardia), especially
during and after a contraction
Fetal heart rate less than 120 or greater
than 170 beats per minute
Progressive decrease in baseline
variability
Late deceleration
Severe variable decelerations
Fetal distress
 Biochemical signs, assessed
by collecting a small sample
of baby's blood from a scalp
prick through the open
cervix in labour
 fetal acidosis
 elevated fetal blood lactate
levels indicating the baby
has a lactic acidosis
Causes
 Abnormal position and
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presentation of the fetus
Multiple births
Shoulder dystocia
Umbilical cord prolapse
Nuchal cord
Placental abruption
Premature closure of the fetal
ductus arteriosus
Treatment
 In many situations fetal
distress will lead the
obstetrician to
recommend steps to
urgently deliver the baby.
This can be done by
labor induction, or in
more urgent cases, a
caesarean section may
be performed.
Intrauterine growth restriction
(Intrauterine growth retardation; IUGR)
 (IUGR) refers to a
condition in which a
fetus is unable to
achieve its genetically
determined potential
size.
Screening the fetus for growth
restriction
 symphysis–fundal height
measurements
 Biometry and amniotic
fluid volumes
 Uterine artery Doppler
measurement
 Umbilical artery Doppler
measurement
 Three-dimensional
ultrasonography
Resuscitation
Algorithm:
Why we need to resuscitate:
pH 7.30
pH 7.00
pH 6.80
How often do we use our
resuscitation skills?
Suction Equipment
Warmer
&
Blankets
Bag,
Mask, &
Oxygen
Laryngoscope and ETT Tube
Universal Precautions
Assessment: Then
 Appearance
 Pulse
 Grimace
 Activity
 Respirations
Apgar score
Assessment: Now
Physiologic Parameters
(Apgar’s best)
 Breathing
 Heart Rate
 Color
Questions to ask yourself
• Clear of Meconium?
• Breathing or Crying?
• Good Muscle tone?
• Color Pink?
• Term Gestation?
Initial Management:
For all deliveries
 Provide warmth
 Position and Clear Airway
 Dry
 Give Oxygen (as necessary)
Providing Warmth: The cycle of hypothermia
Acidosis
Anaerobic
metabolism
Pulmonary
Vasoconstriction
Pulmonary
Hypertension
Tissue
hypoxia
Hypoxemia
Right to left
shunting
Positioning: Sniffing
The “Trusty” Bulb Syringe
Clear of Meconium?
Color pink?
Pulse Oximetry: Resuscitation monitor
 Not affected by
acrocyanosis
 Be patient and get a
reading
 If baby in shock, get
central IV access
Breathing or Crying?
 Indications for PPV (Positive
pressure ventilation)
 Apnea or gasping
 Heart rate <100 even if breathing
 Persistent central cyanosis (saturation
<90%) despite 100% free-flow oxygen
Self-Inflating Bag
O2 Reservoir
Pressure manometer
attaches
PEEP valve port
200-750ml Bag size
Neopuff
 CPAP(continuous positive
airway pressure (with
mask)
 Pressure limited
ventilation with PEEP
 Blended oxygen
 Eliminates variability
associated with bag
ventilation
Masks
Smallest sizes are for preterm infants
 Make sure the airway is
clear
 Lift the baby’s jaw into the
mask
 Keep the mouth slightly
open
Rate 40-60
Indications for Intubation
 Meconium and baby is not vigorous
 PPV by bag-mask does not result in good chest rise
 PPV needed beyond a few minutes
 Chest compressions necessary
 Route to administer epinephrine
 Special indications: Prematurity, CDH
Miller 0
Miller 1
>2000 gm
3.5
3.0
2.5
1000-2000 gm
<1000 gm
Stylet
Intubation Technique
Indications for Compressions
 Heart rate <60 bpm
after 30sec of PPV
 Coordinate with
ventilation
 4 events in 2 seconds
 90 compressions and 30
breaths per minute
One and Two and Three and Breathe
2 seconds
Compressions
2 thumb technique preferred
Medications: Epinephrine
 Indication: Heart rate <60 after 30 sec of
coordinated ventilation and compressions
 1:10,000 (0.1mg/ml)
 Route: ETT or IV
 0.1-0.3 ml/kg
 1ml Term
 0.5ml Preterm
 0.25ml Extreme preterm
Extended Algorithm
 Endotracheal Intubation if
not already accomplished
 Establish IV access with
UVC
 Stat CXR
 Discontinue efforts if no
heart rate after 15 minutes
 Indication: Heart rate
<60 after 30 sec of
coordinated ventilation
and compressions
 1:10,000 (0.1mg/ml)
 Route: ETT or IV
 0.1-0.3 ml/kg
 1ml Term
 0.5ml Preterm
 0.25ml Extreme preterm
IV Access: “Low” UVC
Volume
 Indication: No response to resuscitation
and evidence of blood loss
 Normal Saline
 Ringers or Blood as alternatives
 10 ml/kg, may repeat
 Route: IV (Umbilical vein)
Sodium Bicarbonate
 Indication: Documented or assumed
metabolic acidosis
 Concentration: 4.2% NaHCO3
(0.5meq/ml)
 Dose: 2meq/kg
 Route: IV (Umbilical vein)
Naloxone (Narcan)
 Indication: Severe
respiratory depression
after PPV has restored a
normal HR and color
and…
 History of maternal
narcotic administration
within the past 4 hours
 Dose: 0.1mg/kg of
1mg/ml solution
 Route: ETT, IV, IM, SQ
Thanks for attention!!!