An Obstetric Case History for You Max Brinsmead MB BS PhD March 2014

An Obstetric Case An Obstetric Case History for YouHistory for You

Max Brinsmead MB BS PhDMarch 2014

Stephanie is a 36-year old who Stephanie is a 36-year old who has been trying to have a baby has been trying to have a baby for 5 years. She has been told for 5 years. She has been told that she has endometriosis and that she has endometriosis and her husband has a low sperm her husband has a low sperm count. She has recently been to a count. She has recently been to a clinic in Bondi for IVF and thinks clinic in Bondi for IVF and thinks she might be pregnant as a she might be pregnant as a result. Today she has result. Today she has experienced a few spots of dark experienced a few spots of dark blood on her pants. She comes to blood on her pants. She comes to you for advice…you for advice…

Stephanie ?pregnant after IVF with Stephanie ?pregnant after IVF with PV bleedingPV bleeding

Do you require further history

Do you examine this patient

What tests might be useful


Further history that is desirable

When did she have the embryo transfer procedure

Exact date Any pain or other

symptoms Luteal phase support

drugs? How many embryos

were transferred Social circumstances,

any other pregnancies or medical problems etc.


Further history 2 embryos transferred 20 days ago

Progesterone pessaries for luteal support

Mastalgia for a week but no other pain

One spontaneous pregnancy 3 years ago. Miscarried “at 5 months”

FH of hypertension & diabetes. Non smoker. Married. School teacher.


Examination that is essential

Why?

Vital signs

Abdominal palpation for mass or tenderness

Must exclude ruptured ectopic pregnancy before Stephanie walks out your door


What is the best way to proceed from here?

What other tests may be desirable

A urine HCG test will confirm instantly if she is pregnant

PV ultrasound may confirm site of pregnancy and plurality

Take blood for quant. HCG, PROG and routine AN tests

Pregnancy test positive. Scan report: Pregnancy test positive. Scan report: “Twin intrauterine gestational sacs “Twin intrauterine gestational sacs identified. Both ovaries enlarged with identified. Both ovaries enlarged with cystic mixed echogenicity. Small amount cystic mixed echogenicity. Small amount of free fluid in the pelvis”of free fluid in the pelvis”

What will you tell Stephanie

What sort of twin pregnancy is this likely to be

What issues need to be explored at this stage of the pregnancy

“Twins” yet to be confirmed and reconfirmed at 12 weeks

Dichorionic and diamniotic from 2 embryos

Start planning for extra rest this pregnancy

Continue pregnancy vitamins, maybe extra iron

Issues of prenatal diagnosis

We need more information about the previous pregnancy

Stephanie with IVF Twins in the 1st Stephanie with IVF Twins in the 1st TrimesterTrimester

Subsequent ultrasound and serum biochemical testing

Further history

Confirmed a DC & DA pregnancy at 6 & 12 weeks. Low risk of aneuploidy for both.

Conception with same partner 3 yrs ago ended at 21w with PROM, pains for 2 hrs and miscarriage. Baby lived for 10 min. Autopsy NAD apart from “chorioamnionitis”

Stephanie 36 yr old G2P0 with IVF Stephanie 36 yr old G2P0 with IVF Twins in the 1st TrimesterTwins in the 1st Trimester

Stephanie wants midwife care and maybe a home birth

What do you recommend

Give facts and figures to back this

Overall perinatal mortality is 2-3x higher with twins

1:6 twin pregnancies end <30w

And a maternity hospital is best place for such to occur

Risk even higher for this patient, (age and reproductive history)

Her risk of complications of pregnancy is high eg pre eclampsia, diabetes

50% of twins are born by CS and many 2nd twins require assisted vaginal birth

Stephanie 36 yr old G2P0 with Twins Stephanie 36 yr old G2P0 with Twins at High Risk of PreTerm Deliveryat High Risk of PreTerm Delivery

What steps could be taken to reduce this patient’s risk of premature delivery

Cervical length measurements (best done serially and plotted)

Vaginal swab for vaginosis screening. GBS too.

Progesterone by injection or pessaries

Close antenatal surveillance and education

Increased rest (?hospital)Cervical suture

At 24 weeks gestation Stephanie comes At 24 weeks gestation Stephanie comes to hospital at 2 am with crampy to hospital at 2 am with crampy abdominal pain and some loss of fluid PVabdominal pain and some loss of fluid PVWhat is the

urgency for assessment

How big are the twins and what chance of survival if born now

What steps would you take to evaluate this pregnancy

Very urgentVery low chance of

survival and high risk of handicap if they do

Assess uterine activityPV speculum and test

fluidFetal Fibronectin testUltrasound for cervical

measurement and look at internal os

Irregular uterine tightenings only, cervix Irregular uterine tightenings only, cervix 2 cm long, closed at both ends but fetal 2 cm long, closed at both ends but fetal Fibronectin positive. Steroids were given Fibronectin positive. Steroids were given and Stephanie was flown to Newcastle for and Stephanie was flown to Newcastle for care.care.

What is the significance of the fetal Fibronectin test

Why steroids?

Why send this patient to Newcastle

50% risk of pre term delivery

Delivery preterm in a hospital with NICU facilities doubles the babies’ chance of survival and reduces the risk of handicap

At the John Hunter a UTI was diagnosed and treated. Stephanie was sent home after 2 weeks

A glucose challenge test was positive A glucose challenge test was positive (AGT) and follow up GTT confirmed (AGT) and follow up GTT confirmed gestational diabetesgestational diabetes

What steps are required in the management of this antenatal problem

Why

Dietary adviceSelf testing for blood

glucose, fasting and postprandial

Keep GLUC inside recommended levels with diet, insulin or Metformin

So as to avoid the complications of Diabetes in Pregnancy

At 29 weeks gestation Stephanie comes At 29 weeks gestation Stephanie comes to hospital with regular abdominal pains to hospital with regular abdominal pains and some loss PV passage of blood and and some loss PV passage of blood and mucous. Evaluation suggested premature mucous. Evaluation suggested premature labourlabour

List available tocolytic drugs and their pros and cons for this patient

IV Betamimetics eg. Salbutamol fast-acting but will complicate her diabetes

Oral Ca-channel blockers are the drug of choice. Watch BP

NSAID – adverse fetal effects

Glyceryl trinitrate patch not much used

Atobisan not available

Stephanie G2P0 at 29 weeks with DC DA Stephanie G2P0 at 29 weeks with DC DA twins in premature labour but twins in premature labour but contractions are suppressed with oral contractions are suppressed with oral NifedipineNifedipine

What other steps are required

Back your recommendations with some facts and figures

IM Betamethasone x2 over 24 hours will double survival and halve all risks of prematurity

IV Mg sulphate reduces risk of cerebral palsy 6-fold

Transfer to a hospital with NICU doubles chance of survival

Penicillin for GBSPsychological care of

the mother is important

Stephanie is transferred to Sydney and Stephanie is transferred to Sydney and delivered by Caesarean 5 days later. delivered by Caesarean 5 days later. Male 1050g and female 960g.Male 1050g and female 960g.

What problems could these babies face now and in the future

Who has the better chance of survival

Hyaline membrane disease

Temperature control and nutrition

JaundiceNecrotising

enterocolitisCerebral palsyOxygen-dependent

lung diseaseBlindnessGirls better than boys

Stephanie delivered of Twins by Stephanie delivered of Twins by Caesarean at 30 weeks. Male 1050g and Caesarean at 30 weeks. Male 1050g and female 960g.female 960g.

What are their chances?

When would the rate of survival be >95% and risk of handicap <2%

Should be 70 – 80% chance of survival and <10% risk of long term handicap

At >34 completed weeks of pregnancy given optimal perinatal care

Any Questions?Any Questions?

For copies of this Powerpoint go to www.brinsmead.net.au and follow the links

to “Postgraduates”. Called “Case of Multiple Pregnancy”

Documents

An Obstetric Case History for You Max Brinsmead MB BS PhD March 2014