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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

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ESSAY 132 - IUD

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		Posted by Sarwat F. Sat Jan 1, 2005 09:54 am
Death of one twin after twenty weeks of gestation occurs in between 0.5% to 6.5% of all twin pregnancies. Subsequent management of this woman will depend on maternal condition, fetal condition and wishes of the parents. Regarding fetal condition, antenatal record should be reviewed to know whether the twins are monochorionic or dichorionic. In case the twins are dichorionic and there is no maternal disease like preeclampsia, diabetes or thrombophilia (investigated after appropriate investigations), parents can be reassured regarding the safety of the live twin. As there are psychological problems regarding carrying a dead baby, mother may consider delivery. In such case appropriate counseling needs to be done regarding risks of prematurity and final decision is made in collaboration with the wishes of the couple. In case of preterm delivery steroids should be given to prevent respiratory distress. On the other hand if the twins are monochorionic, available evidence suggests that the death of one twin confers a risk of cerebral damage in 25% and of death in further 25% in the surviving twin. This situation is further compounded if there is any maternal disease present. In such circumstances delivery is considered. If however there is no maternal disease present the best plan of management is to delay delivery till sufficient maturity is gained and weekly ultrasound of fetal brain is done to determine any signs of fetal damage. In case of signs of fetal brain damage couple may be offered feticide and subsequent delivery. If the fetal brain is normal pregnancy can be continued. Continuation of pregnancy necessitates maternal and fetal monitoring. Maternal clotting status is monitored by weekly measurement of fibrinogen, prothrombin time, partial thromboplastin time and maternal platelets. Fetal monitoring is by cardiotocography, Doppler and ultrasound. The frequency of these tests is according to fetal condition. Route of delivery will take into account presentation of the live twin apart from other factors. Couple should be counselled that existing data favors abdominal delivery in case the live twin is breech or if the dead twin is leading, however the couples’s wishes take priority.
		Posted by vijaya L. Sat Jan 1, 2005 07:55 pm
Management of this tricky situation depends upon the probable cause of the death and condition of the surviving twin. The most important part of the management is adequate counseling of the mother. If the surviving twin may need early delivery probably because of growth restriction , which is common among the twins and which can affect both or one. Steroids should be offered and mother counseled regarding the need for the delivery and the mode of delivery . If the surviving twin is healthy , then pregnancy should continued until up to 34 weeks after intense counseling. The risks identified are encephalopathy of the surviving twin and coagulopathy for the mother. Mother can be monitored by weekly fibrinogen levels, a level below 100mg/dl is said to be critical and delivery considered Foetus is monitored by weekly ultrasound for growth and well-being, because maternal perception of foetal movements or nonstress test are not reliable in this condition. In case of foetal compromise or at the completion of 34 weeks delivery should be offered . mode of the delivery will depend on the presenting twin and its presentation. If the surviving twin is the first twin presenting as cephalic, then vaginal delivery is attempted. Prostaglandin ripening of the cervix might be required before the induction the labour. On the other hand if the surviving twin is presenting as breech then ceaserean section can be offered because it is more risky to deliver preterm breech vaginally.should the mother decline the offer an experienced obstetrician should conduct or supervise the delivery and a senior peadiatrician should be present for the delivery . Coagulopathy should be kept in mind when risk assessment for the thromboembolism is being done.. Should the mother decline delivery at 34 weeks, then informed written consent should be taken and the pregnancy continued to be monitored. Neonate should be investigated for the possible brain damage after the birth.
		Posted by uma M. Sun Jan 2, 2005 01:48 am
Death of single twin has an incidence of 0.5-6.5% of all twin gestations .subsequent management aims at avoiding maternal &surviving fetal complications As a part of evaluation I would elicit brief history _ history of any medical disorders like Diabetes, SLE, HTN, any history of PIH. Review past obstetric history -any IUGR,PIH, fetal losses.I would also review AN record dating , note any complications in this pregnancy like PIH ,GDM.I will review US report for e/o IUGR, HYDRAMNIOS, oligoamnios, cord abnormalaties, amnionicity chorionicity as subsequent management & prognosis depends on chorionicity. I will examine the patient check her BP for PIH, abdominal examination to note uterine size, check presentation of fetuses, Fetal heart, and if she is in labour.Investigations aim to identify any cause, maternal complications &damage to surviving fetus. These include GTT, KleihaurBetke Test for FMH, U&E, RFT , Coagulation profile as mother is at risk of coagulopathy.US of surving fetus , growth, liquor, any cord complications like entangelment.Note AN inv already done like group typing HIV,HBsSG,VDRL,CBP. Subequent management depends on presense or absense of complications like PIH Diabetes which might effect other fetus, chorionicity, status of living twin. If any pregnancy complications are present it carries poor prognosis to surving fetus and so delivery immediately is advisable.In case of monochrionic placentationwith no other complications main risk to surviving fetus is brain damage leading to prosencephaly, CP from passage of thromboplastin material from dead twin to surviving through shared circulation.Weekly monitoring of fetus with USfor brain damage, monitoring mother for coagulopathy isdone.Over all there is 50% risk of death or damage of other fetus. Acute TTTS is a complication needs monitoring as death occurs to living twin in majority of cases.If pregnancy is Dichorionic twin then , as ther e is no shared placentation only maternal coagulation needs to be monitored. Referral to teritary center with NICU facilities is advisable. If delivery is before 36 wks offer steroids for lung maturity.Monitor co twin with weekly CTG ,Doppler , AFI, BPP.Weekly maternal coagulation profile will be done.Spontaneous labour ensues in in majority in few weeks. If not delivery after 36 wks is preferable if living fetus is doing well with no evidence of maternal complications.Early delivery if any maternal or fetel complications develop.Route of delivery _vaginal. c.section only if living twin is nonvertex. Continous EFM is advocated. After delivery examine the placenta for any calcifications ,abnormalities, cord knots. send placenta for biopsy . councel mother regarding fetal autopsy, take x-rays to exclude skeletal abn. Councel the couple regarding the prognosis of surviving twin.there is increased incidence of CP, NICU admission, Cystic brain damage,Neonatal death, prematurity, stillbirth. This has a lot of emotional pressure for parents.Immediate councelling by attending doctor, sterss that she had nothig to do with the death, she could have done nothing to avoid this complication, . arrange for Bereavement counselling. assist her to make a memorobilia of dead twin, take pictures foot prints, arrange for funneral. Adive regarding support groups (SANDS)
		Posted by uma M. Sun Jan 2, 2005 01:50 am
Death of single twin has an incidence of 0.5-6.5% of all twin gestations .subsequent management aims at avoiding maternal &surviving fetal complications As a part of evaluation I would elicit brief history _ history of any medical disorders like Diabetes, SLE, HTN, any history of PIH. Review past obstetric history -any IUGR,PIH, fetal losses.I would also review AN record dating , note any complications in this pregnancy like PIH ,GDM.I will review US report for e/o IUGR, HYDRAMNIOS, oligoamnios, cord abnormalaties, amnionicity chorionicity as subsequent management & prognosis depends on chorionicity. I will examine the patient check her BP for PIH, abdominal examination to note uterine size, check presentation of fetuses, Fetal heart, and if she is in labour.Investigations aim to identify any cause, maternal complications &damage to surviving fetus. These include GTT, KleihaurBetke Test for FMH, U&E, RFT , Coagulation profile as mother is at risk of coagulopathy.US of surving fetus , growth, liquor, any cord complications like entangelment.Note AN inv already done like group typing HIV,HBsSG,VDRL,CBP. Subequent management depends on presense or absense of complications like PIH Diabetes which might effect other fetus, chorionicity, status of living twin. If any pregnancy complications are present it carries poor prognosis to surving fetus and so delivery immediately is advisable.In case of monochrionic placentationwith no other complications main risk to surviving fetus is brain damage leading to prosencephaly, CP from passage of thromboplastin material from dead twin to surviving through shared circulation.Weekly monitoring of fetus with USfor brain damage, monitoring mother for coagulopathy isdone.Over all there is 50% risk of death or damage of other fetus. Acute TTTS is a complication needs monitoring as death occurs to living twin in majority of cases.If pregnancy is Dichorionic twin then , as ther e is no shared placentation only maternal coagulation needs to be monitored. Referral to teritary center with NICU facilities is advisable. If delivery is before 36 wks offer steroids for lung maturity.Monitor co twin with weekly CTG ,Doppler , AFI, BPP.Weekly maternal coagulation profile will be done.Spontaneous labour ensues in in majority in few weeks. If not delivery after 36 wks is preferable if living fetus is doing well with no evidence of maternal complications.Early delivery if any maternal or fetel complications develop.Route of delivery _vaginal. c.section only if living twin is nonvertex. Continous EFM is advocated. After delivery examine the placenta for any calcifications ,abnormalities, cord knots. send placenta for biopsy . councel mother regarding fetal autopsy, take x-rays to exclude skeletal abn. Councel the couple regarding the prognosis of surviving twin.there is increased incidence of CP, NICU admission, Cystic brain damage,Neonatal death, prematurity, stillbirth. This has a lot of emotional pressure for parents.Immediate councelling by attending doctor, sterss that she had nothig to do with the death, she could have done nothing to avoid this complication, . arrange for Bereavement counselling. assist her to make a memorobilia of dead twin, take pictures foot prints, arrange for funneral. Adive regarding support groups (SANDS)
		Posted by Nibedita R. Mon Jan 3, 2005 12:54 am
Management of this woman includes evaluation of psychological status of the mother, identification of the risk to the surviving twin, risk to the mother of carrying a dead foetus, surveillance of the surviving twin and planning for timing for delivery. Consideration should be pain on parental view and wishes and bereavement counselling is crucial in this circumstance. Understanding that death of one twin may be due to hostile environment, which is a potential threat to the surviving twin. From history examination and antenatal records identify possible risk factors like preeclampsia, IDDM, thrombophilia and infection. In which case severe intrauterine growth retardation and hypoxia may be the possible cause of the foetal demise. Relevant investigations like FBC, kleihaeur, blood group Rh status and saving, GTT or fasting glucose and infection screen should be performed. In these circumstances a dichorionic twin is also under threat. Development, growth of second twin and the chorionicity of the pregnancy would influence management. Identification of the chorionicity of the twin from early week scan is important as a monochorionic placenta would indicate a raised risk of communicating vessels putting the surviving twin at particular risk of neurological damage (20-25%), cerebral palsy, porencephaly, cerebral infarction, renal cortical necrosis, structural congenital anomalies and also at increased risk of foetal demise and prematurity. Neurological problems in surviving twin may not be predictable and close monitoring with the help of detailed ultrasound scan, biophysical profile, Doppler and cardiotocography for at least 7 days to establish whether any intracerebral insult has occurred. If no abnormality detected weekly ultrasound may be performed for foetal surveillance and growth monitoring. Mother is at increased risk of coagulopathy, although the risk is lower than singleton pregnancy. Monitoring the clotting status of fibrinogen, PT, APTT and maternal platelet on weekly basis and a low dose heparin may be beneficial. Prophylactic steroid should be given to promote surfactant production. If premature labour starts, no attempt is made to stop labour, as this is likely to be a sign of foetal compromise. To deliver the surviving twin, balancing the risk of prematurity versus risk of remaining in utero is necessary. After 34 weeks the risk of prematurity is less than the risk of continuation of pregnancy. Therefore, delivery may be expediated following consultation with SCBU and transfer the patient to tertiary centre if appropriate facilities are not available. Mode of delivery should be least traumatic for the surviving twin. In the presence of malpresentation (breech or transverse lie of first twin), signs of foetal compromise or unfavourable cervix, caesarean section is commonly the preferred route. It should be preformed by an experienced obstetrician, as this may be difficult at 34 weeks gestation specially if associated with malpresentation. Provide psychological support to the mother during delivery. Active management of third stage of labour with the help of oxytocic and prostaglandin will minimise atonic PPH. After delivery examine the baby for structural anomaly and placenta for abnormality. Discuss with the parent regarding post mortem examination and the extent of organ and tissue being removed. Careful paediatric surveillance is justified for the neonate and should be investigated by cranial ultrasound or MRI to identify cranial insult. Bereavement counselling and advice regarding support group should be given during discharge and discuss regarding contraceptive options and arrange for follow up appointment.
		Posted by SWATI M. Mon Jan 3, 2005 12:09 pm
The situation may have profound psychological implication due to loss of one baby and news must be disclosed in a sympathetic manner by a senior personnel.This condition may increase maternal morbidity and has potential to affect the health of surviving fetus.Woman and preferably her family should be involved ,explained the situation .They should be provided with the information to enable them to make informed choice and her wishes are taken into consideration for the further management. Before formulating plan her antenatal records are viewed,noting her blood pressure readings,and ultrasound details. Look for the chorionicity of twins in ultrasound records which influences management,obvious cause of structural deformity in dead fetus ,note time of detection of death and also serial growth pattern for surviving twin as growth retardation is common in twin pregnancy and clinical examination have limited value in predicting fetal growth in twins.History of duration of decreased movements to predict time of death as mother develops complication , disseminated intravascular coagulation if dead fetus remains for prolonged period in ?utero.Parity,mode of previous delivery ,any risk factor during current pregnancy such as preeclampsia taken into consideration. Clinical examination to detect high risk factor such as preeclampsia ,risk of developing is higher in twins which may indicate need for early delivery.Note fetal heart rate.Ensure fetal well being of surviving fetus by cordiotocography and biphysical profile if growth restriction. Investigations done antenatally reviewed ,coagulation screen performed as DIC can complicate. Delivery will be indicated if complications detected such as severe preeclampsia,evidence of DIC.If fetal compromise in surviving fetus, risks of preterm delivery weighed against benefits of continuation.Neonatologist should be involved during the decision. Antenatal steroids are given but it?s efficacy in twins is reduced. Role of expectant management depends on chorionicity if urgent delivery is not indicated.Woman should be conselled,in monochorionic twins, 25 % risk of sudden intrauterine death in surviving fetus due to thromboplastin release and vascular anastomoses.Also 25% risk of developing neurological handicap in cotwin.Such risk does not exist for dichorionic twins. Consevative management is appropriate for dichorionic. If monochorionic and woman opt for consevative management,she is monitored biweekly with cardiotocography,weekly coagulation studies. Conservative management till fetus is mature( till 34 weeks. ) Vaginal delivery if surviving fetus is presenting first in dichorionic and monochorionic diamniotic if no obstretric contraindication to vaginal delivery.Caesarean section is indicated if dead fetus is presenting first irrespective of chorionicity as risk of prolonged labour(dead fetus can deliver from partially dilated cervix)and also indicated in monoamniotic monochorionic as risk of cord prolapse with membrane rupture.Neonatologist to attend at delivery.Neonate needs paediatric follow up for neurological development if monochorionic. Look for obvious cause for fetal death,true knots of cord. Ensure support at all stages.At delivery may have mixed reaction.Help is offered for bereavement.Let them see and hold dead baby if wished.Discuss postmartem if no obvious cause. Discuss future contraception.
		Posted by Vaijayanti R. Tue Jan 4, 2005 04:30 am
Explain the implications of the diagnosis, and the possible consequences to the mother - coagulation defects, psychological sequelae in the mother; and neurological damage, prematurity in the surviving twin. bereavement counselling must be organized for the couple. Further management will not only be based on chorionicity and the condition ofthe surviving twin, but also on the parents wishes. Review history, examination and past records to identify any factors that may modify management - diabetes, hypertension,growth retardation.USG reports are examined to determine chorionicity( 100% accurate in first trimester scans), anomalies in the survivor, discordant growth, TTTS or the TRAP sequence. Review baseline investigations - ABO grouping . Rh typing, hematocrit,diabetes and infection screen. A coagulation profile( fibrinogen, Pt,APTT,paltelet count) is done on the mother, though in this case the risk of DIC is low( risk of 25% after 3 weeks of IUD) Any inutero fetal compromise inthe surviving twin is assessed by liquor volume, BPP, cardiotocograph and Doppler studies.The extent of neurological damage is not only difficult to predict ( upto 20% may have multicystic encephalomalacia, cerebral infarcts ) but is also difficult to assess.MRI may be better in doing so than USG. Delivery should be conducted at a tertiary care centre with facilities for neonatal intensive care. Evidence of fetal distress warrants immediate delivery( caesarean section) irrespective of chorionicity. There is no role for the routine use of tocolytics, but these drugs( nifedipind, atosiban, ritodrine) may be used to cover an inutero transfer to a specialist centre Prophylactic steriods ( 12 mg Betamethasone IM x 2 doses , 24 hrs apart) are recommended in view of the high risk of iatrogenic prematurity, even though their role in multiple gestation is controversial. Dichorionic pregnancies, with no evidence of fetal compromise can be allowed to continue, although with careful monitoring - weekly or bi weekly BPP with liquor volume and weekly coagulation profile for the mother.Consider terminating pregnancy by 34 weeks if not delivered til then Monochorionic pregnancies are at higher risk for perinatal mortality ( upto 50%). Delivery is recommended as the risks of prematurity at 30 weeks is much less than the risks of the neurological sequelae if the pregnancy is allowed to continue. The couple are counselled regarding the prognosis of both the options. The mode of delivery depends on the presentation of the first twin, and associated risk factors. Whatever be the modality, minimal trauma must be ensured for the surviving twin. Consideringthe prematurity , it may be a better to perfrom an elective caserean section, than allow for a vaginal delivery The delivery should be conducted by a senior obsyetrician, with a neonatologist in attendance. The couple should be provided adequate psychological support during the delivery and after,as there is a higher incidence of postnatal depressionin these women. The parents wishes regarding the remains of the dead twin must be respected. A postmortem is offered to determine any possible cause if none was evident Access to social services and support groups must be organized If here is a risk of Rh Isoimmunization, 500 iu Anti D is given within 72 hrs Contraception is discussed, and supplies offered. Follow up appointment is arranged.
		Posted by SWATI M. Thu Jan 6, 2005 12:27 pm
Dear Paul, Please mark my essay. Thanks.
		Posted by narmin B. Fri Jan 7, 2005 12:23 am
A 30 year old woman with a twin pregnancy complains of reduced foetal movements at 30 weeks gestation. Ultrasound scan reveals intrauterine death of one twin. Justify your subsequent management of her pregnancy. Following the death of one twin, the surviving twin is at risk of intrauterine death, intrauterine growth retardation and prematurity. Also the mother is at risk of coagulation disorders and disseminated intravascular coagulation (DIC). Therefore the subsequent management includes, counselling the mother about the risks, administration of steroids, regular maternal blood test for coagulation, close monitoring of the surviving foetus and plan for delivery, and follow-up. Mother should be counselled in a sympathetic and supportive way, as this is a very difficult time for her. Since the parents are very anxious to know the cause of death, if there is any reason such as twin to twin transfusion (TTT) syndrome in monochorionic twins, it should be explained. Although in the majority of cases it is difficult to determine the cause of death at this stage. The risks to the second twin and the plan of management should be explained, as the mother should understand the need for frequent monitoring of the foetal wellbeing and the need for performing regular blood tests. As there is high risk of preterm delivery, corticosteroids should be given to the mother. The usual method is the administration of two doses of dexamethasone 12 mg, 12 hours apart. Corticosteroids reduce the incidence of respiratory distress syndrome and intraventricular haemorrhage. Repeat doses are not indicated as there is no evidence about its efficacy or safety. Maternal blood should be sent for coagulation tests every week, as there is risk of coagulopathy after intrauterine death. If coagulation profile was abnormal, induction of labour is indicated because of the risk of DIC and bleeding. Although it is uncommon, but DIC and bleeding may be seen which should be managed by administration of whole blood, and coagulation factors and cryoprecipitate and fresh frozen plasma. Close monitoring of the foetal wellbeing is mandatory. Weekly Doppler studies and amniotic fluid index and fortnightly growth scans should be performed. In the presence of absent or reversed end diastolic flow or oliogohydramnios; the mother should be admitted for delivery because these abnormal results are associated with foetal distress in the majority of cases. Since there is a risk of intrauterine death in spite of normal Doppler studies and amniotic fluid index, induction of labour is advisable at 34 weeks. Induction of labour at this stage of pregnancy is associated with high failure rate because the cervix is usually unfavourable and malpresentation such as breech is more common. Therefore caesarean section can be the first choice in some cases. After delivery the foetuses should be examined for gross abnormalities. The parents should be seen to review the process of labour and delivery and also to obtain a consent form for performing an autopsy. Another appointment should be arranged for the mother to be seen in the postnatal clinic six weeks after delivery. In this visit the whole period of pregnancy and delivery and the steps that have been taken should be reviewed. Also the result of post mortem examination should be discussed. Some mothers may need further counselling which should be arranged. Also there are some support groups for multiple pregnancies which can provide further help and support.