lecture 10 fetal distress. definition definition fetal distress is the term commonly used to...

Lecture 10Lecture 10

FETAL DISTRESSFETAL DISTRESS

DEFINITIONDEFINITION

•Fetal distress is the term commonly used to Fetal distress is the term commonly used to describe fetal describe fetal hypoxiahypoxia

•It is a clinical diagnosis made by It is a clinical diagnosis made by indirectindirect methods and should be defined as: methods and should be defined as:

Hypoxia that may result in fetal damage / death if Hypoxia that may result in fetal damage / death if not reversed or the fetus delivered immediatelynot reversed or the fetus delivered immediately

•It includes It includes acuteacute distress and distress and chronicchronic distress distress

ETIOLOGYETIOLOGY

Maternal:Maternal:

poor placental perfusionpoor placental perfusion

hypovolaemiahypovolaemia

hypotensionhypotension

myometrial hypertonusmyometrial hypertonus

• prolonged laborprolonged labor

• excess oxytocinexcess oxytocin

Fetal:Fetal:

cord compressioncord compression

• oligohydramniosoligohydramnios

• entanglemententanglement

• prolapseprolapse

pre-existing hypoxia or growth pre-existing hypoxia or growth

retardationretardation

infectioninfection

cardiaccardiac

ETIOLOGYETIOLOGY

MECHANISMMECHANISM

• There are potentially limitless causes for There are potentially limitless causes for fetal distress, but several key mechanisms fetal distress, but several key mechanisms are usually involvedare usually involved

• Contractions reduce temporarily placental Contractions reduce temporarily placental blood flow and can compress the umbilical blood flow and can compress the umbilical cordcord

• If a women is in labor longer then this can If a women is in labor longer then this can

cause fetal distress via the above cause fetal distress via the above mechanismmechanism

MECHANISMMECHANISM

• Acute distress can be a result of:Acute distress can be a result of: placental abruptionplacental abruption prolapse of the umbilical cordprolapse of the umbilical cord (especially with (especially with

breech presentations)breech presentations) hypertonic uterine stateshypertonic uterine states use of oxytocinuse of oxytocin

• HypotensionHypotension can be caused by either epidural can be caused by either epidural anesthesia or the supine position, which reduces anesthesia or the supine position, which reduces inferior vena cava return of blood to the heartinferior vena cava return of blood to the heart

• The decreased blood flow in hypotension can be The decreased blood flow in hypotension can be a cause of fetal distressa cause of fetal distress

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS

Acute fetal distressAcute fetal distress

• Cardiotocography signsCardiotocography signs::

Increased / decreased fetal heartIncreased / decreased fetal heart (tachycardia (tachycardia and bradycardia), especially and bradycardia), especially duringduring and and afterafter a a contraction decreased varibility in the fetal contraction decreased varibility in the fetal heart rateheart rate

Abnormal fetal heart rateAbnormal fetal heart rate (< 120 or > 160 bpm) (< 120 or > 160 bpm)

• A normal fetal heart rate may slow during a A normal fetal heart rate may slow during a contraction but usually recovers to normal as contraction but usually recovers to normal as soon as the uterus relaxessoon as the uterus relaxes

• A very slow fetal heart rate in the absence of A very slow fetal heart rate in the absence of contractions or persisting after contractions is contractions or persisting after contractions is suggestive of fetal distress suggestive of fetal distress


• A A rapid fetal heart raterapid fetal heart rate may be a response to: may be a response to: maternal fever maternal fever drugsdrugs hypertension hypertension amnionitisamnionitis

• In the absence of a rapid maternal heart rate, a In the absence of a rapid maternal heart rate, a rapid fetal heart rate = a sign of fetal distressrapid fetal heart rate = a sign of fetal distress

• For a diagnosis of fetal distress to be made, one For a diagnosis of fetal distress to be made, one or more of the following must be present: or more of the following must be present: persistent severe variable decelerationpersistent severe variable deceleration persistent and non-remediable late declarationspersistent and non-remediable late declarations persistent severe bradycardiapersistent severe bradycardia


• Amniotic fluid is contaminated by Amniotic fluid is contaminated by meconiummeconium

• There are 3 degrees about contaminatedThere are 3 degrees about contaminated

I - I - slight slight contaminationcontamination• The color of the amniotic fluid = The color of the amniotic fluid = slight greenslight green

IIII -- mildmild contamination contamination • Color of the amniotic fluid = Color of the amniotic fluid = dark greendark green

III - III - severesevere contamination contamination • Color of the amniotic fluid is dark yellow. Color of the amniotic fluid is dark yellow. • If the amniotic fluid is severely contamination, If the amniotic fluid is severely contamination,

it suggests the, it suggests the, fetal distressfetal distress - it must be - it must be managed as soon as possiblemanaged as soon as possible


• Decreased fetal movement felt by the Decreased fetal movement felt by the mothermother

• Biochemical signs - Biochemical signs - assessed by collecting a assessed by collecting a small sample of baby‘s blood from a scalp small sample of baby‘s blood from a scalp prick through the open cervix in labor:prick through the open cervix in labor:

Fetal acidosis elevated fetal blood lactate Fetal acidosis elevated fetal blood lactate levels levels

A fetal scalp A fetal scalp pH < 7.2pH < 7.2 , , PoPo22 >60mmHg >60mmHg suggests fetal distresssuggests fetal distress


Chronic Fetal Distress Chronic Fetal Distress

• Decreased or disappear fetal movement:Decreased or disappear fetal movement:

< 10 times per 12 hours is regarded as decreased< 10 times per 12 hours is regarded as decreased

With the first effect of hypoxia, the fetal With the first effect of hypoxia, the fetal movement is increasedmovement is increased

If the hypoxia persists, the fetal movement is If the hypoxia persists, the fetal movement is decreased, and may disappeardecreased, and may disappear

If the fetal movement lost, the fetal heart beat If the fetal movement lost, the fetal heart beat will be disappearing within 24 hourswill be disappearing within 24 hours

Cautions: Dangerous for the fetus if the fetal Cautions: Dangerous for the fetus if the fetal movement disappear. Management movement disappear. Management immediately!!immediately!!


• Abnormal cardiotocography signs:Abnormal cardiotocography signs:

Slow fetal heart rate(<120bpm) or Slow fetal heart rate(<120bpm) or rapid fetal heart rate (>180bpm) rapid fetal heart rate (>180bpm) last last more than 10 minmore than 10 min in the absence of in the absence of contractions contractions is suggestiveis suggestive of fetal of fetal distressdistress

The fetal heart rate > 160 bpm , The fetal heart rate > 160 bpm , especially > 180 bpm, it suggests especially > 180 bpm, it suggests early early hypoxiahypoxia, unless the maternal heart , unless the maternal heart rate is fasterrate is faster


• FHR < 120bpm, typically less than 100bpm FHR < 120bpm, typically less than 100bpm It is very danger for fetusIt is very danger for fetus

• The fetal heart rate normally show The fetal heart rate normally show continuous minor variations, with a range of continuous minor variations, with a range of about 5 bpm, loss of base line variability about 5 bpm, loss of base line variability implies that the cardiac reflexes are implies that the cardiac reflexes are impaired, either from the effect of impaired, either from the effect of hypoxiahypoxia or of or of drugsdrugs such as such as valiumvalium It may be seriousIt may be serious


• Early decelerationEarly deceleration: with each contraction the : with each contraction the rate often slows, but it returns to normal soon rate often slows, but it returns to normal soon after removal of the stressafter removal of the stress

• The early deceleration in the heart rate start The early deceleration in the heart rate start within 30 seconds of the onset of the within 30 seconds of the onset of the contraction and return rapidly to the baseline contraction and return rapidly to the baseline rate rate

• It is not of serious significanceIt is not of serious significance as a rule and as a rule and indicate that while the fetus is undergoing indicate that while the fetus is undergoing some stress the cardiac control mechanisms some stress the cardiac control mechanisms are responding normallyare responding normally


EARLY DECELERATIONEARLY DECELERATION

• Variable decelerationVariable deceleration: no consistent : no consistent relationship with uterine contraction. relationship with uterine contraction.

• It is sometimes caused by compression of the It is sometimes caused by compression of the umbilical cord between the uterus and the umbilical cord between the uterus and the fetal body, or because it is looped round fetal body, or because it is looped round some part of the fetussome part of the fetus

• Provided that it does not persist for more Provided that it does not persist for more than a few minutes it may have little than a few minutes it may have little significance, but significance, but persistence for more than persistence for more than 15 minutes15 minutes would call for treatment would call for treatment


VARIABLE DECELERATIONVARIABLE DECELERATION

• The most serious pattern of heart rate The most serious pattern of heart rate changes is changes is fetal bradycardiafetal bradycardia with loss of with loss of baseline variability and baseline variability and late decelerationslate decelerations

• Decrease (defined as onset of deceleration to Decrease (defined as onset of deceleration to nadir =30 seconds) and return to baseline nadir =30 seconds) and return to baseline FHR associated with a uterine contraction. FHR associated with a uterine contraction.

• The deceleration is delayed in timing, with The deceleration is delayed in timing, with the nadir of the deceleration occurring after the nadir of the deceleration occurring after the peak on the contractionthe peak on the contraction


LATE DECELERATIONLATE DECELERATION

• Biophysical Profile:Biophysical Profile: Amniotic Fluid Volume Normal = 2 Points Amniotic Fluid Volume Normal = 2 Points Non-Stress Test Result Positive = 2 Points Non-Stress Test Result Positive = 2 Points Fetal Breathing Movements Active = 2 Points Fetal Breathing Movements Active = 2 Points Fetal Extremity/Trunk Movements Active = 2 Fetal Extremity/Trunk Movements Active = 2

PointsPoints Fetal Movements Active= 2 PointsFetal Movements Active= 2 Points

• If Biophysical Profile scores If Biophysical Profile scores < 4< 4 suggest fetal suggest fetal distressdistress

• Placental Insufficiency: Low estriol levels, EPlacental Insufficiency: Low estriol levels, E33 in in urine urine < 10mg/24h< 10mg/24h

BIOPHYSICAL PROFILEBIOPHYSICAL PROFILE

TREATMENTTREATMENT

• Reposition patient: left-side-lying positionReposition patient: left-side-lying position

• Administer oxygen by maskAdminister oxygen by mask

• Perform vaginal examination to check for Perform vaginal examination to check for

prolapsed cordprolapsed cord

• Ensure that qualified personnel are in Ensure that qualified personnel are in attendance for resuscitation and care of the attendance for resuscitation and care of the newbornnewborn

Note: each institution shall define in writing Note: each institution shall define in writing the term qualified personnel for the term qualified personnel for resuscitation and care of the newbornresuscitation and care of the newborn

• Each of the following actions should be Each of the following actions should be performed and documented prior to starting a performed and documented prior to starting a Cesarean section for fetal distress:Cesarean section for fetal distress:

Perform vaginal exam to rule out imminent Perform vaginal exam to rule out imminent vaginal deliveryvaginal delivery

Initiate preoperative routinesInitiate preoperative routines

Monitor fetal heart tones (by continuous Monitor fetal heart tones (by continuous

fetal monitoring or by auscultation) fetal monitoring or by auscultation) immediately prior to preparation of the immediately prior to preparation of the abdomen abdomen

TREATMENTTREATMENT

• Ensure that qualified personnel are in Ensure that qualified personnel are in attendance for resuscitation and care of attendance for resuscitation and care of the newborn (each institution shall define the newborn (each institution shall define in writing the term qualified personnel for in writing the term qualified personnel for resuscitation and care of the newborn)resuscitation and care of the newborn)

• STOPSTOP using using oxytocinoxytocin ! !

Oxytocin can strengthen the contraction Oxytocin can strengthen the contraction of uterine which affects the baby's heart of uterine which affects the baby's heart raterate

TREATMENTTREATMENT

DEFINITIONS MUST GRASPEDDEFINITIONS MUST GRASPED

• Baseline FHRBaseline FHR::

approximate mean FHR rounded to approximate mean FHR rounded to

increments of 5 bpm during a 10-minute increments of 5 bpm during a 10-minute segment, excluding periodic or episodic segment, excluding periodic or episodic changes, periods of marked FHR changes, periods of marked FHR variability, and segments of the baseline variability, and segments of the baseline that differ by > 25 bpmthat differ by > 25 bpm

In any 10-minute window, the minimum In any 10-minute window, the minimum baseline duration must be at least 2 baseline duration must be at least 2 minutes or the baseline for that period is minutes or the baseline for that period is indeterminate indeterminate

• Baseline FHR variabilityBaseline FHR variability::

Fluctuations in the baseline FHR =2 cycles / minFluctuations in the baseline FHR =2 cycles / min

These fluctuations are irregular in amplitude These fluctuations are irregular in amplitude and frequency, and are visually quantitated as and frequency, and are visually quantitated as the amplitude of the peak to the trough in the amplitude of the peak to the trough in beats per minute as follows: beats per minute as follows: • amplitude range undetectable, absent FHR amplitude range undetectable, absent FHR

variability; variability; • amplitude range greater than undetectable but = amplitude range greater than undetectable but =

5 bpm, minimal FHR variability; 5 bpm, minimal FHR variability; • amplitude range 6 bpm to 25 bpm, moderate FHR amplitude range 6 bpm to 25 bpm, moderate FHR

variability; variability;

• amplitude range >25 bpm, marked FHR variabilityamplitude range >25 bpm, marked FHR variability

DEFINITIONS MUST GRASPED DEFINITIONS MUST GRASPED

• BradycardiaBradycardia:: a baseline FHR <120 bpma baseline FHR <120 bpm

• TachycardiaTachycardia:: a baseline FHR >160 bpma baseline FHR >160 bpm


• Early decelerationEarly deceleration::

a visually-apparent, gradual decrease a visually-apparent, gradual decrease (defined as onset of deceleration to nadir (defined as onset of deceleration to nadir =30 seconds) and return to baseline FHR =30 seconds) and return to baseline FHR associated with a uterine contractionassociated with a uterine contraction

The decrease is calculated from the most The decrease is calculated from the most recently determined portion of the recently determined portion of the baselinebaseline

It is coincident in timing with the nadir of It is coincident in timing with the nadir of the deceleration occurring at the same the deceleration occurring at the same time as the peak of the contractiontime as the peak of the contraction

In most cases the onset, nadir, and In most cases the onset, nadir, and recovery of the deceleration are coincident recovery of the deceleration are coincident with the beginning, peak, and ending of with the beginning, peak, and ending of the contraction, respectivelythe contraction, respectively


• Variable decelerationVariable deceleration::

a visually-apparent, abrupt decrease in a visually-apparent, abrupt decrease in FHR below the baselineFHR below the baseline


The decrease in FHR below the baseline is The decrease in FHR below the baseline is

=15 bpm, lasting =15 seconds and =2 =15 bpm, lasting =15 seconds and =2 minutes from onset to return to baselineminutes from onset to return to baseline


• Late decelerationLate deceleration::

a visually-apparent, gradual decrease a visually-apparent, gradual decrease (defined as onset of deceleration to nadir = (defined as onset of deceleration to nadir = 30 seconds) and return to baseline FHR 30 seconds) and return to baseline FHR associated with a uterine contraction associated with a uterine contraction


The deceleration is delayed in timing, with The deceleration is delayed in timing, with the nadir of the deceleration occurring the nadir of the deceleration occurring after the peak on the contractionafter the peak on the contraction


DIAGNOSIS:DIAGNOSIS:Absence of uterine growthAbsence of uterine growthSerial ß-hcgSerial ß-hcgLoss of fetal movementLoss of fetal movementAbsence of fetal heartAbsence of fetal heartDisappearance of the signs & symptoms of pregnancyDisappearance of the signs & symptoms of pregnancyX-ray X-ray Spalding signSpalding sign Robert’s signRobert’s signU/S U/S 100% accurate Dx100% accurate Dx

DEFINITION:DEFINITION: • dead fetuses or newborns weighing > 500g or dead fetuses or newborns weighing > 500g or > 20 wks gestation> 20 wks gestation

4.54.5 / /10001000 total birthstotal births

INTRAUTERINE FETAL DEATH INTRAUTERINE FETAL DEATH (IUFD) (IUFD)

Fetal causes 25-40%Fetal causes 25-40%•Chromosomal anomaliesChromosomal anomalies•Birth defectsBirth defects•Non immune hydropsNon immune hydrops•InfectionsInfectionsPlacental 25-35%Placental 25-35%•AbruptionAbruption•Cord accidentsCord accidents•Placental insufficiencyPlacental insufficiency•Intrapartum asphyxiaIntrapartum asphyxia•P PreviaP Previa•Twin to twin transfusion STwin to twin transfusion S•ChrioamnionitisChrioamnionitis

Maternal 5-10%Maternal 5-10%•Antiphospholipid antibodyAntiphospholipid antibody•DMDM•HPTHPT•TraumaTrauma•Abnormal laborAbnormal labor•SepsisSepsis•Acidosis/ HypoxiaAcidosis/ Hypoxia•Uterine ruptureUterine rupture•Postterm pregnancyPostterm pregnancy•DrugsDrugs•ThrombophiliaThrombophilia•Cyanotic heart diseaseCyanotic heart disease•EpilepsyEpilepsy•Severe anemiaSevere anemiaUnexplained 25-35%Unexplained 25-35%

CAUSES OF IUFDCAUSES OF IUFD

A systematic approach to fetal death is valuable inA systematic approach to fetal death is valuable in determining the etiologydetermining the etiology

11--HISTORYHISTORY

A-Family historyA-Family history•Recurrent abortionsRecurrent abortions•VTE/ PEVTE/ PE•Congenital anomaliesCongenital anomalies•Abnormal karyptypeAbnormal karyptype•Hereditary conditionsHereditary conditions•Developmental delayDevelopmental delay

B-Maternal HistoryB-Maternal HistoryI-Maternal medical conditionsI-Maternal medical conditions•VTE/ PEVTE/ PE•DMDM•HPTHPT•ThrombophiliaThrombophilia•SLESLE•Autoimmune diseaseAutoimmune disease•Severe AnemiaSevere Anemia•EpilepsyEpilepsy•ConsanguinityConsanguinity•Heart diseaseHeart diseaseII-Past OB HxII-Past OB Hx•Baby with congenital anomaly / hereditary Baby with congenital anomaly / hereditary conditioncondition•IUGRIUGR•Gestational HPT with adverse sequeleGestational HPT with adverse sequele•Placental abruptionPlacental abruption•IUFDIUFD•Recurrent abortionsRecurrent abortions

Current Pregnancy HxCurrent Pregnancy Hx•Maternal age Maternal age •Gestational age at fetal deathGestational age at fetal death•HPTHPT•DM/ Gestational DDM/ Gestational D•Smooking , alcohol, or drug abuseSmooking , alcohol, or drug abuse•Abdominal traumaAbdominal trauma•CholestasisCholestasis•Placental abruptionPlacental abruption•PROM or prelabor SROMPROM or prelabor SROM

Specific fetal conditionsSpecific fetal conditions•Nonimmune hydropsNonimmune hydrops•IUGRIUGR•InfectionsInfections•Congenital anomaliesCongenital anomalies•Chromosomal abnormalitiesChromosomal abnormalities•Complications of multiple gestationComplications of multiple gestation

Placental or cord complicationsPlacental or cord complications•Large or small placentaLarge or small placenta•HematomaHematoma•EdemaEdema•Large infarctsLarge infarcts•Abnormalities in structure , Abnormalities in structure , length or insertion of the length or insertion of the umbilical cordumbilical cord•Cord prolapseCord prolapse•Cord knotsCord knots•Placental tumorsPlacental tumors

11--HISTORYHISTORY

2-EVALUATION OF STILL BORN INFANTS2-EVALUATION OF STILL BORN INFANTS

Infant descriptionInfant description•MalformationMalformation•Skin stainingSkin staining•Degree of macerationDegree of maceration•Color-pale ,plethoricColor-pale ,plethoricUmbilical cordUmbilical cord•ProlapseProlapse•Entanglement-neck, arms, Entanglement-neck, arms, legslegs•Hematoma or strictureHematoma or stricture•Number of vesselsNumber of vessels•LengthLengthAmniotic fluidAmniotic fluid•Color-meconium, bloodColor-meconium, blood•VolumeVolume

PlacentaPlacenta•WeightWeight•StainingStaining•Adherent clotsAdherent clots•Structural Structural abnormalityabnormality•Velamentous insertionVelamentous insertion•Edema/hydropic Edema/hydropic changeschangesMembranesMembranes•Stained Stained •ThickeningThickening

33--INVESTIGATIONSINVESTIGATIONS

Maternal investigationsMaternal investigations•CBCCBC•Bl Gp & antibody screenBl Gp & antibody screen•HB A1 CHB A1 C•Kleihauer Batke testKleihauer Batke test•Serological screening for Serological screening for RubellaRubella•CMV, Toxo, Sphylis, Herpes & CMV, Toxo, Sphylis, Herpes & ParovirusParovirus•Karyotyping of both parents Karyotyping of both parents (RFL,(RFL,Baby with malformationBaby with malformation•Hb electrophorersisHb electrophorersis•Antiplatelet anbin tibodiesAntiplatelet anbin tibodies•Throbophilia screening Throbophilia screening (antithrombin(antithrombinProtein C & S , factor IV leiden,Protein C & S , factor IV leiden, Factor II mutation, , lupus Factor II mutation, , lupus anticoagulant, anticoagulant, anticardolipin antibodies)anticardolipin antibodies)•DICDIC

Fetal investigationsFetal investigations•Fetal autopsyFetal autopsy•Karyotype Karyotype

))specimen taken from cordspecimen taken from cord blood, intracardiac bloodblood, intracardiac blood,,body fluid, skin, spleenbody fluid, skin, spleen,,placental wedge, or amnioticplacental wedge, or amniotic fluidfluid((•FetographyFetography•RadiographyRadiography

Placental investigationsPlacental investigations•Chorionocity of placenta Chorionocity of placenta inin twins twins •Cord thrombosis or Cord thrombosis or knots knots •Infarcts, thrombosis, Infarcts, thrombosis, abruptionabruption•Vascular malformationsVascular malformations•Signs of infectionSigns of infection•Bacterial culture for Bacterial culture for E.coli, E.coli, Listeria, gp B strptListeria, gp B strpt..

IUFD COMPLICATIONSIUFD COMPLICATIONS

• Hypofibrinogenemia Hypofibrinogenemia 4-5 wks after IUFD 4-5 wks after IUFD

• Coagulation studies must be started 2 wks Coagulation studies must be started 2 wks after IUFDafter IUFD

• Delivery by 4 wks or if fibrinogen Delivery by 4 wks or if fibrinogen < < 200mg/ml200mg/ml

PSYCHOLOGICAL ASPECT & COUNSELINGPSYCHOLOGICAL ASPECT & COUNSELING

• A traumatic eventA traumatic event

• Post-partum depressionPost-partum depression

• AnxietyAnxiety

• PsychotherapyPsychotherapy

• Recurrence 0-8% depending on the cause of Recurrence 0-8% depending on the cause of IUFDIUFD

lecture 10 fetal distress. definition definition fetal distress is the term commonly used to...

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