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Fetal distress

Fetal distress. Abnormal Liquor Volume. Women Hospital , School of Medical, ZheJiang University Yang Xiao Fu. Abnormal Liquor Volume. Polyhydramnios. Oligohydramnios. Polyhydramnios. Defined as amniotic fluid volume more than 2000ml at any period of gestation Incidence 0.5% - 1.6%

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Fetal distress

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  1. Fetal distress Abnormal Liquor Volume Women Hospital , School of Medical, ZheJiang University Yang Xiao Fu

  2. Abnormal Liquor Volume Polyhydramnios Oligohydramnios

  3. Polyhydramnios • Defined as amniotic fluid volume more than 2000ml at any period of gestation • Incidence 0.5% - 1.6% • If amniotic fluid volume increase progressively over months, the symptoms are usually milder, known as chronic polyhydramnios • If amniotic fluid volume increase rapidly over days, can causse severe compression symptoms, known as acute polyhydramnios • Fetal structural deformity: ( neural tube defect, NTD)

  4. Ultrasound examination • Amniotic fluid index, AFI >18cm or AFI >20cm • Depth of largest amniotic fluid pool (amniotic fluid volume, AFV) >= 7cm • AFV 8-11cm, as mild polyhydramnios • AFV 12-15cm, as moderate polyhydramnios • AFV >= 16cm, as severe polyhydramnios

  5. Oligohydramnios • Third trimester amniotic fluid volume less than 300ml is known as oligohydramnios • Incidence 0.5% - 5.5% • Fetal structural deformity

  6. Ultrasound examination • AFV <= 2cm • AFI < 5cm • 5cm < AFI < 8cm, known as suspicious oligohydramnios

  7. Fetal distress

  8. Definition • Fetus encountering acute or chronic hypoxia intrauterine causing threat to its life and health, is known as fetal distress • Fetal distress may be acute or chronic.

  9. Etiology of acute fetal distress • Placenta previa, placental abruptio • Inappropriate use of oxytocin: too strong, too frequent and uncoordinated uterine contraction • Cord prolapse, true entanglement, torsion • Shock of mother

  10. Etiology of chronic fetal distress • Inadequate maternal blood oxygen saturation • Utero-placental vascular sclerosis, stenosis • Placental pathological changes • Fetal factor: severe cardiovascular deformity, all causes leading to hemolytic anemia, etc

  11. Clinical presentations and diagnosis • Fetal heart rate abnormality • Meconium stained amniotic fluid • Reduced or absent fetal movement

  12. Diagnosis of acute fetal distress • Fetal heart rate abnormality • early stage tacchycardia>160bpm; during severe hypoxia <120bpm • CST shows late deceleration, variable deceleration • fetal heart rate <100bpm, with frequent late decelrations indicating severe fetal hypoxia, may die intrauterine any moment

  13. Late deceleration

  14. Variable deceleration

  15. Diagnosis of acute fetal distress • Meconium stained amniotic fluid: green color, dirty, thick and little volume I degree: light green, II degree: yellowish green, dirty, III degree:brownish yellow, thick

  16. Diagnosis of acute fetal distress • Fetal movement: early stage frequent fetal movement, subsequently reduced to absent • Fetal acidosis: fetal scalp blood analysis pH <7.2 (normal 7.25 – 7.35) PO2 <10mmHg (normal 15 – 30mmHg) PCO2 >60mmHg (normal 35 – 55mmHg)

  17. Diagnosis of chronicfetal distress • Reduced or absent fetal movement • Abnormal fetal monitoring • Low fetal biophysical profile scoring • Fetal retardation • Reduced placental function • Meconium stained amniotic fluid • Abnormal fetal pulse oxymetry

  18. Reduced or absent fetal movement • Reduced fetal movement <10 times/12hours, is an important manifestation of fetal hypoxia • Usually 24 hours after absent of fetal movement fetal heart beat disappears • Normal fetal movement count: 30-100 times/12hours

  19. Abnormal fetal electronic monitoring • NST is known as non-reactive type, during 20 minutes continuous fetal movement fetal heart rate acceleration <= 15bpm, sustaining <= 15s, baseline variability < 5bpm • OCT frequent variable decelerations or late decelerations are seen

  20. Low biophysical profile scoring • Based on ultrasound assessment of fetal body movement, breathing movement, flexor tone, amniotic fluid volume, couple with fetal electronic monitoring NST results combined scoring (each variable score 2, total score is 10) • Score <= 3 indicates fetal distress, score 4-7 suspicious fetal hypoxia

  21. Fetal retardation • Sustained chronic fetal hypoxia, cause fetal intrauterine growth retardation • reduced cells number in organs, • reduced organ volume, • low fetal weight • presenting as fundal height and abdominal girth being lower than 10th percentile of the same gestational age

  22. Low placental function • Decreased urine estriol: 24hours urine E3 <10mg or serial test show reduction >30% • Estrogen : creatinine (E:C) ratio <10 • Placental prolactin (hPRL) <4mg/L • Pregnancy specific ß1 glycoprotein decrease <100mg/L

  23. Meconium stained amniotic fluid • Amnioscopy examination shows dirty amniotic fluid in light green or brownish yellow color

  24. Abnormal fetal pulse oxymetry • Fetal pulse oxymetry principally monitor the blood oxygen partial pressure through measuring fetal blood oxygen saturation(饱和度）

  25. Management • Acute fetal distress: emergent treatment • Chronic fetal distress: management plan depends on severity of the pregnancy complications, gestational age, fetal maturity, fetal distress condition

  26. Management of acute fetal distress • Give oxygen: face mask or nasal prong continuous oxygen at 10L/min flow • Search for cause, active management: if patient has supine hypotensive syndrome, lie the patient on left lateral position; if excessive oxytocin leading to uterine hyperstimulation, stop oxytocin immediately, use tocolytics when necessary

  27. Management of acute fetal distress • Terminate pregnancy soonest possible: • Cervix not fully dilated with the following conditions, immediate caesarean section: (1)fetal heart rate <120bpm or >180bpm, accompanied by II degree meconium stained amniotic fluid; (2) III degree meconium stained amniotic fluid, with low amniotic fluid amount; (3) CST or OCT shows frequent late decelerations or severe variable decelerations; (4) fetal scalp blood pH <7.20

  28. Management of acute fetal distress • Fully dilated cervix: fetal biparietal diameter, has descend below ischial spines, perform assisted vaginal delivery • Prepare for newborn resuscitation

  29. Management of chronic fetal distress • Routine management: left lateral position, give oxygen regularly (30mins, 2-3times/day) • Active treatment of pregnancy complications • Terminate pregnancy: pregnancy nearing term with less fetal movement or OCT shows late decelerations, severe variable decelerations, or biophysical profile <= 3 score, caesarean is indicated

  30. Management of chronic fetal distress • Expectant treatment: early gestation, low chance of survival if delivered, prolong pregnancy while inducing fetal lung maturation • Must explain to the family that during the process of expectant treatment, there is risk of sudden fetal death, poor placental function might affect fetal growth, poor outcome.

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