AAFP Journal Review Dec 15 2009

1. AAFP Journal ReviewDec 15 2009 Ayesha Shaikh PGY3 Emory Family Medicine

2. We will review… • Intrapartum fetal monitoring: Review definitions and FHR tracings • Evaluation of hematospermia: Most common causes and management • NSAIDs prescribing precautions: System based risk assessment

3. Intrapartum Fetal Monitoring

4. Intrapartum Fetal Monitoring • Developed in 1960 • External or internal transducers, became a part of routine maternity care during the 1970s. • Cesarean delivery and instrumental vaginal delivery • Neonatal mortality and cerebral palsy. • Neonatal seizures.

5. Selection of FHR Monitoring Method • Structured intermittent auscultation: The systematic use of a Doppler assessment of fetal heart rate (FHR) during labor at defined timed intervals. For low-risk patients, a nurse-to-patient ratio of 1:1 • Continuous EFM: When abnormalities in structured intermittent auscultation, high-risk patients

6. Maternal and Fetal High-Risk Factors That Indicate Use of Continuous Electronic Fetal Monitoring Antenatal Fetal • Oligohydramnios • Breech presentation • Intrauterine growth restriction • Multiple pregnancies • Rh isoimmunization • Abnormal umbilical artery Doppler velocimetry Maternal • Anemia • Antepartum hemorrhage • Cardiac disease • Diabetes • Hypertension (preeclampsia or eclampsia) • Hyperthyroidism • Maternal motor vehicle collision or trauma • Morbid obesity • Renal disease • Vascular disease Intrapartum Fetal • Abnormal fetal heart rate on auscultation or admission • tracing (20-minute strip) • Meconium-stained amniotic fluid Maternal • Hypertonic uterus • Induced or augmented labor • Intrauterine infection or chorioamnionitis • Post-term pregnancy (> 42 weeks' gestation) • Preterm labor (< 32 weeks' gestation) • Previous cesarean delivery • Prolonged membrane rupture > 24 hours at term • Regional analgesia, particularly after initial bolus and after top-ups (continuous electronic fetal monitoring is not required with mobile or continuous-infusion epidurals) • Vaginal bleeding in labor

7. Interpretation of FHR tracings • National Institute of Child Health and Human Development (NICHD) 1997 definations • Adopted by • ACOG in 2002 • The Society of Maternal-Fetal Medicine

8. DR C BRAVADO Mnemonic for Interpretation of Continuous Electronic Fetal Monitoring

9. Fetal Heart rate Characteristics Accelerations Visually apparent, abrupt (onset to peak < 30 seconds) increase in FHR from the most recently calculated baseline Peak ≥ 15 bpm above baseline, duration ≥ 15 seconds, but < 2 minutes from onset to return to baseline; before 32 weeks’ gestation: peak ≥ 10 bpm above baseline, duration ≥ 10 seconds Baseline FHR Approximate mean FHR rounded to increments of 5 bpm during a 10-minute segment, excluding periodic or episodic changes, periods of marked variability, and segments of baseline that differ by > 25 bpm In any 10-minute window, the minimum baseline duration must be ≥ 2 minutes, or the baseline for that period is indeterminate Bradycardia Baseline rate: < 110 bpm

10. Fetal Heart rate characteristics • Decelerations Early The nadir of the deceleration occurs at the same time as the peak of the contraction Late The nadir of the deceleration occurs after the peak of the contraction Variable Abrupt decrease in FHR; if the nadir of the deceleration is ≥ 30 seconds, it cannot be considered a variable deceleration • Tachycardia:Baseline rate: > 160 bpm Variability • Absent :Amplitude range: undetectable • Minimal :Amplitude range: detectable, but ≤ 5 bpm • Moderate : Amplitude range: 6 to 25 bpm • Marked : Amplitude range: > 25 bpm

11. Normal baseline FHR • Normal baseline fetal heart rate (FHR), shown at 135 beats per minute (bpm). Normal baseline rate ranges from 110 to 160 bpm for a 10-minute segment and duration ≥ 2 minutes. Excludes periodic and episodic changes, marked variability, and segments differing by ≥ 25 bpm.

12. Tachycardia • Tachycardia of fetal heart rate (FHR), shown at 170 beats per minute (bpm). Baseline rate with tachycardia is > 160 bpm.

13. Minimal variability of fetal heart rate (FHR). Amplitude range of FHR tracing is undetectable.

14. Minimal variability of fetal heart rate (FHR). Amplitude range of FHR tracing ≤ 5 beats per minute.

15. Moderate variability of fetal heart rate (FHR). Amplitude range of FHR tracing is 6 to 25 beats per minute.

16. Marked variability of fetal heart rate (FHR). Amplitude range of FHR tracing > 25 beats per minute.

17. Acceleration of fetal heart rate (FHR). Visually apparent, abrupt (onset to peak < 30 seconds) increase in FHR from the most recently calculated baseline. Peak ≥ 15 beats per minute (bpm) above the baseline, and duration ≥ 15 seconds, but < 2 minutes from onset of the acceleration to return to baseline. Before 32 weeks’ gestation, peak ≥ 10 bpm above baseline, duration ≥ 10 seconds.

18. Early deceleration of fetal heart rate (FHR). Gradual decrease and return of FHR is associated with a uterine contraction. In most cases, the onset of the deceleration, nadir, and recovery coincide with the beginning, peak, and ending of the contraction, respectively (FHR mirrors the contraction).

19. Variable deceleration of fetal heart rate (FHR). Abrupt decrease in FHR < 30 seconds from the beginning of the deceleration to the nadir. The decrease in FHR (measured at the nadir) is ≥ 15 beats per minute, with a duration ≥ 15 seconds, but < 2 minutes.

20. Repetitive late deceleration of fetal heart rate (FHR). National Institute of Child Health and Human Development Category II: repetitive late deceleration with minimal variability.

21. Prolonged deceleration of fetal heart rate (FHR) with slow recovery. National Institute of Child Health and Human Development Category II: prolonged deceleration ≥ 2 minutes and < 10 minutes.

22. Prolonged deceleration of fetal heart rate (FHR) without recovery. National Institute of Child Health and Human Development Category III: absent variability and bradycardia.

23. Interpretation and Management of Continuous EFM Findings Finding: NICHD Category I: Normal Moderate baseline FHR variability, late or variable decelerations absent, accelerations present or absent, and normal baseline FHR (110 to 160 bpm) Significance: Normal pH and fetal well-being Management: Continue current monitoring method (SIA or continuous EFM)

24. Interpretation and Management of Continuous EFM Findings • NICHD Category II: Indeterminate Finding:Baseline FHR changes (bradycardia [< 110 bpm] not accompanied by absent baseline variability, or tachycardia [> 160 bpm]) Significance: Bradycardia- expedite delivery if persists, Tachycardia- general measures Finding: Change in FHR variability (absent and not accompanied by decelerations; minimal; or marked) Significance: Medication/sleep cycle- general measure, Change in monitoring technique, fetal hypoxia/acidemia- consider expedite delivery Finding: No FHR accelerations after fetal stimulation Significance: fetal hypoxia/acidemia- general mesaures, stop pitocin, expedite delivery Findings: FHR decelerations without absent variability Significance:Variable: cord entrapment or prolapse- general measure, amnioinfusion Late:possible uteroplacental insufficiency; epidural hypotension; tachysystole general measure, D/C oxytocin expedite delivery

25. Interpretation and Management of Continuous EFM Findings • NICHD Category III: Abnormal Finding:Absent baseline FHR variability with recurrent decelerations (variable or late) and/or bradycardia sinusoidal FHR pattern Singnificance: Uteroplacental insufficiency; fetal hypoxia or acidemia General measures: Discontinue oxytocin, Expedite delivery

26. Interventions for Abnormal Electronic Fetal Monitoring • 1. Change maternal position • 2. Assess maternal vital signs (temperature, blood pressure, pulse) • 3. Discontinue oxytocin (Pitocin) infusion, if in use • 4. Initiate oxygen at 6 to 10 L per minute • 5. Perform a vaginal examination (check for cord prolapse, rapid descent of the head, or vaginal bleeding suggestive of placental abruption) • 6. Give intravenous fluids if not already administered; consider bolus • 7. Assess fetal pH (fetal scalp stimulation, scalp pH, or acoustic stimulation) • 8. Give amnioinfusion for recurrent, moderate to severe variable decelerations • 9. Consider need for expedited delivery (operative vaginal delivery or cesarean delivery)

27. Tocolytic agents such as terbutaline (formerly Brethine) may be used to transiently stop contractions, with the understanding that administration of these agents improved FHR tracings compared with untreated control groups, but there were no improvements in neonatal outcomes.A recent study showed a significant effect of maternal oxygen on increasing fetal oxygen in abnormal FHR patterns

28. SORT: KEY RECOMMENDATIONS FOR PRACTICE

29. Which one of the following is associated with fetal bradycardia ( check one) A: fetal myocardial conduction defects B: maternal dehydration C: maternal fever D: maternal chorioamnionitis

30. Which one of the following is associated with fetal bradycardia ( check one) A: fetal myocardial conduction defects B: maternal dehydration C: maternal fever D: maternal chorioamnionitis

31. Compared with structured intermittent auscultation, continuous EFM reduces the incidence of which one of the following? ( check one) A: Perinatal deaths B: Neonatal seizures C: Cerebral Palsy D: Cesarean Section

32. Compared with structured intermittent auscultation, continuous EFM reduces the incidence of which one of the following? ( check one A: Perinatal deaths B: Neonatal seizures C: Cerebral Palsy D: Cesarean Section

33. Author And References. • The Author • R. EUGENE BAILEY, MD, FAAFP, is an associate professor and the director of the Family Medicine Clerkship in the Department of Family Medicine, SUNY Upstate Medical University, Syracuse, NY. He is currently advisory faculty and instructor certified for the Advanced Life Support in Obstetrics (ALSO) course, and previously served on the ALSO National Advisory Board. • Address correspondence to R. Eugene Bailey, MD, FAAFP, SUNY Upstate Medical University, 475 Irving Ave., Ste. 200, Syracuse, NY 13210 (e-mail: baileye@upstate.edu). Reprints are not available from the author. • Author disclosure: Nothing to disclose. • The author would like to thank Dr. Kim Hinshaw for his expert contributions in the preparation of this manuscript and his development of the DR C BRAVADO mnemonic, and Dr. Larry Leeman for his endless hours of assistance and editorial prowess. • This article is one in a series on “Advanced Life Support in Obstetrics (ALSO),” initially established by Mark Deutchman, MD, Denver, Colo. The series is now coordinated by Larry Leeman, MD, MPH, ALSO Managing Editor, Albuquerque, N.M. • REFERENCES • 1. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2002. Natl Vital Stat Rep. 2003;52(10):1–113. • 2. Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2006;(3):CD006066. • 3. National Institute for Health and Clinical Excellence. Intrapartum care: management and delivery of care to women in labour. September 2007. http://guidance.nice.org.uk/CG55. Accessed July 6, 2009.

34. 5. ACOG Practice Bulletin No. 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Obstet Gynecol. 2009;114(1):192–202. • 6. Bix E, Reiner LM, Klovning A, Oian P. Prognostic value of the labour admission test and its effectiveness compared with auscultation only: a systematic review. BJOG. 2005;112(12):1595–1604. • 7. Hindley C, Hinsliff SW, Thomson AM. English midwives' views and experiences of intrapartum fetal heart rate monitoring in women at low obstetric risk: conflicts and compromises. J Midwifery Womens Health. 2006;51(5):354–360. • 8. Kripke CC. Why are we using electronic fetal monitoring? Am Fam Physician. 1999;59(9):2416, 2421–2422. • 9. Bailey RE. Intrapartum fetal surveillance. In: Leeman L, ed. Advanced Life Support in Obstetrics Program: Provider Course Syllabus. Leawood, Kan.: American Academy of Family Physicians; 2009. • 10. Parer JT, Ikeda T. A framework for standardized management of intrapartum fetal heart rate patterns. Am J Obstet Gynecol. 2007;197(1):26.e1–e6. • 11. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. Obstet Gynecol. 2008;112(3):661–666. • 12. Todros T, Preve CU, Plazzotta C, Biolcati M, Lombardo P. Fetal heart rate tracings: observers versus computer assessment. Eur J ObstetGynecolReprod Biol. 1996;68(1–2):83–86. • 13. Bernardes J, Costa-Pereira A, Ayres-de-Campos D, van Geijn HP, Pereira-Leite L. Evaluation of interobserver agreement of cardiotocograms. Int J Gynaecol Obstet. 1997;57(1):33–37. • 14. Electronic fetal heart rate monitoring: research guidelines for interpretation. National Institute of Child Health and Human Development Research Planning Workshop. Am J Obstet Gynecol. 1997;177(6):1385–1390. • 15. Hinshaw K, Ullal A. Peripartum and intrapartum assessment of the fetus. Anaesth Intensive Care Med. 2007;8(8):331–336. • 16. The International Federation of Obstetrics and Gynecology (FIGO). Guidelines for the use of fetal monitoring. Int J Gynaecol Obstet. 1987;25(2):159–167. • 17. Low JA, Victory R, Derrick EJ. Predictive value of electronic fetal monitoring for intrapartum fetal asphyxia with metabolic acidosis. Obstet Gynecol. 1999;93(2):285–291. • 18. Feinstein N, Torgersen KL, Atterbury J, for the Association of Women's Health, Obstetric and Neonatal Nurses. Fetal Heart Monitoring: Principles and Practices. 3rd ed. Dubuque, Iowa: Kendall/Hunt Publishing Company; 2003. • 19. Skupski DW, Rosenberg CR, Eglinton GS. Intrapartum fetal stimulation tests: a meta-analysis. Obstet Gynecol. 2002;99(1):129–134. • 20. The American College of Obstetricians and Gynecologists, American Academy of Pediatrics. Neonatal Encephalopathy and Cerebral Palsy. Defining the Pathogenesis and Pathophysiology. Washington, DC: American College of Obstetricians and Gynecologists; 2003: 74. • 21. Chez BF. Electronic fetal monitoring then and now. J Perinat Neonatal Nurs. 1997;10(4):1–4. • 22. Hofmeyr GJ. Amnioinfusion for potential or suspected umbilical cord compression in labour. Cochrane Database Syst Rev. 1998;(1):CD000013. • 23. Kulier R, Hofmeyr GJ. Tocolytics for suspected intra-partum fetal distress. Cochrane Database Syst Rev. 2000;(2):CD000035. • 24. Haydon ML, Gorenberg DM, Nageotte MP, et al. The effect of maternal oxygen administration on fetal pulse oximetry during labor in fetuses with nonreassuring fetal heart rate patterns. Am J Obstet Gynecol. 2006;195(3):735–738. • 25. Neilson JP. Fetal electrocardiogram (ECG) for fetal monitoring during labour. Cochrane Database Syst Rev. 2006;(3):CD000116.

35. Evaluation and treatment of Hematospermia

36. Evaluation and treatment of Hematospermia • Presence of blood in the semen, known as hematospermia or hemospermia. • Blood in fewer than 10 consecutive ejaculations or for less than 12 weeks. • The incidence of hematospermia is difficult to quantify because most men do not observe their semen.Prevalence in clinical settings is highest in men younger than 40 years. • Management: younger than 40 years without risk factors and in men with no associated symptoms vs 40 years and older, and patients with persistent or recurrent hematospermia

37. Etiologies of Hematospermia and Their Typical Presentations • Behavioral - abstinence, masturbation or rigorus intercourse • Infectious - 40% of cases: STD,TB, Schistosoma, echinococcus • Inflammatory -prostitis, vasculitis • Neoplastic- bladder, urethra, prostate, seminal vesicles and so on • Structural - polyps, cysts, stones. • Systemic - amyloidosis, bleeding disorder, liver disease, uncontrolled hypertension • Trauma (iatrogenic)- injections, biopsies, instumentations • Vascular- AVM, varicies, hemangiomas

38. Hematospermia Evaluation

39. History • R/O pseudo-spermia • Age of patient • Duration of symptoms • Presence of associated symptoms or risk factors

40. Evaluation • Isolated Hematospermia • Hematospermia with associated conditions or symptoms

41. Isolated Hematospermia First Episode: Excessive sex or masturbation/ prolonged sexual abstinence-> UA STI -> Testing and treat as appropriate UTI -> UA and Culture BPH -> symptom index, post void residual Prostatic cancer -> PSA, urology referral Persistent, Recurrent or high volume hematospermia Vascular- UA -> urology referral Tumors- UA+cytology ->Urology referral Bleeding Diathesis -> CBC, PT, PTT, treat as indicated

42. Hematospermia with associated conditions or symptoms • Trauma: self inflicted or iatrogenic: UA, U cx, consider Urology referral for endoscopy, penile doppler studies • Genitourinary infection or inflammation: UTI/STI, Prostitis, Epididmytis: UA,urine culture, STI testing,sperm culture, scrotal doppler ultrasound treat as indicated, urology referral • Voiding symptoms: UA, PSA, post void residual, AUA symptoms index, urology referral, alpha blocker +/- 5 alpha reductase inhibitor • Pain with ejaculation: Prostatitis, obstruction( polyp, strictures etc): treat as indicated, urology referral • Systemic disorder: HTN, Bleeding disorder, malignancy , liver disease: investigate and treat underlying disorder. • Travel or exposure history: TB, Schistosomiasis: evaluate and treat as indicated or ID referral.

43. Physical Exam • Vitals: BP, Tachycardia, fever indicate systemic cause • Abdominal and urogenital exam for trauma, inflammation, discharge, lymphadenopathy • Full scrotal exam for inflammation, infection, testicular mass, epididymis, spermatic cord • Rectal exam for prostate

44. Indications for Hematospermia Urology Referral Based on symptoms: • Hematospermia associated with genitourinary pain • Hematospermia associated with unexplained voiding symptoms • Recurrent, persistent, high-volume hematospermia Based on evaluation: • Abnormal examination findings suggestive of tumor or structural problems • Abnormal prostate-specific antigen findings • Abnormal urinalysis findings (hematuria, sterile pyuria) • Suspected foreign body, stent migration • Suspected vascular malformation • Based on lack of response to initial management • Symptoms or abnormal findings persist

45. Treatment • Directed at the diagnosed etiology • Suspected infection, empiric two-week treatment with an antibiotic that penetrates the prostate-blood barrier (e.g., fluoroquinolones, doxycycline, trimethoprim, trimethoprim/sulfamethoxazole [Bactrim, Septra]) • Most men with an easily treatable cause of hematospermia do not need follow-up, otherwise within three to six months to reassess symptoms

47. Which one of the following factors suggest the need for a urology referral in the evaluation of hematospermia? (check one) A: Prolonged sexual abstinence B resolution with treatment of STI C: younger age D: Persistent, recurrent or heavy bleeding

48. Which one of the following factors suggest the need for a urology referral in the evaluation of hematospermia? (check one A: Prolonged sexual abstinence B resolution with treatment of STI C: younger age D: Persistent, recurrent or heavy bleeding

49. A 65 yo man presents with multiple episodes of hematospermia. On further questioning, he states that he has had some difficulty voiding. Which one of the following the most likely cause of his hematospermia? (check one) A: BPH B: Epididimitis C: pseudo-hematospermia D: Excessive masterbation

50. A 65 yo man presents with multiple episodes of hematospermia. On further questioning, he states that he has had some difficulty voiding. Which one of the following the most likely cause of his hematospermia? (check one) A: BPH B: Epididimitis C: pseudo-hematospermia D: Excessive masterbation