Teaching With Dr Bahiyah..I really enjoy teaching with Dr Bahiyah =)35 years old, malay housewife, grandmultipara G6P5 @ 33weeks POA, with the background of low socioeconomic&low education, antenatally she was underweight, anemic which improves with hematinic & diagnosed to have Gestational hypertension at 28 weeks but not on medication. The baby is IUGR with abnormal doppler, FM good. Was admitted for delivery in view of abnormal doppler & waiting for availability of ventilator.
Since the problem is underweight, need to highlight about her weight gain throughout the pregnancy & comment wether it is normal or not
In social history, dont forget to ask how many children the patient wants, this can help in managing this patient.
In examination, you should elicit the causes of IUGR
Look for signs of anemia, connective ts ds such as SLE (malar rash, oral ulcer, alopecia,etc)
& ask for blood pressure (PIH is one of the cause & BP is one of bedside examination)
Abdomen: elicit uterus smaller than date & if could feel obviously the fetal parts - evidence of oligohydramnios. But bear in mind, IUGR can also have normal AFI
What is causes uterus smaller than date??
mother: wrong date, small build mother, malnutrition, anemia, PIH, DM cx pregnancy, Conn TS Dz
fetus: IUGR/SGA, IUD, fetal abnormality (renal agenesis/PCKD), transverse lie
What is causes of oligohydramnios??
Mother: DM cx pregnancy, PIH, drugs (NSAIDS)
Fetus: IUGR, renal agenesis, PCKD
IUGR Vs SGA. How to determine which one??
DO serial scan & plot growth of the fetus
IUGR - initially it is growing (can be normal weight initially) than the growth become plateu & cross the centiles
SGA - the growth is following the normal growth curve but below the 3rd centiles
If you only have one scan?? how to determine?
Look at HC & AC parameters. There will be head sparing effect. Ratio of HC:AC >1 with HC value could be normal or bigger than AC
If you met this patient at 28 weeks & was told this patient had IUGR. What would you do?
TRO cause of smaller than date first
Confirm the date. check LMP
Ask about maternal disease - anemia, PIH & Conn TS disease
Ask about any history of fetal anomaly before
Previous obs history - PIH, DM, small baby before, previous baby weight
Physical examination : like what have been discussed as the above
Mother: FBC - to look at the Hb (evidence of anemia) & RBS
Fetus:US - confirm date, serial scan to plot growth , AFI
Doppler if indicated (need to mention this)
Doppler is done 2weekly
if plan to scan the mother again after 2weeks, what should you advice the mother at home??
How do u advice the patient?
Councel - this is to be done to monitor the condition of the baby, there is risk baby could IUD anytime.
Start count the baby movements about 10 times starting at 9am for 12 hours. Each time baby moves, please tick. Write down at what time the baby complete 10 movements. If the baby did not complete movement about 10 times within 12 hours which is at 9pm, please come to hospital immediately.
Plan For this patient...
Monitor her blood pressure & vital signs
In view of her condition, the baby with abnormal doppler, I would like to plan for CS to this patient as soon the ventilator is available
Counsel the patient regarding the needs for CS
This patient, her BP was constant at 140/90 in each follow up & dx to have Gest hypertension. WHy she was not on any hypertensive medication???
In gest hypertension, the target BP are systolic 120 - 160 & diastolic 90-100. So in this patient, her BP was in the range. Lower down the BP, the diastolic will drop & will cause reduce perfusion to placenta which cause hypoxia to the baby. Bear in mind, hypertensive mother, the placenta has high resistance. Low BP can precipitate hypoxia to the baby.
As HO please watch out the diastolic also not only the systolic reading =)
Last Qs...Regarding Doppler~
if the doppler has abnormal result??is the patient need immediate delivery???
(this is a homework..read about doppler..masih dlm proses membaca....what I know, absent diastolic flow can buy about few days but reversed flow need immediate operation...but doctor said to me to read more.Haha=P)