Group B Strep and the Neonate

Recognition of the sick neonate

  • Increased work of breathing
  • Apnoeic episodes
  • Lethargy
  • Poor feeding
  • Evidence of haemodynamic instability / poor perfusion

Workup

  • Full workup
    • FBC
    • CRP
    • Gastric aspirate M/C/S correlates well with amniotic fluid culture
    • Blood culture
    • Ear swab
    • Consider LP and CXR
  • Perform full workup if
    • Maternal GBS status unknow and neonatal signs of sepsis
    • Maternal temperature >38
    • Maternal chorioamnionitis
    • Previous obstetric history of GBS disease
  • Perform limited septic screen if
    • Mother GBS positive and intrapartum Abx >4 hours before delivery

Management

  • BenPen + Gent if
    • Maternal GBS status unknow and neonatal signs of sepsis
    • Maternal temperature >38
    • Maternal chorioamnionitis
    • Previous obstetric history of GBS disease
  • Observe 24-48 hours if
    • Mother GBS positive and intrapartum Abx >4 hours before delivery
  • FBP + CRP and repeat 12 hourly if:
    • Mother GBS positive and IAP <4 hours before delivery
    • Prematurity
    • PROM  > 18 hours

 

Female Genital Mutilation (FGM)

Definition: All procedures involving partial or total removal of the female external genitalia, or injury to other female genital organs for non-medical purposes.

Illegal to perform in Australia, or take a person from Australia.

  • Affects approximately 130-140 million women, commonly between 4-10yo.
  • Practiced mainly in Africa, but also in some parts of Asia and the middle East.

Reasons: psychosexual, sociological, aesthetics, myths, religious beliefs.

Classification

  • Type I – removal of prepuce ± clitoris
  • Type II – removal of clitoris and labia minora ± labia majora
  • Type III – infibulation (narrowing of the vaginal orifice) by cutting and appositioning the labia ± excision of clitoris
  • Type IV – all other harmful procedures eg pricking, piercing, incising, scraping and cauterisation

Female Genital Mutilation

Complications

  • Short term
    • Infection/Sepsis
    • Pain/Severe pain
    • Bleeding
    • Dysuria
    • Urinary retention
    • Injury to nearby tissue
    • Bony fractures or dislocation
  • Long term
    • Dyspareunia
    • Dysuria
    • Infertility
    • Infection
    • Cysts
    • Increased obstetric complications – PPH, C/S, episiotomies, infant resus, perinatal death.
    • Abscess and fistula formation
    • Psychological disorders

Obstetric Management

  • Culturally sensitive environment – have interpreters, female chaperones
  • Check during booking visit
  • Discuss
    • potential difficulty of doing VE
    • Advise of potential need to de-infibulate, and that we won’t re-infibulate.
    • Bladder management for UTIs
    • Application of fetal scalp electrode.
  • Postpartum
    • Monitor urine output
    • Advise about changes in voiding stream with anterior episiotomy
    • Parent made aware of legal issues with FGM in WA.

Malpresentation

Terminology

  • Lie – the long axis of the fetus
    • Transverse
    • Longitudinal
  • Presentation – the part of the body facing the outlet
    • Cephalic
    • Shoulder
    • Breech
  • Presenting Part – the actual organ facing the outlet
  • Position – a description of the AP angle of the child in relation to the maternal AP line
    • OP/OA/ROP/ROA/LOP/LOA/ROL/LOL
    • Breech positions are described relative to the heel

Breech presentation

  • Numbers
    • 4% of term births
    • 75% of term breeches would have been breeches at 32/40
    • 20% of term breech babies have handicaps irrespective of mode of delivery
  • Varieties
    • Footling – feet first (rare)
    • Frank – bottom first, legs flexed at hip and extended at knees (major form)
    • Complete – hips and knees flexed
    • Kneeling (extremely rare)
  • Antenatal management
    • Repeat USS at 36/40
      • Presentation
      • Fetal biometry
      • AFI
      • Placental location
      • Position of fetal legs
      • Attitude of neck
  • External cephalic version
    • Sucess rate >50%
    • Aim to perform between 34 and 37/40
    • Technique
      • Tocolyse with terbutaline
      • Wedge under buttocks
      • Lubricate abdomen
      • Place hands between breech and pubic symphysis’
      • Dislodge the breech
      • Guide fetal heart in a backwards or forwards roll towards the pelvis
      • Abandon after both backwards and forwards roll fails
      • CTG for 40 minutes after regardless of success
  • Elective Casesarian
    • Term Breech Trial: 2/3 reduction in perinatal mortality with no difference in maternal mortality
    • Modest short term increase in maternal morbidity
    • 2 year followup to TBT: no difference in death or abnomal neurodevelopment
  • Vaginal birth
    • High risk of NELUSC (43% of planned vaginal births in TBT)
    • Criteria
    • Exlusion of footling breech
      • No previous CS
      • CTG
      • Flexed fetal head
      • Availablity for emergent CS

Shoulder presentation

  • Definition: transverse lie where the shoulder faces the pelvic outlet
  • Risks
    • Cord prolapse
    • Obstructed labour
  • Antenatal management
    • USS to look for contributing causes esp. pelvic tumours
  • Expectant management
    • 80% of cases will stabilise into a longitudinal lie
    • Think very carefully about this if membranes have ruptured as cord prolapse risk is high
  • Active management
    • ECV + IOL (highish risk of reversion back to transverse lie)
    • ELUSC

Twin Pregnancy

Permutations

  • MCMA = one placenta, one amniotic sac; always identical
    • Perinatal loss rate 30-60%
  • MCDA = one placenta, separate amniotic sacs
  • DCDA = separate placentae, spearate sacs; may be fused (next to each other but with a septa divinding the sacs and placentae or separate
  • DCMA = mot possible

First Trimester Screening

  • Biochemical risk assesement alone not recommended as hormone levels reflect twin status more than aneuploidy
  • Nuchal translucency + biochemical risk assesement test of choice
  • Rate of miscarriage doubles with twins for CVS and amniocentesis

Other abnormalities

  • The risk in dizygous twins is not increased
  • Risk in monozygous twins of a fetal abnormality approaches 10%
  • NTD and congenital heart disease particular concerns
  • Disconcordant abnormality not uncommon in monozygous twins

Vanishing twin and papyraceous

  • 20% of twin pregnancies compliated by miscarriage or loss of one twin in the early stages
    • Pregnancy likely to rogress as for a singleton pregnancy
  • Loss of twin in 2nd trimester up carries risk of prematurity, neurological sequelae or death to remaing twin
  • Lost twin may be anatomically preserved as a papyraceous twin

Twin-twin transfusion syndrome

  • Confined to monochrionic gestations
  • 10-20% incidence in MC pregnancies
  • Blood flows from a donor twin to a recipeint twin via anastamoses resulting in hypovolemia and oligohydramnios for one and the converse for the other
  • Donor consequences
    • IUGR
    • Absent or reversed end-distolic uterine artery frequencies
  • Recipient consequences
    • Organomegaly
    • Polycythemia and hydrops
    • Tricuspid regurgitation (bad outcome)
  • Diagnosis – USS
  • Management
    • Laser ablation of anastamoses
    • Amnioreduction
    • Selective occlusion

Twin reversed arterial perfusion sequence (TRAP)

  • Arterial blood flows from the pump twin towards affected twin via an arterio-arterial anastamosis
  • This blood is poorly oxygenated and preferrentially perfuses caudad structures
  • Abnormal development of all organ systems
  • Intrafetal vascular ablation

Antenatal management

  • Add a FBC at 20/40 as increased risk for anaemia
  • PET prohyplaxis with low dose aspirin from 12/40 if fat, >40, FHx of PET or G1
  • For DC twins, USS 8 weekly until 3rd trimester, then 4 weekly
  • For MC twins, 3 weekly

Delivery

  • Aim to deliver MCMA twins at 32/40 following steroids
  • Aim to deliver DCDA and MCDA twins at term or late prematurity
  • Indication for CS – non-vertex lower twin
  • Vaginal delivery may be attempted if lower twin is vertex and upper twin is breech
  • Vaginal delivery usually recommended for vertext vertex twins

Endometriosis

Pathophysiology – theoretical

  1. Retrograde menstruation
  2. Coelomic metaplasia
  3. Muellerianosis

Symptoms

  1. Dysmenorrhea
  2. Menorrhagia
  3. Dyspareunia
  4. Premenstrual spotting
  5. Mid-cycle bleeding
  6. Cyclical extra-genital bleeding
  7. Painful defecation

Examination

  • Abdo
    • Nodules on uterus
  • Speculum – rule out vaginal/cervical causes of bleeds
  • VE
    • Thickening of uterosacral ligaments
    • Nodules in vaginal fornices
    • Adnexal masses
    • Fixed, retroflexed uterus

Workup

  1. TVUS
  2. MRI pelvis – 90% sensitive
  3. Diagnostic laprascopy gold standard (sens 97% but operator dependent)

Management

  • Medical
    • OCP
    • Depot, Mirena, Implanon
    • GnRH analogues
    • Danazol
    • Aromatase inhibitors
  • Surgical
    • More risk for more gain

Termination of Pregnancy

Legality

  • Legal under 20/40
  • Above 20/40, 2 doctors from a a panel appointed by the Minister of Health must agree that a serious medical condition exists and justifies an abortion
    • Anecdotally, as a baseline, Down’s is not considered sufficiently severe for abortion after 20/40
  • Must ensure that the following counseling steps are followed
    • Counsel about the risks of TOP vs. continuing the pregnancy
    • Offer referral to counselling related to TOP and continuing the pregnancy
    • Offer post-abortion or post-delivery counselling
  • The alternatives to abortion should also be discussed
  • If the woman is <16 years AND financially dependent
    • Custodian MUST be informed and given opportunity to participate in counselling and consultations
      • This requirement may be waived by a CHiildren’s COurt order
    • However, the dependant minor may still give informed consent for the procedure even if the custodian is opposed.

Surgical abortion

  • Options
    • Vacuum aspiration / suction curettage (predominant method in WA <12/40)
    • Dilation and evacuation
  • Cervical preparation with prostaglandin analogues or osmotic dilators should be routine when
    • Patient <18 years
    • Gestation >10/40
  • Risks
    • Usual operative and anaesthetic risks
    • Failure or procedure and RPOC
    • Cervical trauma
    • Rhesus isoimmunisation
    • Scaring, Asherman’s, etc.

Medical abortion

  • Placental sac sepration from uterus by progesterone antagonist (eg. mifepristone) or methotrexate
  • Prostaglandin analogue (eg. misoprostol) given PV, PO or SL 3 days later causing expulsion
  • Complete abortion rate aorund 95%
  • May need to proceed to surgical abortion if incomplete/unsucessful
  • Risks
    • Pain
    • Failure and need for surgical procedure
    • N+V+D
    • Relatively low risk of infection