Pregnancy and Birth

• Medline and NHS databases • Women’s Hospitals Australasia – Clinical Practice Guidelines - Cord Prolapse – Last Reviewed June 2005 • RCOG - Green-top Guideline - No. 50 - April 2008   Levels of Evidence   Evidence Category and Source   Grading of Recommendations   Recommendation Grade  Definition Cord prolapse has been defined as descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes.   Definition Cord presentation is the presence of one or more loops of umbilical cord between the fetal presenting part and the cervix, without membrane rupture.   Background • The overall incidence of cord prolapse ranges from 0.1% 0.6% • With breech presentation, the incidence is just above 1% • Male fetuses seem to be predisposed. • The incidence is higher in multiple gestations.  Background Cases of cord prolapse appear consistently in perinatal mortality enquiries, and one large study found a perinatal mortality rate of 91 per 1000.  Background • Prematurity and congenital malformation account for the majority of adverse outcomes associated with cord prolapse in hospital settings, but cord prolapse is also associated with birth asphyxia and perinatal death with normally-formed term babies, particularly with home birth. • Delay in transfer to hospital appears to be an important factor with home birth.  Background • Asphyxia may also result in hypoxic-ischaemic encephalopathy and cerebral palsy. • The principal causes of asphyxia in this context are thought to be:

The catgut is fed through posteriorly and vertically over the fundus to lie anteriorly and vertically compressing the fundus on the left side as occured on the right.

Presented by Dr. Narayan M. Patel Prof. Emeritus, ob/gyn.muni.medical collage, Postal address: - Mahalaxmi institute of medical teaching3, shantiniketan park, Nr. S. P. Colony Ahmedabad-380014 Gujarat state (INDIA) Phone: - (079) 27682572 Email: narayanpatel1932@yahoo.com

TORCH INFECTIONS AND PRENATAL ULTRASOUND FINDINGS Eran Casiff M.D. Department of Obstetrics and Gynecology Kaplan Medical Center Rehovot 76100, Israel Limitations • Most infected fetuses are sonographically normal • Ultrasound findings may change with time • no correlation with infant outcome Cerebral Ventriculomegaly • Measured at the posterior aspect of the choroid plexus • Almost always symmetric • 5% of cases can be attributed to fetal infection Intracranial Calcifications • Intrauterine infection • Periventricular hyperechoic foci - the hallmark • May be located in the thalami and basal ganglia • Small with no acoustic shadowing • Most frequently seen with CMV and Toxoplasmosis Hydranencephaly • Most severe manifestation of the destructive process • Cerebral hemispheres replaced by fluid, brain stem preserved, falx present, absent or deviated, posterior fossa structures can be identified • Reported in Herpes simplex, Toxoplasmosis and CMV Microcephaly • Often associated with other CNS anomalies • Diagnosed as three SD below the mean for gestational age • Abnormal HC/AC and HC/FL ratios • Isolated microcephaly documented in CMV, Rubella and Herpes simplex Cardiac Abnormalities • Cardiomegaly, mostly in CMV • Cardiothoracic ratio • VSD, ASD, Pulmonic stenosis and coarctation of the aorta in Rubella Hepatosplenomegaly • Documented in all TORCH infection • Often a transient finding • Normograms are available   Intra-abdominal Calcifications • Typical appearance: echogenic foci with acoustic shadowing • Peritoneum, intestinal lumen, organ parenchyma, biliary tree and vascular structures • Echogenic bowel in CMV and Toxoplasmosis Hydrops, Placenta and Amniotic Fluid • Hydrops reported in most TORCH but may be transient • Placentomegaly is usually associated with intrauterine infection, but small placentae have also been reported • Hydramnios and oligohydramnios have been reported with similar frequency Fetal Growth Restriction • Estimated weight below the 10th percentile • Common feature with CMV, Rubella, Herpes simplex and Varicella • Usually not seen with Toxoplasmosis and Syphilis TOXOPLASMOSIS • Ventriculomegaly is the most frequently documented finding Intracranial calcifications, placentomegaly, liver calcifications and ascites Hyperechoic bowel have been reported Microcephaly never been reported in utero SYPHILIS • Hepatomegaly and Placentomegaly are the most frequent sonographic manifestations • Ascites, Hydrops and Hydramnios are less commonly reported • Resolution of sonographic signs have been reported with maternal antibiotic therapy RUBELLA • Incidence less than 1:100,000 live birth • Prenatal diagnosis by sonographic findings have never been reported • Potential detected abnormalities include: cardiac anomalies, microcephaly, hepatosplenomegaly, FGR, microphtalmia and cataract CMV • The most common congenital infection affecting 1% of all live births • 10% of infected neonates demonstrate clinical manifestations that potentially could be identified by prenatal sonography • Ventriculomegaly, FGR, Intracranial calcifications and oligohydramnios are the most frequently reported findings HERPES SIMPLEX • HSV are usually acquired at birth Intrauterine infections resulting in clinical signs has been reported in 100 cases worldwide • Hydranencephaly is the only sonographic sign reported antenatally • Microcephaly, interracial calcifications and FGR are potentially detectable VARICELLA ZOSTER • The most common finding is Hydramnios • Also reported: liver calcifications, hepatomegaly, hydrops, limb deformities, ventriculomegaly and FGR SUMMARY • Sonography is not a sensitive test for fetal infection • Normal fetal anatomy survey cannot predict a favorable outcome • Multiple organ systems are affected in 50% of cases THANK YOU