1. An Obstetric Case History for You
Max Brinsmead MB BS PhD
March 2016

2. Stephanie is a 36-year old who has been trying to have a baby for 5 years. She has been told that she has endometriosis and her husband has a low sperm count. She has recently been to a clinic in Bondi for IVF and thinks she might be pregnant as a result. Today she has experienced a few spots of dark blood on her pants. She comes to you for advice…

3. Stephanie ?pregnant after IVF with PV bleeding
Do you require further history
Do you examine this patient
What tests might be useful

4. Stephanie ?pregnant after IVF with PV bleeding
Further history that is desirable
When did she have the embryo transfer procedure
Exact date
Any pain or other symptoms
Luteal phase support drugs?
How many embryos were transferred
Social circumstances, any other pregnancies or medical problems etc.
When did she have the embryo transfer procedure i.e Exact date
Any pain or other symptoms
Luteal phase support drugs?
How many embryos were transferred
Social circumstances, any other pregnancies or medical problems etc.

5. Stephanie ?pregnant after IVF with PV bleeding
Further history
2 embryos transferred 20 days ago
Progesterone pessaries for luteal support
Mastalgia for a week but no other pain
One spontaneous pregnancy 3 years ago. Miscarried “at 5 months”
FH of hypertension & diabetes. Non smoker. Married. School teacher

6. Stephanie ?pregnant after IVF with PV bleeding
Examination that is essential
Why?
Vital signs
Abdominal palpation for mass or tenderness
Must exclude ruptured ectopic pregnancy before Stephanie walks out your door
Vital signs
Abdominal palpation for mass or tenderness
Must exclude ruptured ectopic pregnancy before Stephanie walks out your door

7. Stephanie ?pregnant after IVF with PV bleeding
What is the best way to proceed from here?
What other tests may be desirable
A urine HCG test will confirm instantly if she is pregnant
PV ultrasound may confirm site of pregnancy and plurality
Take blood for quant. HCG, PROG and routine AN tests
A urine HCG test will confirm instantly if she is pregnant
PV ultrasound may confirm site of pregnancy and plurality
Take blood for quant. HCG, PROG and routine AN tests

8. What will you tell Stephanie
Pregnancy test positive. Scan report: “Twin intrauterine gestational sacs identified. Both ovaries enlarged with cystic mixed echogenicity. Small amount of free fluid in the pelvis”
“Twins” yet to be confirmed and reconfirmed at 12 weeks
Dichorionic and diamniotic from 2 embryos
Start planning for extra rest this pregnancy
Continue pregnancy vitamins, maybe extra iron
Issues of prenatal diagnosis
We need more information about the previous pregnancy
What will you tell Stephanie
What sort of twin pregnancy is this likely to be
What issues need to be explored at this stage of the pregnancy
“Twins” yet to be confirmed and reconfirmed at 12 weeks
Dichorionic and diamniotic from 2 embryos
Start planning for extra rest this pregnancy
Continue pregnancy vitamins, maybe extra iron
Issues of prenatal diagnosis
We need more information about the previous pregnancy

9. Stephanie with IVF Twins in the 1st Trimester
Subsequent ultrasound and serum biochemical testing
Further history
Confirmed a DC & DA pregnancy at 6 & 12 weeks. Low risk of aneuploidy for both.
Conception with same partner 3 yrs ago ended at 21w with PROM, pains for 2 hrs and miscarriage. Baby lived for 10 min. Autopsy NAD apart from “chorioamnionitis”

10. Stephanie 36 yr old G2P0 with IVF Twins in the 1st Trimester
Stephanie wants midwife care and maybe a home birth
What do you recommend
Give facts and figures to back this
Overall perinatal mortality is 2-3x higher with twins
1:6 twin pregnancies end <30w
50% of twins are born by CS and many 2nd twins require assisted vaginal birth
And a maternity hospital is best place for such to occur
Risk even higher for this patient, (age and reproductive history)
Her risk of complications of pregnancy is high eg pre eclampsia, diabetes
Overall perinatal mortality is 2-3x higher with twins
1:6 twin pregnancies end <30w
50% of twins are born by CS and many 2nd twins require assisted vaginal birth
And a maternity hospital is best place for such to occur
Risk even higher for this patient, (age and reproductive history)
Her risk of complications of pregnancy is high eg pre eclampsia, diabetes

11. Stephanie 36 yr old G2P0 with Twins at High Risk of PreTerm Delivery
What steps could be taken to reduce this patient’s risk of premature delivery
Cervical length measurements (best done serially and plotted)
Vaginal swab for vaginosis screening. GBS too.
Progesterone by injection or pessaries
Close antenatal surveillance and education
Increased rest (?hospital)
Cervical suture
Cervical length measurements (best done serially and plotted)
Vaginal swab for vaginosis screening. GBS too.
Progesterone by injection or pessaries
Close antenatal surveillance and education
Increased rest (?hospital)
Cervical suture

12. What is the urgency for assessment
At 24 weeks gestation Stephanie comes to hospital at 2 am with crampy abdominal pain and some loss of fluid PV
What is the urgency for assessment
How big are the twins and what chance of survival if born now
What steps would you take to evaluate this pregnancy
Very urgent
Very low chance of survival and high risk of handicap if they do
Assess uterine activity
PV speculum and test fluid
Fetal Fibronectin test
Ultrasound for cervical measurement and look at internal os
Very urgent
Very low chance of survival and high risk of handicap if they do
Assess uterine activity
PV speculum and test fluid
Fetal Fibronectin test
Ultrasound for cervical measurement and look at internal os

13. What is the significance of the fetal Fibronectin test
Irregular uterine tightenings only, cervix 2 cm long, closed at both ends but fetal Fibronectin positive. Steroids were given and Stephanie was flown to Newcastle for care.
What is the significance of the fetal Fibronectin test
Why steroids?
Why send this patient to Newcastle
50% risk of pre term delivery. 95% sensitive for preterm delivery
Steroids doubles the survival and halves the rate of most prematurity complications
Delivery preterm in a hospital with NICU facilities doubles the babies’ chance of survival and reduces the risk of handicap
At the John Hunter a UTI was diagnosed and treated. Stephanie was sent home after 2 weeks

14. Stephanie is sent to John Hunter Hospital at 24 weeks with twins in threatened premature labour
At the John Hunter a UTI was diagnosed and treated. Stephanie was sent home after 2 weeks

15. At 29 weeks gestation Stephanie comes to hospital with regular abdominal pains and some loss PV passage of blood and mucous. Evaluation suggested premature labour
IV Betamimetics eg. Salbutamol fast-acting but will complicate her diabetes
Oral Ca-channel blockers are the drug of choice. Watch BP
NSAID – adverse fetal effects
Glyceryl trinitrate patch not much used
Atobisan not available
List available tocolytic drugs and their pros and cons for this patient
IV Betamimetics eg. Salbutamol fast-acting but will complicate her diabetes
Oral Ca-channel blockers are the drug of choice. Watch BP
NSAID – adverse fetal effects
Glyceryl trinitrate patch not much used
Atobisan not available

16. What other steps are required
Stephanie G2P0 at 29 weeks with DC DA twins in premature labour but contractions are suppressed with oral Nifedipine
IM Betamethasone x2 over 24 hours will double survival and halve all risks of prematurity
IV Mg sulphate reduces risk of cerebral palsy 6- fold
Transfer to a hospital with NICU doubles chance of survival
Penicillin for GBS
Psychological care of the mother is important
What other steps are required
Back your recommendations with some facts and figures
IM Betamethasone x2 over 24 hours will double survival and halve all risks of prematurity
IV Mg sulphate reduces risk of cerebral palsy 6-fold
Transfer to a hospital with NICU doubles chance of survival
Penicillin for GBS
Psychological care of the mother is important

17. What problems could these babies face now and in the future
Stephanie is transferred to Sydney and delivered by Caesarean 5 days later. Male 1050g and female 960g.
Hyaline membrane disease
Temperature control and nutrition
Jaundice
Necrotising enterocolitis
Cerebral palsy
Oxygen-dependent lung disease
Blindness
Girls better than boys
What problems could these babies face now and in the future
Who has the better chance of survival
Hyaline membrane disease
Temperature control and nutrition
Jaundice
Necrotising enterocolitis
Cerebral palsy
Oxygen-dependent lung disease
Blindness
Girls better than boys

18. When would the rate of survival be >95% and risk of handicap <2%
Stephanie delivered of Twins by Caesarean at 30 weeks. Male 1050g and female 960g.
Should be 70 – 80% chance of survival and <10% risk of long term handicap
At >34 completed weeks of pregnancy given optimal perinatal care
What are their chances?
When would the rate of survival be >95% and risk of handicap <2%
Should be 70 – 80% chance of survival and <10% risk of long term handicap
At >34 completed weeks of pregnancy given optimal perinatal care

19. Any Questions or Comments
Please leave a note on the Welcome Page to this Websitee