1. An Obstetric Case History for You Max Brinsmead MB BS PhD March 2014

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.

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

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

8. 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” 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 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 50% of twins are born by CS and many 2 nd twins require assisted vaginal birth

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

12. 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

13. 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 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. A glucose challenge test was positive (AGT) and follow up GTT confirmed gestational diabetes What steps are required in the management of this antenatal problem Why Dietary advice Self testing for blood glucose, fasting and postprandial Keep GLUC inside recommended levels with diet, insulin or Metformin So as to avoid the complications of Diabetes in Pregnancy

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 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. Stephanie G2P0 at 29 weeks with DC DA twins in premature labour but contractions are suppressed with oral Nifedipine 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. Stephanie is transferred to Sydney and delivered by Caesarean 5 days later. Male 1050g and female 960g. 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. Stephanie delivered of Twins by Caesarean at 30 weeks. Male 1050g and female 960g. 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? For copies of this Powerpoint go to www.brinsmead.net.au and follow the links to “Postgraduates”. www.brinsmead.net.au Called “Case of Multiple Pregnancy”