Duncan F. Farquharson

Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline

OBJECTIVE This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the antepartum and intrapartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing and intrapartum electronic fetal surveillance to what has been used previously. This guideline is intended for use by all health professionals who provide antepartum and intrapartum care in Canada. OPTIONS Consideration has been given to all methods of fetal surveillance currently available in Canada. OUTCOMES Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered. EVIDENCE A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance both antepartum and intrapartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care. SPONSOR This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program.

Prenatal spinal evaluation and functional outcome of patients born with myelomeningocele : Information for improved prenatal counselling and outcome prediction

OBJECTIVE Prenatal ultrasonography can localize the level of the spinal cord malformation, allowing prediction of the potential postnatal neurological deficit and functional prognosis. METHODS This study has two evaluations: (a) a retrospective prenatal review of 26 fetuses with spinal dysraphism (1987-1991), and (b) a follow-up descriptive study of patients (1971-1981) who underwent closure of the spinal lesion and ventricular shunting in the neonatal period. RESULTS Prenatal ultrasound evaluation enabled the accurate definition of the last intact vertebral level which allows separation of fetuses into three functional groups (last intact level L2, L3-4, L5-sacral). Patterns of ambulation, urinary and bowel continence, and school performance vary according to level of spinal lesion and the neurological deficit. The need for ventricular shunts, the incidence of other spinal malformations and surgical interventions did not vary with the level of the spinal lesion. CONCLUSIONS The functional outcome for patients with myelomeningocele is variable; however, distinct patterns emerge based on the level of spinal dysraphism and the resultant neurological deficit. By relating the level of the fetal spinal lesion to outcome data, more precise functional prognoses can be given to families.

Parents' Perspectives on Decision Making After Antenatal Diagnosis of Congenital Heart Disease

OBJECTIVE To discover and describe how prospective parents make decisions when they learn of their babys congenital heart disease (CHD) during pregnancy, and to provide professionals with direction for their interactions with these families. DESIGN AND METHOD Qualitative analysis informed by symbolic interactionism. SETTING A tertiary care womens health center that provided referral services for a province with a population of 4 million. PARTICIPANTS Mothers and fathers of 19 babies with antenatally diagnosed CHD participated in interviews during pregnancy and after the birth of their baby. Thirty-four interviews were analyzed for common themes and distinguishing characteristics of antenatal decision making. RESULTS Parents approached their antenatal decisions regarding further testing and continuation of the pregnancy as their first parenting decisions. They made their decisions with differing degrees of apparent ease or deliberation, and some parents more readily sought the opinion of professionals. The offered opinions offended some parents, even though the professionals may have intended the information as descriptive of options, not suggestive of a particular decision. CONCLUSION Although advances in technology have enabled diagnosis of CHD antenatally, health care professionals, including nurses, must elicit each parents particular perspective, be cognizant of their professional influence, and actively support parents from the time of the antenatal diagnosis.

Outcome of fetuses diagnosed with atrioventricular septal defect

OBJECTIVE To quantify the association of prenatally diagnosed atrioventricular septal defect with Down syndrome and to evaluate its impact on obstetric and neonatal outcomes. METHODS Charts of 42 cases of atrioventricular septal defect diagnosed by fetal echocardiography from July 1985 to July 1997 were reviewed for prenatal history and outcome data (pregnancy outcome, pathologic confirmation, postnatal echocardiographic findings, and neonatal outcome). Statistical analysis was done using Fisher exact test and odds ratios. RESULTS The mean gestational age at diagnosis was 26 weeks. Four cases could not be confirmed antenatally on repeat echocardiograms and were excluded. Reasons for referral of the remaining 38 fetuses included an abnormal four-chamber view in 76%. Twenty-two fetuses (58%) had abnormal karyotypes: 19 trisomy 21, one trisomy 18, one trisomy 13, and one mosaicism. The cardiac lesions were isolated in 20 fetuses (53%). After excluding cases of termination, ten of 12 fetuses (83%) with Down syndrome survived, compared with seven of 13 (54%) with normal karyotypes (P = .125). The odds of trisomy 21 were 16 times higher (95% confidence interval 3.0, 85.3) in fetuses with isolated cardiac lesions compared with those with associated cardiac anomalies. CONCLUSION Prenatal diagnosis of atrioventricular septal defect was associated with a 58% risk of aneuploidy (mainly trisomy 21). Down syndrome fetuses with this cardiac anomaly appeared to have a better survival rate than fetuses with normal karyotypes. Our sample did not have enough power to show a statistically significant difference. When an isolated atrioventricular septal defect was diagnosed prenatally, the odds of trisomy 21 were significantly higher than when other associated cardiac lesions were diagnosed. This information should be considered in prenatal counseling for atrioventricular septal defect.

Management of quintuplet pregnancy by selective embryocide

Selective embryocide was performed as a two-stage procedure in a patient with a quintuplet pregnancy in the first trimester. No complications occurred, and the patient was delivered of healthy twins at term. This procedure may be offered to selected patients with pregnancies with greater than five embryos.

Antenatal invasive and noninvasive management of alloimmune thrombocytopenia

The outcome analysis of 10 pregnancies at risk for neonatal alloimmune thrombocytopenia (NAIT) is presented. An experimental protocol of cordocentesis and maternal administration of intravenous immunoglobulin (IVIG) is compared to a control group of older untreated affected siblings. The outcome in pregnancies treated with IVIG shows improved fetal platelet count in 70% and no intraventricular hemorrhage. We conclude that maternal administration of IVIG appears to improve clinical outcome in fetuses at risk for NAIT.

Cardiovascular collapse following an overdose of prostaglandin F2 alpha: a case report

A case report is presented of a parturient who suffered severe hypotension and pulmonary oedema following an overdose of intramyometrial prostaglandin F2 alpha. Oxytocin induction of labour in this patient led to a rapid delivery, followed by a hypotonic uterus and postpartum haemorrhage. After resuscitation with blood and crystalloid fluids, the uterus was explored under general anaesthesia. The uterus was free of retained products but the lower uterine segment failed to contract despite bimanual uterine compression and intravenous oxytocin. Prostaglandin F2 alpha was injected into the lower uterine segment via a transvaginal approach. This was rapidly followed by cardiovascular collapse and later by pulmonary oedema. The differential diagnosis and subsequent management are discussed.RésuméIl se petit qu’ un surdosage de prostaglandine F2 alpha injectée dans le myomètre entraine de l’ hypotension et de l’ oedème pulmonaire; en voici un exemple. Avec stimulation aux ocytociques, une patiente accouche rapidement mais l’ utérus devient atone et saigne abondamment. On infuse alors du sang et des solutions de cristalloïdes, suivis d’ un curetage sous anesthésie générale qui confirme l’ absence de rétention placentaire. Le segment inférieur de l’ utérus demeure flasque malgré le massage utérin et l’ ocytocine intraveineuse. C’ est alors que par voie vaginale, l’ on injecte de la prostaglandine F2 alpha dans l’ utérus. Il s’ensuit rapidement un collapsus cardiovasculaire et un oedème pulmonaire. Voir l’ article pour le diagnostic différentiel et la suite des événements.

Multifetal Pregnancy Reduction and Selective Termination: The Canadian Experience

Objective: To describe the experience of two Canadian referral centres with multifetal pregnancy reduction (MFPR) and selective termination (ST). Methods: Retrospective chart review of all MFPR and ST procedures during the periods from January 1, 1990, to December 31, 1997 (Vancouver), and from September 1, 1995, to December 31, 1997 (Toronto). Outstanding outcome data were obtained by telephone. All women were managed according to standard protocols. Non-parametric analysis of continuous variables and Fisher’s exact test for categorical variables were used. Results: 61 women underwent transabdominal MFPR (n = 44) or ST (n = 17). Median maternal age: MFPR and ST 33.0 years; gestational age at reduction: MFPR 11.4, ST 20.2 weeks; procedure duration: MFPR 4, ST 10 min. 89% MFPR and 12% ST cases followed assisted reproduction. 7% MFPR and 18% ST pregnancies lost <24 weeks (n.s.). 97% MFPR and 83% ST non-reduced fetuses delivered alive. Median delivery gestational age: MFPR and ST 37 weeks. Conclusions: The results are similar to published series. This procedure has increased options for Canadian couples, offering the procedure ‘close to home’, reducing costs and, more importantly, the significant psychological morbidity following these procedures.

Diagnosis and outcome of dilated cardiomyopathy in the fetus

To identify the echocardiographic features and natural history of dilated cardiomyopathy in fetal life, we reviewed records of all fetal echocardiograms over the 10 year period 1980–1989 to identify cases of dilated cardiomyopathy without left ventricular outflow obstruction and conducted a retrospective review of the fetal echocardiograms and clinical course of those fetuses with dilated cardiomyopathy. In addition, all fetal losses, perinatal deaths and live-born infants presenting with dilated cardiomyopathy in the first seven days of life were identified from the British Columbia Pediatric Cardiovascular Pathology Registry and from inpatient records. The pathological findings and outcome for this group were also reviewed. Marked left ventricular dilatation and dysfunction without left ventricular outflow obstruction was diagnosed in five of 1,158 fetuses undergoing feta lechocardiography. These five fetuses were correctly distinguished from two others with critical aortic stenosis and severe left ventricular dysfunction. Two of the five fetuses had additional right ventricular dysfunction and dilatation and developed hydrops, while the remaining three with isolated severe left ventricular dysfunction did not and showed normal somatic growth. All fetuses were live-born with spontaneous labour occurring in four of five cases at a mean gestational age of 36.5 weeks. Four of the five infants died, with three deaths occurring in the first week of life. During the same 10 year period, two of 2450 autopsied stillbirths (both hydropic) were diagnosed with dilated cardiomyopathy. An additional 15 neonates (including the five identified by fetal echocardiography) were diagnosed in the first week of life with dilated cardiomyopathy, congenital myocarditis or endocardial fibroelastosis. Four were hydropic (all with associated right ventricular dysfunction). Only three of the 15 survive. Fetal echocardiography can accurately distinguish dilated cardiomyopathy from left ventricular outflow obstruction. In the absence of right-sided disease or premature closure of the oval fossa, severe left ventricular dysfunction is well tolerated in utero. The prognosis for fetal dilated cardiomyopathy is very poor.

P05.01: Is the nuchal index increased in fetuses with congenital structural heart defects? A prospective study

Objectives: To determine if the Nuchal Index (NIx) is increased in euploid fetuses diagnosed with an isolated structural congenital heart defect (CHD) on fetal echocardiogram. Methods: A prospective case-control study was conducted from March 2002 to July 2003. All patients between 18 and 24 weeks’ gestation referred for fetal echocardiography were approached for participation. Patients were excluded if other major anomalies or an abnormal karyotype were present. The NIx was calculated as the mean nuchal thickness/mean biparietal diameter ×100. Fetal cardiac axis was calculated from hard copy images in a blinded fashion. Analysis was by standard descriptive tests, 2-tailed t-test, receiver operating characteristic (ROC) curve, univariate analysis and discriminant analysis. Cases were classified as normal or abnormal as per the co-authors diagnosis at the time of the fetal echocardiogram. Results: Of the 607 echocardiograms performed, 314 were eligible. Two hundred and seven (22 abnormals and 185 normals) were recruited for a capture rate of 65.9%. The mean NIx in the abnormal and normal group was 9.3 and 7.8 respectively. This was statistically significant (p = 0.003). Using a cut-off of 10.4 at a 5% false positive rate, the sensitivity was 29% with an ROC of 0.699 [95%CI 0.582, 0.816]. Eleven of the 22 abnormal hearts and 7/185 normals had an abnormal cardiac axis. (OR 0.04 [95%CI 0.01, 0.12, p < 0.00001]). Although NIx and Nth were different between the study groups, discriminant analysis was unable to identify an adequate cut-off to allow adequate prediction of CHD. Conclusions: The NIx and CA were significantly different in fetuses with CHD in a high-risk population. However, an appropriate cutoff value could not be found in our study. Further studies in a low-risk population are warranted.