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Intrapartum assessment of fetal well-being: a comparison of fetal acoustic stimulation with acid-base determinations skin care 3 months before marriage cheap 30 mg aisoskin free shipping. Comparison of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation in detecting fetal acidemia at birth skin care wiki discount aisoskin 20mg with amex. Weary of these poor outcomes acne on neck buy discount aisoskin line, clinicians begged the question: can treatment of the fetus lead to better postnatal outcomes in specific congenital anomalies In 1982 skin care 5th avenue peachtree city purchase aisoskin 5 mg fast delivery, the first therapeutic human fetal surgical intervention was performed for bilateral ureteropelvic junction obstruction. Further advances in imaging techniques have allowed clinicians to make earlier and more accurate diagnoses of fetal anomalies. As a result, clinicians have identified measurable parameters that allow for prognostication for many prenatally diagnosed anomalies. The fact still remains that most prenatal anomalies are best managed postnatally because outcomes for the fetus are unchanged and this strategy minimizes unnecessary maternal risk. However, in cases that carry a grim prognosis, fetal intervention can be lifesaving and may therefore be considered if the fetus is not yet at a viable gestational age. Fetal intervention is complicated not only by the risk to the unborn patient, but by the risk to the mother as well. No health benefit is gained by the mother, yet she is placed at significant risk, including the risk of death, with any fetal surgical intervention. Short-term morbidity after fetal surgery includes preterm labor, the potential risk of anesthesia, the potential need for blood transfusion, premature rupture of membranes, chorioamniotic separation, chorioamnionitis, and placental abruption. Long-term morbidity related to the hysterotomy used in open fetal cases includes infertility, uterine rupture during future pregnancies, and mandatory cesarean section with future pregnancies. For these reasons, any consideration for fetal interventions should include multidisciplinary input and extensive discussions with the pregnant woman and her family. Percutaneous approaches require realtime ultrasound to visualize the fetal and maternal anatomy and guide the appropriate instruments. Shunts can be inserted for more definitive drainage of fluid into the amniotic space. For many fetoscopic procedures, a 3-mm fetoscope with a 1-mm working channel is sufficient. This approach permits direct visualization at the time of intervention but is still facilitated by the use of ultrasound. Given the larger caliber of these instruments relative to the smaller catheters used for percutaneous techniques, it is optimal to identify a "window" in the uterus that is devoid of the placenta to reduce the risk of maternal bleeding, placental abruption, and fetal morbidity. In such cases, an amnio exchange may be performed with warm, isotonic crystalloid solutions to optimize visualization. Fetal Access Access to the fetus can be considered in three general categories: percutaneous, fetoscopic, and open hysterotomy. Preoperative and intraoperative ultrasound are critical for defining the anomaly (or anomalies), delineating the placental anatomy, determining the position of the fetus, detecting the location of the maternal blood vessels, and monitoring the fetal heart rate during the procedure. Fortunately, the continuing advancements in less invasive approaches have gradually reduced the need for open fetal procedures. The fascia can be opened in a vertical or transverse fashion, depending on the exposure needed. Preoperative and intraoperative ultrasounds are crucial to map out the placenta and determine the ideal placement of the uterine incision to optimize exposure and avoid injury to the placenta. Typically, fetal exposure is limited to the site specific to the intervention to avoid hypothermia and unnecessary manipulation of the umbilical cord, which is prone to spasm that can result in fatal fetal ischemia. A fetal extremity may also be exposed for placement of an intravenous access if indicated. The uterus should be stabilized within the maternal abdomen to minimize tension on the uterine blood vessels that could impede placental flow. At the conclusion of the procedure, the amniotic fluid is completely restored, and the uterus is closed in multiple layers using absorbable sutures. Postoperatively, the mother and fetus are monitored continuously for uterine contractions and heart rate, respectively. Patients are often dismissed with oral nifedipine as a tocolytic, and close follow-up is arranged. Open fetal surgery requires cesarean section for the current and all future pregnancies owing to the potential for uterine rupture with subsequent births. However, at the conclusion of the case, with an established airway, the fetus is delivered. Anesthetic Considerations Maintenance of uteroplacental relaxation and circulation is a central component to maternal and fetal anesthesia during fetal surgical procedures. In addition, all other tenets of anesthesia must also be considered and applied according to the level of invasiveness associated with a specific procedure to ensure adequate pain control, amnesia (when desired), and appropriate patient monitoring. In all cases, the mother is positioned supine with her left side down to minimize compression of the inferior vena cava by the gravid uterus. Routinely provided is a dose of indomethacin as a tocolytic and a prophylactic dose of cefazolin preoperatively unless there is a maternal contraindication to either medication. The maternal bladder should always be decompressed by either straight catheterization for short procedures or an indwelling bladder catheter for longer or open procedures. Special consideration for spinal anesthesia should be undertaken when an emergency cesarean section is desired by the patient for fetal distress. Spinal anesthesia can cause hypotension, which negatively impacts uteroplacental blood flow; therefore, with spinal anesthesia normotension is maintained with a phenylephrine infusion.
Differences between selective termination of pregnancy and fetal reduction in multiple pregnancy: a narrative review acne rosacea treatment aisoskin 20mg free shipping. Chorionicity and perinatal complications in twin pregnancy: a 10 years case series skin care qvc generic aisoskin 40 mg with visa. Noninvasive diagnosis by Doppler ultrasonography of fetal anemia due to maternal red-cell alloimmunization: Collaborative Group for Doppler Assessment of the Blood Velocity in Anemic Fetuses acne on temples cheap aisoskin express. Threedimensional ultrasound diagnosis of cleft palate: "reverse face acne near mouth buy aisoskin uk," "flipped face" or "oblique face"-which method is best Posterior fossa and vermian morphometry in the characterization of fetal cerebellar abnormalities: a prospective three-dimensional ultrasound study. Unusual presentation of sacrococcygeal teratomas and associated malformations in children. The discourse around usefulness, morality, risk and trust: a focus group study on prenatal genetic testing. Suspected skeletal dysplasias: femur length to abdominal circumference ratio can be used in ultrasonographic prediction of fetal outcome. National Institute of Child Health and Development Workshop Participants: National Institute of Child Health and Development Conference summary: amniotic fluid biology- basic and clinical aspects. Fetal cardiac screening and variation in prenatal detection rates of congenital heart disease: why bother with screening at all Acoustic output as measured by thermal and mechanical indices during fetal nuchal translucency ultrasound examinations. Role of threedimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and color Doppler techniques. Second-trimester ultrasound to detect fetuses with Down syndrome: a meta-analysis. Imaging of pregnant and lactating patients: part 1, evidence-based review and recommendations. First trimester trisomy screening, nuchal translucency measurement training and quality assurance to correct and unify technique. Perinatal outcomes in women with subchorionic hematoma: a systematic review and meta-analysis. Brainstem-vermis and brainstem-tentorium angles allow accurate categorization of fetal upward rotation of cerebellar vermis. A false-negative test will be one that fails to identify a fetus at risk of death or major morbidity, which could have been prevented by delivery. Falsepositive results, however, can lead to iatrogenic preterm birth, which itself can be associated with significant morbidity. Even if testing does not lead to delivery, positive results can also generate significant maternal anxiety and stress, as well as cost. The optimal antepartum fetal testing strategy would appropriately identify an at-risk fetus prior to an irreversible event while minimizing maternal anxiety, cost, and iatrogenic prematurity. Thus it is primarily useful in a fetus at risk for hypoxemia specifically because of chronic uteroplacental insufficiency. Intrauterine demise from sudden catastrophic events, such as abruption secondary to maternal trauma or cord compression at the time of membrane rupture, are likely not predictable by antepartum monitoring. The indications for antenatal testing are those that increase the risk of uteroplacental insufficiency, many of which are listed in Table 13-1. The optimal antenatal testing strategy for each of these would be beyond the scope of a single chapter, and additionally in many circumstances the exact strategy is controversial because there is often little or no prospective or randomized data from which to determine an optimal approach. Many conditions for which testing has been suggested are those for which epidemiological studies have identified an increased risk of intrauterine demise. However, in some circumstances the risk of stillbirth, although achieving statistical significance in large studies, may remain small in actual magnitude. For example, a history of a prior unexplained stillbirth is associated with an increased risk of stillbirth,12 though because there are few or no prospective interventional studies, monitoring for these conditions is primarily based upon expert opinion. This is primarily to allow for the interpretation of fetal heart rate decelerations relative to uterine contractile activity. Uterine contraction monitoring alone as a method of identifying patients at increased risk of preterm birth is of low clinical utility. In experiments involving animal and human fetuses, hypoxemia and acidosis have been shown consistently to alter fetal biophysical parameters such as heart rate, movement, breathing, and tone. Beyond this generalized recommendation, various formalized strategies of fetal monitoring (colloquially referred to as "kick counts") have been proposed. However, systematic reviews have identified neither an optimal strategy nor clear evidence that routine, quantified fetal movement assessment can prevent stillbirth. As described above, fetal movement decreases with increasing hypoxia, which serves as the physiologic basis of the biophysical profile as well as subjective fetal movement monitoring. In the outpatient setting the patient typically rests in a reclining chair with a lateral tilt. Although commonly provided in antepartum testing units, the maternal ingestion of juice or food has not been demonstrated to increase the probability of a reactive nonstress test. A reactive test is one in which there are at least two accelerations that peak 15 beats/min above the baseline and last (not at the peak) for at least 15 seconds before returning to baseline (Figure 13-1), colloquially referred to as "15 15. For tests that are not, possibly because of a fetal sleep cycle, an additional 20 minutes of monitoring may be needed. The optimal gestational age at which to begin antenatal surveillance depends on the clinical condition. In making this decision, the physician must weigh the risk of intervention at a premature gestational age against the risk of intrauterine fetal death. Of note, the magnitude of accelerations in fetuses less than 32 weeks can vary normally over time, thus a fetus at less than 32 weeks is reactive by 10 10 criteria even if it had previously demonstrated 15 15 accelerations.
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The diagnosis of neonatal alloimmune thrombocytopenia involves typing platelet antigens in the newborn and in the parents to show that the mother lacks a platelet antigen that is present on the platelets of the father and the neonate acne complex 20mg aisoskin. Testing the infant is generally unnecessary if the father is available for testing skin care vegetables cheap aisoskin 20mg visa. Several techniques are known acne in ear purchase aisoskin with visa, and the polymerase chain reaction with sequence-specific primers is used skin care 50s generic aisoskin 40 mg fast delivery. Older methods that measure the antibody associated with platelets lack adequate specificity, but newer enzyme-linked immunosorbent assays specifically detect the antiplatelet antibody. In antigen capture immunoassays, monoclonal antibodies directed against platelet antigens are used to identify various known platelet antigens individually, although these may be negative in maternal blood 2 to 4 weeks after delivery in 30% of the cases. Establishing the diagnosis of neonatal alloimmune thrombocytopenia has immediate importance and implications for future pregnancies. Management of the Neonate In suspected cases of neonatal alloimmune thrombocytopenia, treatment should be started on the basis of the clinical diagnosis without waiting for the results of the immunologic workup. Management depends on the gestational age of the infant, the severity of the thrombocytopenia, the presence of bleeding, and the presence of additional risk factors for bleeding. This transfusion is compatible in approximately 90% of cases of neonatal alloimmune thrombocytopenia. In any case, the neonatal platelet count should be closely monitored during the first days of life. Management of a Subsequent Pregnancy When the diagnosis of alloimmune thrombocytopenia is established, parents need to be counseled regarding risks and management of future pregnancies. The recurrence rate of neonatal alloimmune thrombocytopenia in a subsequent pregnancy is greater than 90%, and the risk for intracranial hemorrhage is the same or greater than in the previous pregnancy. The difference is, however, that in a subsequent pregnancy the patient and her caregivers are aware of the neonatal alloimmune thrombocytopenia affecting the first child. In the absence of screening (which has very low cost-effectiveness) for the presence of antiplatelet antibodies in maternal blood, the diagnosis is almost impossible without a history of neonatal alloimmune thrombocytopenia in a previous gestation. One exception is an incidental finding of intracranial hemorrhage during an ultrasound scan. Although screening procedures are not indicated to detect neonatal alloimmune thrombocytopenia, a high index of suspicion is needed in certain cases (Box 21-2). Typically, a woman presents in early pregnancy with a history of delivering an infant with neonatal alloimmune thrombocytopenia or presents with some clues to the diagnosis. Failure to treat carries the risk for intrauterine intracranial hemorrhage, which is expected to occur in 30% of cases, with 10% of affected newborns dying and 20% experiencing neurologic sequelae secondary to intracranial hemorrhage. Percutaneous umbilical vein blood sampling has a high risk for miscarriage or fetal death. The operator must be prepared to transfuse platelets if the results show a dangerously low platelet count. Because the survival of transfused thrombocytes is short, performing serial intrauterine transfusions requires repeating the procedure every week or 10 days. The authors calculated a cumulative risk for serial weekly transfusions of approximately 6% per pregnancy, indicating the need to develop less invasive approaches. Intravenous immune globulin also stabilizes endothelial cells and reduces the incidence of intracranial hemorrhage even when the fetal platelet count remains low. The authors found that fetuses with a sibling history of antenatal intracranial hemorrhage or severe thrombocytopenia (a platelet count of <20,000/) had significantly lower pretreatment platelet counts than fetuses whose siblings had less severe thrombocytopenia or postnatal intracranial hemorrhage. Maternal therapy resulted in a platelet count exceeding 50,000/ in 67% of cases. None of the fetuses managed by serial platelet intrauterine transfusions had intracranial hemorrhage after treatment. The results of this study suggest that the start of therapy can be stratified on the basis of the sibling history of neonatal alloimmune thrombocytopenia and support the use of maternal therapy as first-line treatment. The infant may present with cardiac, dermatologic, hepatic, and hematologic manifestations. In children with neonatal lupus, there is commonly involvement of only one or two organ systems. The skin lesions on the face and scalp, often in a distinctive periorbital distribution, may be present at birth, but usually develop within the first few weeks of life and tend to resolve in a few weeks or months without scarring. In some instances, this begins as first- or second-degree heart block and progresses to third-degree heart block. The noncardiac manifestations are transient and tend to resolve within months after birth. The recurrence rate of neonatal lupus for a mother with anti-Ro autoantibodies, which are present in almost 95% of patients, is approximately 25%. Maternal anti-Ro and anti-La antibodies and complement components are deposited in fetal heart tissues, leading to inflammation, calcification, necrosis, and fibrosis of the conducting tissue (and, in some cases, of the surrounding myocardium). The process by which maternal anti-Ro or anti-La antibodies begin and propagate inflammation that leads to scarring of the atrioventricular node is not entirely clear. Echocardiography can show the conduction defect and estimate the cardiac function. About 10% of fetuses with congenital heart block are born with hydrops fetalis and congestive heart failure, and their prognosis is poor (see Chapter 24). Neonatal mortality rate in infants born with a congenital heart block ranges from 20% to 30%; however, death may occur from late pacemaker failure later in childhood. Most neonates born with a heart block secondary to neonatal lupus require pacemaker placement in the neonatal period or later in life. Most children with neonatal lupus do not seem to develop rheumatic diseases, but follow-up has been limited to late adolescence. The most common subgroups involved in disease states are anticardiolipin antibodies, lupus anticoagulant antibodies, and antiglycoprotein I antibodies.
State intervention is disproportionately oppressive toward poor and minority women skin care urdu cheap aisoskin 40mg with amex. Use of a physiologic definition of viability acne doctor discount aisoskin 20 mg line, such as the point at which life can be maintained outside of the uterus acne 101 aisoskin 40mg, might suggest that every neonate born at such gestational ages should be given an opportunity for extrauterine life and be actively supported acne yeast purchase 10 mg aisoskin free shipping. Other definitions of viability do not focus exclusively on the likelihood of survival, but rather include quality-of-life considerations, in which there is an explicit value judgment regarding the degree of morbidity that is acceptable if such a life were to be maintained. Viability, so understood, might suggest that full support should be provided only at a gestational age at which a "good enough" quality of life is foreseen. In clinical practice, there is no universally accepted definition of a viable fetus; however, guidelines from professional societies in several countries have defined gestational age ranges at which the benefit-to-burden ratio of aggressive obstetric or neonatal care becomes questionable. A discussion with the pregnant patient about the limits of viability even earlier in pregnancy, free of the threat of imminent delivery and the lack of time for absorption of information and ability to participate objectively in such difficult decisions, has been proposed. Additionally, how a parent may respond when facing a hypothetical preterm delivery may differ considerably from her response when faced with the actual circumstance. To Provide Data on Which Decisions Can Be Based It is important to have the best data available52-data that are current, based on a number of pertinent factors rather than simply gestational age, and germane to the unit in which the patient is being cared for (or the geographic region, where appropriate). The data should include survival statistics and information about the long-term outcomes, with quantitative and qualitative measures (functional abilities, learning, behavior, impact on family). Tyson and co-workers, for example, developed an "outcomes estimator" that takes into account five factors (gestational age, estimated birth weight, singleton status, antenatal steroids, and gender) and provides the likelihood of death or adverse neurodevelopmental outcome. In an in-depth qualitative study on the discussion between neonatologists and parents at risk of premature delivery between 23 and 25 weeks, two divergent models were used by neonatologists regarding resuscitation decisions at this threshold. Parents were expected to manage the probabilities and uncertainties via their own decision-making process. Prognostic statistics were used as information to justify and reflect on the suggested course of action. In the first model, the neonatologist was described as a "messenger of uncertainty," and parents felt essentially on their own to make decisions. Parents expressed the need for a more individualized and humane relationship, which could not be addressed by a clinical focus on "objective/neutral facts. This study advocated that between the "liberal autonomous decision" and a "paternalistic decision-making process,"65 there is the need for an intermediate "shared relational space"-for a more caring relationship between the decision makers, and more time to allow exploration of the facts, expectations, and values that are inherent in this interaction. To Explore the Values of the Pregnant Patient and Her Partner and Negotiate a Shared Decision Between Them and the Medical Team It is crucial to explore with prospective parents their preferences in relation to the data provided. Some parents may regard 20% as a fair chance of a "good enough" outcome, whereas others may regard 80% as not enough of a guarantee. In the "negotiated" model, parental input is maximized, and the decision attends to the moral values of the physician and the parents. It is worth reflecting on the reasons for the lack of congruency in decisions between physicians and parents, where differences seem to arise from three sources:68 1. Physicians attempt to be as objective as possible with facts and figures, whereas parents reformulate those chances. For physicians, it is after they are convinced the parents have fully understood the information; whereas for parents, it is after they have had their experience taken into account and it is supported by a scientifically competent and humane medical team. By focusing first on the parents, sharing two-way information, recognizing the importance of "relational space," and overcoming to any degree these different starting points, physicians may achieve greater consensus and more acceptable decisions for all parties in this complex and contentious arena. The challenge in moving forward from a purely information-sharing interaction cannot be overemphasized; most neonatologists in New England who responded to a questionnaire viewed their primary role as providing factual information almost exclusively, with few considering their role being to assist in weighing risks and benefits, and only 2% regarding their primary role to discuss potential differences in views between parents and the medical team. Treatment considerations for extremely premature infants must be viewed in context against other areas of medicine in which difficult decisions must be made. There is evidence that, without clear justification, premature infants are considered "morally different" from older children and adults. In addition, the individuals undertaking these decisions need to make their reasoning behind their approach explicit, because this has a major impact on the way they present information-how mortality and survival statistics are framed and options are discussed. Clinicians must recognize the difficulty in predicting outcomes with certainty, as studies suggest that in many circumstances neither clinical intuition nor objective scoring systems are reliably able to predict mortality in critically ill neonates. Treatment that is not meeting or would not meet the goals set for that treatment is considered ineffective. The criteria involved in assessment of quality of life have been described earlier. Despite the difficulty in determining the quality of a life with limited cognitive or relational capacity, mobility, or self-awareness, or a life of continued pain and suffering, a poor quality of life is a valid consideration as to whether treatment should be initiated or continued in the face of an extremely poor predicted outcome. Some authors cite futility of medical treatment as a criterion for withholding or withdrawing medical treatment. It is difficult to know what follows from such claims, however, because there is considerable debate and diversity of opinion as to the meaning of futility. In addition to the debate about the meaning of the term futility, arguments have emerged about the authority of the physician to determine when an intervention is futile. Some authors contend that futility is a medical decision to be made by the physician alone, whereas others believe that the decision is value-laden and that parents should be involved in this determination. When futility is determined solely on the basis of medical or physiologic factors (a rare occurrence unless death is imminent), unilateral decision making by the physician based on sound medical knowledge and expertise may be appropriate. When subjective elements form part of the determination, however, the physician has no unique claim to moral expertise. Instead of attempting to center decision making using references to futility, physicians should state their reasons for considering withdrawing or withholding medical treatment. Use of the listed criteria-the inevitability of death, the low probability of successful treatment, or a poor predicted quality of life-should rather be cited. Although there is some hesitancy to use quality-of-life considerations, in the study by Wall and Partridge,87 23% of deaths resulting from a decision to withhold or withdraw medical treatment did include quality-of-life considerations. For many families, there is a major distinction between withholding and withdrawing care.
