Question 1: What are the controversial issues with regard to                                      management of shoulder d...
Question 2: Controversies in the role of antenatal corticosteroidtherapy in threatened preterm labour.WELL ESTABLISHED: Si...
Supported by: Garite TJ, Kurtzman J, Maurel K, Clark R; Obstetrix                                   Collaborative Research...
Supportive Management including admission to hospital, iv-fluid, packed cells,                                   Anti D, c...
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  1. 1. Question 1: What are the controversial issues with regard to management of shoulder dystocia and discuss these briefly Shoulder Dystocia - associated with significant morbidity Baby: cerebral hypoxia/palsy, fractured clavicle/humerus, brachial p plexus injuries/nerve palsies Mother: PPH, perineal trauma, uterine rupture, psychological trauma HOWEVER: hard to predict – therewith hard to prevent Known risk factors (mother: previous SD, DM, BMI>30/ labour: prolonged first or 2nd stage, induction/augmentation, assisted delivery/ baby: macrosomia, postmaturity) predict <<half of cases –> most cases occur in patients without risk factors. NO large trials available to recommend preventative measures (eg elective c/ s), however may offer elLSCS if: USS evidence of macrosomia >4.5kg (Evidence Level IV). USS has 10-15% error in estimating fetal weight though and vast majority of macrosomic babies do not have shoulder dystocia (2-5%). Also most cases of SD do not result in injury.if prev SD + morbidity like bad May offer elLSCS if previous shoulder dystocia (recurrence risk of 10%) –brachial plexus injuries or death Evidence Level IV. IOL for suspected macrosomia failed to alter maternal or neonatal morbidity compared to expectant Mx. Prophylactic McRobert´s widely used in patients with risk factors. No clear evidence of reducing SD, but not harmful. >>> LACK OF EVIDENCE for clear recommendation of preventative measures at this stage. Once it happens, management well established (aim for delivery within 5min, McRoberts, suprapubic pressure, internal manoeuvres (RubanII, Woodscrew, reversed Woodscrew), r/o posterior arm, all fours position. - 30-60s for each manoeuvre - Order as per clinicians preference - Stop pushing during manoeuvre as may worsen impaction - 3rd line: fracture of clavicle, symphysiotomy, Zavanelli - Fundal pressure NOT recommended as associated with uterine rupture and may worsen impactionif talking about management,bring in epis and call for helpother controversies-can weactually have 6 to 7 min fordelivery of the body?, direct fetalmanoeuvres more effective thanmaternal, counsel women aboutexcessive weight gain inpregnancy
  2. 2. Question 2: Controversies in the role of antenatal corticosteroidtherapy in threatened preterm labour.WELL ESTABLISHED: Single course of Celestone (2 doses) reduces fetalmorbidity and mortality in preterm labour. (reduced risk of NND, RDS, IVHand NEC as well as reduced risk of systemic infections in the first 48 hours oflife). It is a safe medication (safe in setting of PROM or maternal HT, no longterm intellectual impairment or learning/behaviour difficulties).Liggins GC and Howie RN ; A controlled trial of antepartum glucocorticoid treatment for prevention ofrespiratory distress syndrome in premature infants. Pediatrics 1972;50:515-25Roberts D, Dalziel S (2006);Cochrane Database System Review; Liverpool UKCONTROVERSIAL: What to do, if remains pregnant and continues at risk ofPTB for > 1wk - repeated doses?✿ TEAMS trial (weekly double dose) stopped early due to other animal andretrospective human studies showing safety concerns. -> Showed significant reduction in severe RDS. -> No difference in head circumference, birth weight or gestational ageGuinn Da et al ; Single vs Weekly courses of antenatal corticosteroids for women at risk ofpreterm delivery: a RCT (JAMA 2001;286:1581-7)✿
ACTORDS I trial (weekly single dose) Australia 2006 -> reduced RDS, severe lung disease, need for O2, ventilation ACTORDS II -> no difference in 2 year follow upCrowther CA et al ; Neonatal respiratory distress syndrome after exposure to antenatalcorticosteroids; a randomised controlled trial (Lancet 2006;367:1913-9)Growther C et al: Outcomes at 2 Years of Age after Repeat Doses of Antenatal Corticosteroids.The New England Journal of Medicine 2007;357:1179.✿
MFMU trial (weekly single dose) America 2006 -> reduce specific neonatal (lung-) morbidities but no improvement in composite neonatal outcome ->↓birth weight / ↑SGAWapner RJ ; Single vs weekly courses of antenatal corticosteroids: Evaluation of safety andefficacy; for NICHD MFMU Network (AJ0G 2006;195:633-42)✿
MACS tria (2weekly double dose)l Canada 2008 ->NO neonatal benefits ->↓birth weight/length/head circumferenceKellie E Murphy, Mary E Hannah; Multiple courses of Antenatal Corticosteroids for preterm birthStudy “MACS” (Lancet 2008;372:2143-51)?? SINGLE DOSE
  3. 3. Supported by: Garite TJ, Kurtzman J, Maurel K, Clark R; Obstetrix Collaborative Research Network: Impact of a rescue course of antenatal corticosteroids: a multicenter randomized placebo-controlled trial. Am J Obstet Gynecol. 2009 Mar;200(3):248.e1-9.  reduced composite neonatal morbidity  decreased respiratory distress syndrome, ventilator support, and surfactant .BUT: so far no long term follow up…what is your policy, probablysingle course followed by rescuedose if delivery more than twoweeks later? Question 3: Management of a patient with 6 weeks amenorrhoeaalso controversy about dexa orbeta, ASTEROID study in progress and some pain and bleeding.sorry I should have added that Single most important investigation – pregnancy testhome pregnancy test is positive If negative: likely to be period, but check for local pathology eg abn PAPs, polyps etc… possible anovulatory cycles may need investigations / OCP / Progesteron depending on specific patient history and exam findings If positive - Differential Diagnosis (quantitative HCG and TV USS):diagnosis of blighted ovum, eg (1) intrauterine pregnancyif empty sac and measures Mx: observe / supportive measures20mm, missed abortion if embryo F/U viability scanpresent and more than 5mm CRL Routine pregnancy careand no cardiac pulsationsif BHCG is more than 1500 and (2) ectopic pregnancyno intrauterine gestation sac, Mx: supportive measuressuspect but PUL if no If pain, haemoperitoneum, large sac, detectable FH, highintraperitoneal fluid, blood or HCG: surgery – laparotomy if critical patientadnexal mass - laparoscopy if stable (controversial if shouldevidence now is for offer salpingostomy as remaining / or ??salpingectomy increased risk of recurring ectopic) If stable, small sac, no haemoperitoneum, no FH etc can repeat HCG ? spontaneous pregnancy failure (-> noif BHG not falling or rising intervention) or MTX if not failing (3) Pregnancy of Unknown location Mx: F/U HCGs and weekly scans – once established Dx manage accordingly (4) Molar pregnancy: D&C – prepare for risk of bleeding (5) M/C: expectant Mx vs D&C according to stability and preference of patient as well as likely patient cooperation and social network (close to hospital, availability of transport, support people)
  4. 4. Supportive Management including admission to hospital, iv-fluid, packed cells, Anti D, close monitoring depending on vital signs and blood investigations.good answer mine wouldprobably be a kind of cascade egat presentation as you said doquant HCG and TV USS, bloodgroup and FBC. If >1500 onewould expect an intrauterinegestation sac on scan; if lessserial bhcg and scans asnecessary

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