IUGR Sem 10 Neocities V3 Sem10

<h3>Hello.</h3> Welcome again to our world of thrills and chills. <img src="/IUGR/startpic.jpg"/> Sit back, relax and click [[here|start]] (track: 'firstbeat', 'play') (track: 'firstbeat', 'volume', 0.2)

Madam P, a 32 year-old G3P2 lady, has been referred from Klinik Kesihatan for persistent uterus smaller than date. Tell me, at what gestation period is the uterus first palpable per abdomen? [[1. 10 weeks POG]] [[2. 12 weeks POG]] [[2. 14 weeks POG]] [[3. 16 weeks POG]]

Oops sorry. At 10 weeks, the uterus is still not palpable per abdomen yet. <img src="/IUGR/skeleton.jpg"/> Try again. (track: 'witch', 'play') (track: 'witch', 'volume', 0.1)

Hey, you are good. At approximately 12 weeks gestation, the uterus becomes large enough to be palpable just above the pubic symphysis. At 16 weeks gestation, the fundus of the uterus can be palpated at the midpoint between the umbilicus and the pubic symphysis. Uterus at the level of umbilicus is 20 weeks. <img src="/IUGR/uteruspregnancy.jpg"/> Now go to the second [[step|History]] (track: 'happykids', 'play') (track: 'happykids', 'volume', 0.1)

Oops, Nooo... Even before 14 weeks, the uterus is already palpable. <img src="/IUGR/skeleton.jpg"/> Try again ;-) (track: 'witch', 'play') (track: 'witch', 'volume', 0.1)

Ohhh, noooo At 16 weeks gestation, the fundus of the uterus can already be palpated at the midpoint between the umbilicus and the pubic symphysis. <img src="/IUGR/skeleton.jpg"/> Try again ;-) (track: 'witch', 'play') (track: 'witch', 'volume', 0.1)

Madam P is currently at 30 weeks period of gestation and has been referred to you by the health clinic for uterus smaller than dates. This is her first proper antenatal check-up. She is certain of the date of her last menstrual period, she is not on any contraception, nor is she breast-feeding. She has a regular 28-day menstrual cycle. I am sure you would try to gather more history to help in the diagnosis. Which of the following histories is/are relevant? [[1. Madam P's husband's personal histories such as smoking, alcohol, recreational drug usage]] [[2. Past obstetric histories such as small for gestation babies]] [[3. Past medical histories of Madam P such as diabetes, hypertension, connective tissue disorders, anemia etc]] [[4. Madam P's personal histories such as smoking, alcohol, recreational drug usage]]

That is absolutely right. You need to ask about: 1. Maternal age, parity, BMI, maternal substance exposure, fertility treatment, daily vigours excercises, diet 2. Previous pregnancy issues such as small for gestational age (SGA), still birth, previous pregnancy interval, previous hypertension in pregnancy 3. Maternal medical histories such as hypertension, diabetes, antiphospholipid syndrome, renal diseases etc 4. Current pregancies: history of thretened miscarriage, anormaly scan findings, maternal weight gain, antepartum haemorrhage etc. For further details, refer to <a href="/IUGR/Risk factors of Small for gestational age RCOG guidelines.pdf" target=_"blank"/> Risks factors of Small for gestational age (RCOG guidelines)</a> Now...the next door is open for you. [[Continue.]] (track: 'lightapplause', 'play') (track: 'lightapplause', 'volume', 0.1)

Uhhhhhhhhhhhhhhhhhhhhhhhhhhhhh Click on the image for an explanation. [[<img src="/IUGR/scream.jpg"/>->here]] (track: 'AAAGH1', 'play') (track: 'AAAGH1', 'volume', 0.1)

Go through the door to proceed to the next section. [[<img src="/IUGR/door.jpg" >->Examination]] (track: 'lidcreak', 'play') (track: 'lidcreak', 'volume', 0.2)

No No.... Paternal personal histories such as smoking, alcohol, recreational drug usage are not risk factors for small babies. Take your time. Read this carefully: <a href="/IUGR/Risk factors of Small for gestational age RCOG guidelines.pdf" target=_"blank"/> Risks factors of Small for gestational age (RCOG guidelines)</a> Then go back to the [[question|History]] and try again.

You have successfully asked all the relevant histories. From the history, Madam P does not have any medical problems. Her first baby was delivered 5 years ago weighing 1.9 kg, and is alive and well. Her second child is now 2 years old, induced at 36 weeks due to intrauterine growth restriction, weighed 1.75 kg at birth, and has speech delay. She denied any antenatal medical problems. She is a fit and healthy lady. On general examination, her height is 167 cm, weight is 92 kg, and BMI is 33 kg/m2. She has mild pallor. Her BP is 128/84 mmHg and pulse rate is 80/minute. The rest of the examination is unremarkable. Now, you would like to perform an abdominal examination. Watch this clip first, then click on 'Next' to proceed: ==> [[Next|inv]] <= <iframe width="800" height="452" src="https://www.youtube.com/embed/-pkkgBX7OFQ" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>

At 30 weeks, antenatal examination of Madam P shows a symphysiofundal height of 25 cm. Fetal parts are easily palpable. Her abdomen is non-tender. Liqour volume feels reduced. Fetal heart is present and can be heard at 145/minute. What important investigations would you like to perform? [[1. Full blood count, ultrasound with uterine artery doppler]] [[2. Blood grouping and Rhesus status, ultrasound with umbilical artery doppler]] [[3. Oral glucose tolearance test, Cardiotocograph]] [[4. Maternal TORCHES screen, ultrasound with uterine artery doppler]]

Ohh uhh. Full blood count should be done to exclude anaemia in pregnancy. Ultrasound needs to be done to look for gross anomalies of the fetus and fetal parameters. Uterine artery doppler done at 20-24 weeks has moderate predictive value for severely SGA neonate (RCOG). However, Madam P is already at 30 weeks so it is quite late for uterine artery doppler. Therefore, this answer pair is not the correct choice. Go back and try again. (track: 'smirk', 'play') (track: 'smirk', 'volume', 0.2)

Bravo! You made the right choice. You need to know Rhesus status because Rhesus isoimmunization is a risk factor for IUGR and later, hydrops fetalis. Ultrasound with umbilical artery doppler is mandatory. In high risk populations, umbilical artery doppler can significantly reduce the risk of perinatal mortality and morbidity. Umbilical artery doppler: <img src="/IUGR/UAdoppler.jpg"/> [[Next|door]] (track: 'lightapplause', 'play') (track: 'lightapplause', 'volume', 0.1)

Bravo! You made the right choice. Oral glucose tolerance test should be done to exclude diabetes mellitus which can lead to both small for gestation as well as macrosomia. Blood grouping is relevant. CTG is also neccessary. In addition to these, Ultrasound with umbilical artery doppler is mandatory. In high risk populations, umbilical artery doppler can significantly reduce the risk of perinatal mortality and morbidity. Umbilical artery doppler: <img src="/IUGR/UAdoppler.jpg"/> [[Next|door]] (track: 'lightapplause', 'play') (track: 'lightapplause', 'volume', 0.1)

Uhh Ohh. Maternal TORCHES screening might be useful to exclude antenatal infection. Ultrasound needs to be done to look for gross anomalies of the fetus and fetal parameters. Uterine artery doppler done at 20-24 weeks has moderate predictive value for severely SGA neonate (RCOG). However, Madam P is already at 30 weeks so it is quite late for uterine artery doppler. Therefore, this answer pair is not the correct choice. Go back and try again. (track: 'smirk', 'play') (track: 'smirk', 'volume', 0.2)

Click on the image to open this mysterious door [[<img src="/IUGR/armdoor2.jpg" >->mnx at 30 weeks]] (track: 'creakydoor', 'play') (track: 'creakydoor', 'volume', 0.3)

Madam P undergoes several neccessary investigations. At 30 weeks, the following information are obtained: ○ Hemoglobin is 8.9 g/dL, low MCV, MCHC. ○ Serum iron study confirms that she has iron deficiency anemia. Since Madam P is asymptomatic, oral haematinics are started twice per day. ○ Her blood group is O+ve ○ Ultrasound scan shows a grossly normal fetus at 5th centile. Placenta is at upper segment. Amniotic fluid index is 8 cm. Umbilical artery doppler is normal. ○ Cardiotocograph is reactive. Choose the MOST appropriate management plan for Madam P at this juncture: [[1. Admit Madam P, prophylactic antibiotics erythromycin for 10 days, daily CTG, two weekly growth scan, weekly umbilical artery doppler]] [[2. Admit Madam P, IV magnesium sulphate for neuroprotection, daily CTG, two weekly growth scan, weekly umbilical artery doppler]] [[3. Admit Madam P, administer dexamethasome 6 mg BDx 4 doses, daily CTG, IV magnesium sulphate for neuroprotection, two weekly growth scan, weekly umbilical artery doppler]]

Ohhh nooooo. You missed the most important treatment. Her baby is delivered with severe respiratory distress syndrome and has to be intubated straight away for ventilator support in the neonatal intensive care unit. Your Paediatrician colleagues are angry with you. You feel so sad... <img src="/IUGR/docsargue.jpg"/> In addition, antibiotics are not neccessary in this case because Madam P does not have preterm prelabour rupture of membranes. Try again. (track: 'attack', 'play') (track: 'attack', 'volume', 0.2)

Ohhh nooooo. You are right that Magesium sulphate would be beneficial for neuroprotection for Madam P's baby. But you missed the most important treatment. Her baby is delivered with severe respiratory distress syndrome and has to be intubated straight away for ventilator support in the neonatal intensive care unit. Your Paediatrician colleagues are angry with you. You feel so sad... <img src="/IUGR/docsargue.jpg"/> But no worries, in this game, there is always a back button to go back and choose a better management plan. Try again. (track: 'attack', 'play') (track: 'attack', 'volume', 0.2)

Bingo. There you go. Yes, you need to admit the patient. A single course of dexamethasone should be given IM, either 6mg BD x4 doses or 12 mg BD x2 doses, for fetal lung maturity. Maternally administered magnesium sulphate has a neuroprotective effect and reduces the incidence of cerebral palsy amongst preterm infants. In addition, monitor by daily or twice daily CTG, weekly umbilical artery doppler, and two weekly growth scan. Good...You are on the right track. Go to the next [[section|Mx at 34 weeks]] (track: 'cheer', 'play') (track: 'cheer', 'volume', 0.1)

Madam P's pregnancy has been closely monitored since 30 weeks period of gestation. She has completed a course of corticosteriods and IV magnesium sulphate. Her CTGs and Dopplers have been acceptable. Go to the next [[page|pictures]]

At 34 weeks, the growth scan and CTG are as follows: <img src="/IUGR/growchart.png"/> <img src="/IUGR/CTG IUGRb.jpg"/> Interpret the findings. [[1. CTG suspicious, Growth scan shows slowing of the growth]] [[2. CTG normal, Growth scan shows slowing of the growth]] [[3. CTG pathological, but fetus is growing satisfactorily.]]

;-) I got you. For growth scan, you are right. But this CTG is perfect. Here are the characteristics of a normal CTG: •&nbsp&nbspBaseline heart rate: 110-160/minutes •&nbsp&nbspBeat to Beat variability: 5-15 •&nbsp&nbspThere should be at least 2 acclerations in 20 minutes •&nbsp&nbspThere should not be any deceleration •&nbsp&nbspUterine contractions: present or absent Try again. (track: 'witch', 'play') (track: 'witch', 'volume', 0.1)

Bravo! The CTG is still normal. Here are the characteristics of a normal CTG: •&nbsp&nbspBaseline heart rate: 110-160/minutes •&nbsp&nbspBeat to Beat variability: 5-15 •&nbsp&nbspThere should be at least 2 acclerations in 20 minutes •&nbsp&nbspThere should not be any deceleration •&nbsp&nbspUterine contractions: present or absent The fetus was growing along the 50th centile until 30 weeks. However, subsequently the growth slows down and falls to the 5th centile at 34 weeks. Go to the next [[section|doppler]] (track: 'clapping', 'play') (track: 'clapping', 'volume', 0.2)

;-) I got you. This CTG is perfect. Here are the characteristics of a normal CTG: •&nbsp&nbspBaseline heart rate: 110-160/minutes •&nbsp&nbspBeat to Beat variability: 5-15 •&nbsp&nbspThere should be at least 2 acclerations in 20 minutes •&nbsp&nbspThere should not be any deceleration •&nbsp&nbspUterine contractions: present or absent Furthermore, the Growth scan is not normal. Try again. (track: 'witch', 'play') (track: 'witch', 'volume', 0.1)

Now you need to think carefully. Madam P is now at 34 weeks period of gestation. The first course of dexamethasone was given at 30 weeks period of gestation. Fetal growth falls to the 5th centile. The umbilical artery shows reverse end-diastolic flow. The CTG is normal. How would you manage her now? [[1. Repeat rescue dose of dexamethasone 12 mg today and induce her tomorrow]] [[2. Emergency lower segment caesarean section today]] [[3. Perform a vaginal examination and, if bishop's score is favourable, arrange for induction of labour today]]

Oh nooo..... You decided to wait until tomorrow. Sadly, the baby died before you could deliver her. OR The fetus is still alive the next day and you decide to induce her. Not surprisingly, the fetus develops severe bradycardia after you ruptured the membranes and started oxytocin. You have to rush the patient to theater for an emergency caesarean. The baby is delivered with an Apgar of 2 at one minute, and 5 at 5 minutes of life, and is subsequently diagnosed with severe hypoxic ischemic encephalopathy. But, remember - in this game story, you can go back and try again... <img src="/IUGR/docsaw.jpg"/> (track: 'yell', 'play') (track: 'yell', 'volume', 0.1)

Excellent! The fetus is so small with an abnormal doppler. It will not be able to tolerate the stress of vaginal delivery. Greentop RCOG guidelines state that in the Small for gestational age fetus with absent or reverse end-diastolic umbilical artery flow, delivery by caesarean section is recommended. Reverse end-diastolic flow implies that the situation is critical, i.e. the resistance is so great that blood may flow back towards the heart during diastole. Therefore, immediate delivery is neccessary. Refer to the IUGR chapter in the <a href="/IUGR/IUGR Oxford Handbook of O&G 3rd Ed.pdf" target=_"blank"/> Oxford Handbook of O&G</a> for more information. Now go to the last [[page|congrats]]

Oh nooo... You decided to induce her. Not surprisingly, the fetus develops severe bradycardia after you ruptured the membranes and started oxytocin. You have to rush the patient to theater for an emergency caesarean. The baby is delivered with an Apgar of 2 at one minute, and 5 at 5 minutes of life, and is subsequently diagnosed with severe hypoxic ischemic encephalopathy. But, remember...In this game story, you can go back and try again... <img src="/IUGR/docsaw.jpg"/> (track: 'yell', 'play') (track: 'yell', 'volume', 0.1)

Together with her growth scan, umbilical artery doppler is performed, showing reverse end-diastolic flow. <img src="/IUGR/UAdopplerreverse.jpg"/> Click [[here|mx at 34 weeks]] to decide on further management.

<h3>Congratulations!</h3> Baby is delivered via a straightforward lower segment caesarean section. Birthweight is 1.8 kg. Apgar score is 6 at 1 min and 9 at 5 minute. pH is 7.21. Baby received immediate care by a neonatologist and does not require intubation. Well done! Don't forget to read these: 1. <a href="/IUGR/IUGR Oxford Handbook of O&G 3rd Ed.pdf" target="_blank"/>IUGR chapter, Oxford Handbook of Obstretics & Gyneacology 3ed</a> 2. <a href="/IUGR/Management of Small for Gestational Age RCOG guidelines.pdf" target="_blank"/> Management of Small for Gestational Age (RCOG guidelines)</a> 3. <a href="/IUGR/Risk factors of Small for gestational age RCOG guidelines.pdf" target="_blank"/>Risk factors of Small for gestational age (RCOG guidelines)</a> <img src="/IUGR/docsend.jpg"/> ==> (link: "Restart Game")[(reload:)] Back to <a href="https://medventure.neocities.org/Semester10/index.html">Home</a> (track: 'cheering', 'play') (track: 'cheering', 'volume', 0.2)

firstbeat: http://nck.yolasite.com/resources/first_beat.mp3 witch: http://nck.yolasite.com/resources/wickedwitchlaugh.mp3 happykids: http://nck.yolasite.com/resources/happykids.mp3 lightapplause: http://nck.yolasite.com/resources/lightapplause.mp3 AAAGH1: http://nck.yolasite.com/resources/AAAGH1.mp3 lidcreak: http://nck.yolasite.com/resources/lidcreak.mp3 smirk: http://nck.yolasite.com/resources/Smirk%2B1.mp3 creakydoor: http://nck.yolasite.com/resources/creaky_door_4.mp3 attack: http://nck.yolasite.com/resources/attack.mp3 cheer: http://nck.yolasite.com/resources/cheer.mp3 clapping: http://nck.yolasite.com/resources/Clapping.mp3 yell: http://nck.yolasite.com/resources/Yell%2BMale%2BWahhh.mp3 cheering: http://nck.yolasite.com/resources/Cheering.mp3