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Fetal Malpresentation

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141. Umbilical Cord Complications (Diagnosis)

, prematurity, and abnormal fetal heart patterns in labor, [ , ] as well as hypoxic ischemic encephalopathy (HIE) of the newborn. [ ] If detected, fetal growth may be monitored with ultrasonography in the third trimester. Consider an elective cesarean delivery to avoid a vasa previa rupture or fetal distress if the velamentous insertion is in the lower segment. [ ] Vasa previa Vasa previa occurs when the fetal vessels in the membrane are situated in front of the presenting part of the fetus. This may occur (...) of antenatal testing in the follow-up of pregnancies with this condition is uncertain. [ ] Nuchal cord The cord may become coiled around various parts of the body of the fetus, usually around the neck. Nuchal cord is caused by movement of the fetus through a loop of cord. One loop around the neck occurs in approximately 20% of cases, [ ] and multiple loops occur in up to 5% of pregnancies. [ ] Nuchal cord has been associated with labor induction and augmentation, prolonged second stage of labor, and fetal

2014 eMedicine.com

142. Premature Rupture of Membranes (Diagnosis)

hours, expectant management and waiting for spontaneous labor may be considered in selected patients for the first 12-24 hours if a patient desires expectant management. The use of expectant management after the first 24 hours is questionable. Digital vaginal examinations should be avoided until labor is initiated; however, fetal presentation should be documented to avoid discovering malpresentation of the fetus long after admission for ROM. All patients with ROM should be asked to come (...) is infection, namely chorioamnionitis, which occurs in about 35%; abruption, which occurs in 19%; and sepsis, which is rare and occurs in less than 1%. [ ] The major morbidity in the fetus with midtrimester ROM is lethal pulmonary hypoplasia from prolonged, severe, early oligohydramnios, which occurs in about 20% of cases. Other morbidities such as RDS (66%), sepsis (19%), grade III-IV IVH (5%), and contractures (3%) also occur with high frequency, resulting in intact survival rates of more than 67%. Fetal

2014 eMedicine.com

143. Vesicovaginal Fistula (Overview)

. Previous Next: Etiology Developing countries Numerous factors contribute to the development of VVF in developing countries. Commonly, these are areas where the culture encourages marriage and conception at a young age, often before full pelvic growth has been achieved. Chronic malnutrition further limits pelvic dimensions, increasing the risk of cephalopelvic disproportion and malpresentation. In addition, few women are attended by qualified health care professionals or have access to medical (...) facilities during childbirth; their obstructed labor may be protracted for days or weeks. [ , ] The effect of prolonged impaction of the fetal presenting part in the pelvis is one of widespread tissue edema, hypoxia, necrosis, and sloughing resulting from prolonged pressure on the soft tissues of the vagina, bladder base, and urethra. Typically in these countries, the UGF is large and involves the bladder, urethra, bladder trigone, and the anterior cervix. Complex neuropathic bladder dysfunction

2014 eMedicine.com

144. Surgical Management of Mullerian Duct Anomalies (Overview)

outcomes are generally poor in this group. Unicornuate uterus is associated with the poorest fetal survival among all müllerian anomalies. [ ] Cesarean delivery rates are high. Common obstetrical complications include malpresentation, intrauterine growth retardation, and preterm birth. [ , ] A review of compiled data from several studies of uterine anomalies and pregnancy outcomes revealed that the unicornuate uterus had the poorest overall reproductive outcomes of all the uterine anomalies. Problems

2014 eMedicine.com

145. Cesarean Delivery (Overview)

. [ ] The emerging consensus is that a randomized prospective study is required to address this issue. [ ] Fetal indications Fetal indications for cesarean delivery include the following: Situations in which neonatal morbidity and mortality could be decreased by the prevention of trauma Malpresentations Certain congenital malformations or skeletal disorders Infection Prolonged acidemia A fetus in a nonvertex presentation is at increased risk for trauma, cord prolapse, and head entrapment. Malpresentation (...) state maternal care collaborative agencies are even implementing tools to decrease the likelihoond of cesarean section in the instance of a breech presentation, with guidelines recommending the formation of a team in the hospital that is trained and confortable with breach and operative deliveries. [ ] If a patient is diagnosed with a fetal malpresentation (ie, breech or transverse lie) after 36 weeks, the option for an external cephalic version is offered to try to convert the fetus to a vertex lie

2014 eMedicine.com

146. Cervical Ripening (Overview)

of . [ ] The major risk of the above prostaglandin preparations is uterine hyperstimulation. The woman and fetus must be monitored for contractions, fetal well-being, and changes in the cervical Bishop score. Finally, Christensen et al demonstrate that the combination of oxytocin induction, preceded by a dinoprostone insert is safe, and this significantly shortens induction-to-delivery times. [ ] The exception to this appears to be women with prior cesarean deliveries. The ACOG Committee on Obstetric Practice (...) with an "unfavorable" or unripened cervix. Previous Next: Contraindications to Cervical Ripening Contraindications to cervical ripening include, but are not limited to, the following: Active herpes Fetal malpresentation Nonreassuring fetal surveillance History of prior traumatic delivery Regular contractions Unexplained vaginal bleeding Placenta previa Vasa previa Prior uterine myomectomy involving the endometrial cavity or classical cesarean delivery Previously, a history of a prior low transverse cesarean

2014 eMedicine.com

147. Face Presentation (Overview)

the longitudinal axis of the uterus. Nonvertex presentations (including breech, transverse lie, face, brow, and compound presentations) occur in less than 4% of fetuses at term. Malpresentation of the vertex presentation occurs if there is deflexion or extension of the fetal head leading to brow or face presentation, respectively. In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying in a longitudinal axis (...) to the pelvic axis and the anterior fontanel is on the right maternal side, the fetus would be in the right frontotransverse position (RFT). Next: Background Face presentation occurs in 1 of every 600-800 live births, averaging about 0.2% of live births. Causative factors associated with a face presentation are similar to those leading to general malpresentation and those that prevent head flexion or favor extension. Possible etiology includes multiple gestations, grand multiparity, fetal malformations

2014 eMedicine.com

148. Eclampsia (Treatment)

delivery until the acute phase of the seizure or coma has passed. The mode of delivery should be based on obstetric indications but should be chosen with an awareness that vaginal delivery is preferable from a maternal standpoint. Adequate maternal pain relief for labor and delivery is vital and may be provided with either systemic opioids or epidural anesthesia. In the absence of fetal malpresentation or fetal distress, oxytocin or prostaglandins may be initiated to induce labor. Cesarean delivery may (...) in the absence of hypertension with proteinuria has been demonstrated to occur in 38% of cases reported in the United Kingdom. [ ] Similarly, hypertension was absent in 16% of cases reviewed in the United States. [ ] The clinical manifestations of maternal preeclampsia are hypertension and proteinuria with or without coexisting systemic abnormalities involving the kidneys, liver, or blood. There is also a fetal manifestation of preeclampsia involving fetal growth restriction, reduced amniotic fluid

2014 eMedicine.com

149. Early Pregnancy Loss (Treatment)

age, which is defined as women older than 35 years. A woman's risk of having an aneuploid fetus is 1 per 80 when she is older than 35 years; this is far greater than the risk of fetal loss after amniocentesis, which is 1 per 200. A study by Warburton et al indicated that routine karyotype analysis after 1 miscarriage is not cost-effective or prognostic. [ ] However, after 2 SABs, analysis of the abortuses is useful. In 1990, Drugan et al examined 305 women with 2 or more miscarriages and found (...) , and malpresentation, although many women with such defects may have uncomplicated pregnancies. Most commonly, the complications result from impaired vascularization and fetal growth restriction. The incidence of uterine anomalies is estimated to be 1 per 200-600 women, depending on the method used for diagnosis. When manual exploration is performed at the time of delivery, uterine anomalies are found in approximately 3% of women. However, uterine abnormalities are present in approximately 27% of women

2014 eMedicine.com

150. Cesarean Delivery (Treatment)

. [ ] The emerging consensus is that a randomized prospective study is required to address this issue. [ ] Fetal indications Fetal indications for cesarean delivery include the following: Situations in which neonatal morbidity and mortality could be decreased by the prevention of trauma Malpresentations Certain congenital malformations or skeletal disorders Infection Prolonged acidemia A fetus in a nonvertex presentation is at increased risk for trauma, cord prolapse, and head entrapment. Malpresentation (...) state maternal care collaborative agencies are even implementing tools to decrease the likelihoond of cesarean section in the instance of a breech presentation, with guidelines recommending the formation of a team in the hospital that is trained and confortable with breach and operative deliveries. [ ] If a patient is diagnosed with a fetal malpresentation (ie, breech or transverse lie) after 36 weeks, the option for an external cephalic version is offered to try to convert the fetus to a vertex lie

2014 eMedicine.com

151. Cervical Ripening (Treatment)

of . [ ] The major risk of the above prostaglandin preparations is uterine hyperstimulation. The woman and fetus must be monitored for contractions, fetal well-being, and changes in the cervical Bishop score. Finally, Christensen et al demonstrate that the combination of oxytocin induction, preceded by a dinoprostone insert is safe, and this significantly shortens induction-to-delivery times. [ ] The exception to this appears to be women with prior cesarean deliveries. The ACOG Committee on Obstetric Practice (...) with an "unfavorable" or unripened cervix. Previous Next: Contraindications to Cervical Ripening Contraindications to cervical ripening include, but are not limited to, the following: Active herpes Fetal malpresentation Nonreassuring fetal surveillance History of prior traumatic delivery Regular contractions Unexplained vaginal bleeding Placenta previa Vasa previa Prior uterine myomectomy involving the endometrial cavity or classical cesarean delivery Previously, a history of a prior low transverse cesarean

2014 eMedicine.com

152. Assisted Reproduction Technology (Treatment)

decreases as the number of oocytes decreases. Cycle fecundity also decreases, largely due to an increase in miscarriages. See the image below. Female age and fertility. The number and quality of a woman’s oocytes declines with age. The decline in the number of oocytes begins at 20 weeks' gestation when the female fetus has approximately 6-7 million oogonia (largest lifetime endowment). The number of oocytes decreases to approximately 2-3 million at birth and decreases again to 300,000 by the time (...) , retained products of conception, or postpartum curettage should alert the clinician to a possible uterine factor. A history of abnormal bleeding, such as heavy menses, midcycle spotting, or irregular bleeding, may represent an intrauterine fibroid, polyp, or synechiae. Malpresentation during pregnancy or often suggests a uterine anomaly, such as a septum or bicornuate uterus. A screening transvaginal ultrasonography performed immediately following the cessation of menses may demonstrate a uterine

2014 eMedicine.com

153. Face Presentation (Treatment)

along the longitudinal axis of the uterus. Nonvertex presentations (including breech, transverse lie, face, brow, and compound presentations) occur in less than 4% of fetuses at term. Malpresentation of the vertex presentation occurs if there is deflexion or extension of the fetal head leading to brow or face presentation, respectively. In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying (...) in a longitudinal axis. The presenting portion of the fetus is the fetal face between the orbital ridges and the chin. The fetal chin (mentum) is the point designated for reference during an internal examination through the cervix. The occiput of a vertex is usually hard and has a smooth contour, while the face and brow tend to be more irregular and soft. Like the occiput, the mentum can present in any position relative to the maternal pelvis. For example, if the mentum presents in the left anterior quadrant

2014 eMedicine.com

154. Uterine Rupture in Pregnancy (Treatment)

either occur in women with (1) a native, unscarred uterus or (2) a uterus with a surgical scar from previous surgery. Uterine rupture occurs when a full-thickness disruption of the uterine wall that also involves the overlying visceral peritoneum (uterine serosa) is present. By definition, it is associated with the following: Clinically significant uterine bleeding Fetal distress Protrusion or expulsion of the fetus and/or placenta into the abdominal cavity Need for prompt cesarean delivery Uterine (...) -existing uterine scar. In addition, in cases of uterine dehiscence (as opposed to uterine rupture), the fetus, placenta, and umbilical cord remain contained within the uterine cavity. If cesarean delivery is needed, it is for other obstetrical indications and not for fetal distress attributable to the uterine disruption. Although a uterine scar is a well-known risk factor for uterine rupture (most of which arise from prior cesarean delivery), the majority of events involving the disruption of uterine

2014 eMedicine.com

155. Premature Rupture of Membranes (Treatment)

hours, expectant management and waiting for spontaneous labor may be considered in selected patients for the first 12-24 hours if a patient desires expectant management. The use of expectant management after the first 24 hours is questionable. Digital vaginal examinations should be avoided until labor is initiated; however, fetal presentation should be documented to avoid discovering malpresentation of the fetus long after admission for ROM. All patients with ROM should be asked to come (...) is infection, namely chorioamnionitis, which occurs in about 35%; abruption, which occurs in 19%; and sepsis, which is rare and occurs in less than 1%. [ ] The major morbidity in the fetus with midtrimester ROM is lethal pulmonary hypoplasia from prolonged, severe, early oligohydramnios, which occurs in about 20% of cases. Other morbidities such as RDS (66%), sepsis (19%), grade III-IV IVH (5%), and contractures (3%) also occur with high frequency, resulting in intact survival rates of more than 67%. Fetal

2014 eMedicine.com

156. Premature Rupture of Membranes (Overview)

hours, expectant management and waiting for spontaneous labor may be considered in selected patients for the first 12-24 hours if a patient desires expectant management. The use of expectant management after the first 24 hours is questionable. Digital vaginal examinations should be avoided until labor is initiated; however, fetal presentation should be documented to avoid discovering malpresentation of the fetus long after admission for ROM. All patients with ROM should be asked to come (...) is infection, namely chorioamnionitis, which occurs in about 35%; abruption, which occurs in 19%; and sepsis, which is rare and occurs in less than 1%. [ ] The major morbidity in the fetus with midtrimester ROM is lethal pulmonary hypoplasia from prolonged, severe, early oligohydramnios, which occurs in about 20% of cases. Other morbidities such as RDS (66%), sepsis (19%), grade III-IV IVH (5%), and contractures (3%) also occur with high frequency, resulting in intact survival rates of more than 67%. Fetal

2014 eMedicine.com

157. Surgical Management of Mullerian Duct Anomalies (Treatment)

outcomes are generally poor in this group. Unicornuate uterus is associated with the poorest fetal survival among all müllerian anomalies. [ ] Cesarean delivery rates are high. Common obstetrical complications include malpresentation, intrauterine growth retardation, and preterm birth. [ , ] A review of compiled data from several studies of uterine anomalies and pregnancy outcomes revealed that the unicornuate uterus had the poorest overall reproductive outcomes of all the uterine anomalies. Problems

2014 eMedicine.com

158. Umbilical Cord Complications (Treatment)

, prematurity, and abnormal fetal heart patterns in labor, [ , ] as well as hypoxic ischemic encephalopathy (HIE) of the newborn. [ ] If detected, fetal growth may be monitored with ultrasonography in the third trimester. Consider an elective cesarean delivery to avoid a vasa previa rupture or fetal distress if the velamentous insertion is in the lower segment. [ ] Vasa previa Vasa previa occurs when the fetal vessels in the membrane are situated in front of the presenting part of the fetus. This may occur (...) of antenatal testing in the follow-up of pregnancies with this condition is uncertain. [ ] Nuchal cord The cord may become coiled around various parts of the body of the fetus, usually around the neck. Nuchal cord is caused by movement of the fetus through a loop of cord. One loop around the neck occurs in approximately 20% of cases, [ ] and multiple loops occur in up to 5% of pregnancies. [ ] Nuchal cord has been associated with labor induction and augmentation, prolonged second stage of labor, and fetal

2014 eMedicine.com

159. Gynecologic Myomectomy (Overview)

. Pedunculated myomas can undergo torsion, causing the same severe pain as torsion of the ovary. Large myomas can outgrow their blood supply, leading to infarction and necrosis (degenerating myoma), which can be extremely painful. Lastly, prolapse of a myoma can be acutely painful. Although general agreement is lacking on the mechanism, myomas are also thought to be related to infertility, fetal malpresentations, and preterm labor. Possible mechanisms for infertility include distortion of the endometrial

2014 eMedicine.com

160. Early Pregnancy Loss (Overview)

age, which is defined as women older than 35 years. A woman's risk of having an aneuploid fetus is 1 per 80 when she is older than 35 years; this is far greater than the risk of fetal loss after amniocentesis, which is 1 per 200. A study by Warburton et al indicated that routine karyotype analysis after 1 miscarriage is not cost-effective or prognostic. [ ] However, after 2 SABs, analysis of the abortuses is useful. In 1990, Drugan et al examined 305 women with 2 or more miscarriages and found (...) , and malpresentation, although many women with such defects may have uncomplicated pregnancies. Most commonly, the complications result from impaired vascularization and fetal growth restriction. The incidence of uterine anomalies is estimated to be 1 per 200-600 women, depending on the method used for diagnosis. When manual exploration is performed at the time of delivery, uterine anomalies are found in approximately 3% of women. However, uterine abnormalities are present in approximately 27% of women

2014 eMedicine.com

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