Fetal skull

obstetrical condition

1. FETAL SKULL

2. INTRODUCTION Fetal skull is to some extent compressible, and made mainly of thin pliable tabular (flat) bones forming the vault.

3. AREAS OF THE SKULL It is divided into several zones of obstetrical importance, these are, Vertex Brow Face

4. VERTEX It is a quadrangular area bounded A nteriorly -by bregma and coronal sutures, P osteriorly - lamda and lambdoid sutures. Laterally – by lines passing through the parietal eminences.

5. it is an area bounded on one side by the anterior fontenelle or bregma and coronal sutures and the other side by the root of the nose and supra orbital ridges of either side. BROW

6. FACE It is an area bounded on one side by the root of the nose and supra –orbital ridges and on other side by the junction of the floor of the mouth with neck.

7. SUTURES Flat bones of the vault are united together by non- ossified membranes attached to the margins of the bones. These are called sutures.

8. TYPES 4types: The saggital suture or longitudinal suture: it lies between two parietal bones. The coronal suture: runs between parietal and frontal bone on either side. The frontal suture: it lies between two frontal bones The lambdoid suture: it represents the occipital bone and the two parietal bones.

9. FONTENELLE A wide gap in the suture line is called fontenelle . Types: 2types Anterior fontenelle ( bregma )- diamond in shape, diametre-4cm, time of ossification- 18months. Posterior fontenelle - triangular in shape, diametre - 1.2cm, time of ossification- 1 half months.

10. DIAMETERS OF SKULL 1. sub- occipito bregmatic : (9.5cm) It extends from the nape of the neck to the centre of the bregma . 2. sub- occipito frontal : (10cm) It extends from the nape of the neck to the anterior end of the anterior fontenelle or centre of sinciput . 3. Occipito – frontal : (11.5cm) It extends from the occipital eminences to the root of the nose.( glabella )

11. 4 . M ento - vertical : (11.5cm) It extends from the mid point of the chin to the highest point on the saggital suture. 5. sub- mento vertical: (11.5cm) It extends from the junction of floor of the mouth and neck to the highest point on the saggital suture. 6. sub- mento bregmatic : (9.5cm) It extends from unction of floor of the mouth and neck of the bregma .

12. TRANSVERSE DIAMETER 1.bi-parietal diametre – (9.5cm) 2.super sub parietal- (8.5cm) 3.bi-temporal diametre - (8cm) 4.bi-mastoid diametre - (7.5cm)

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14. Screening strategy for detecting GDM Low risk: * Blood glucose testing not routinely required in: Member of an ethnic group with low prevalence No known diabetes in 1st degree relatives Age < 25yrs Weight normal before pregnancy Weight normal at birth No history of abnormal glucose metabolism No history of poor obstetrical outcome

15. Screening strategy for detecting GDM Average risk * Blood glucose testing at 24-28 wks (1 step/2step) Member of an ethnic group with high prevalence Diabetes in a first degree relative Age ≥ 25yrs Overweight before pregnancy Weight high at birth

16. Screening strategy for detecting GDM High risk * Blood glucose testing as soon as feasible Severe obesity Strong family history of type 2 diabetes Previous history of GDM Impaired glucose metabolism Glucosuria

17. Screening (OGTT) Plasma glucose level measured 1 hr after 50g glucose load Without regarding to time of day/ time of last meal Plasma glucose level > 130mg/dl; sensitivity 90% Plasma glucose level > 140mg/dl; sensitivity is 80%

18. Diagnosis of GDM by OGTT Time 100 g Glucose (American diabetes association criteria) 75 g glucose (WHO criteria) Fasting 95 mg/dl 5.3 mmol /L 95 mg/dl 5.3mmol/L 1-h 180mg/dl 10mmol/L 180mg/dl 10mmol/L 2-h 155mg/dl 8.6mmol/L 155mg/dl 8.6mmol/L 3-h 140mg/dl 7.8mmol/L - -

19. Maternal risks Birth trauma Operative delivery Polyhydraminos 50% lifetime risk in developing Type II DM Recurrence risk of GDM is 30-50%

20. Fetal risks No increase in congenital anomalies Increased risk of stillbirth if fasting+ PP hyperglycemia Macrosomia, BW >4000gm occurs in 17-29% of pregnancies Birth trauma-shoulder dystocia and related complications Neonatal hypoglycemia

21. Fetal macrosomia Defined as fetal weight > 4000gm Brain not effected, shoulder dystocia 3% Maternal hyperglycemia Fetal hyperinsulinemia Excessive somatic growth Diagnosis and management is important USG should begin at 20wks; to be done at every 4 wks Also due to IGF-1 and IGF-2 Maternal obesity is important confounding factor

22. Management of GDM Class Onset Fasting 2 hour PP Therapy A1 Gestational <105 mg/dl <120 mg/dl Diet A2 Gestational >105 mg/dl >120 mg/dl Insulin Nutritional therapy-total calorie intake: average 2000-2500 kcal/day. BMI >40 -- 12 kcal/kg/ideal body weight/d BMI>27 -- 25 kcal/kg/ideal body weight/d BMI 20-26 -- 30 “ BMI<20 -- 38 “

23. Management of GDM Diet : general principles 55% CHO 25% Protein 20% fat Normal weight gain 10-12 kg Avoid ketosis Liberal exercise program to optimize BG control Daily self BG monitoring Breakfast should provide 25%, Lunch 30% and dinner 30%. Obese women may be managed with lower caloric intake.

24. Management of GDM If persistent hyperglycemia after one week of diet control proceed to insulin 6-14 weeks 0.5u/kg/day 14-26 weeks 0.7u/kg/day 26-36 weeks 0.9u/kg/day 36-40weeks 1 u /kg/day

25. Oral hypoglycaemic agents Traditionally not recommended in pregnancy because of teratogenic effects Glyburide and Metformin

26. Glyburide Sulfonylureas MOA- release of insulin Hypoglycemia and weight gain are the main side effects Non- teratogenic , classified as category B drug

27. Glyburide treatment regimen who fail Diet therapy Glucometer BG measurment fasting and 1 or 2 hrs following breakfast, lunch and dinner Glucose level goals (mg/dl): fasting < 100, 1-h < 155 and 2hrs < 130 Glyburide starting dose 2.5mg orally with morning meals Increased daily glyburide dose by 2.5mg/wk, increment until 10mg/day, then switch to twice daily dosing until max of 20mg/day, then switch to insulin if 20mg/day does not achieve glucose goal.

28. Obstetrical management Cesarean delivery should be considered in women with sonographical estimated weight > 4500gm Elective cesarean delivery has no significant effect on incidence of brachial plexus injury Fetal monitoring

29. Postpartum evaluation Women diagnosed with GDM to be evaluated with 75gm OGTT at 6-12wks postpartum Metabolic assessment recommended after preg with GDM Contraception: low dose hormonal contraceptives Time Test purpose Postdelivery (1-3 d) Fasting or random plasma glucose Detect persistent, overt diabetes Early postpartum (6-12wk) 75g 2h OGTT PP classification of Glu met 1yr Postpartum 75g 2h OGTT Assess Glu metabolism Annually Fasting plasma glucose Assess Glu metabolism Tri- annually 75g 2h OGTT Assess Glu metabolism Prepregnancy 75g 2h OGTT Classify glu metabolism

30. Pregestational diabetes/ overt diabetes Patients with symptoms of DM and plasma Glucose concentration 200mg/dl or more The condition may be preexisting or detected during present pregnancy

31. Criteria for diagnosis of impaired Glucose tolerance and diabetes with 75g oral glucose Time Normal tolerance Impaired glucose tolerance diabetes Fasting < 110 mg/dl ≥ 110 and <126 ≥ 126 mg/dl 2 hr Post glucose <140 mg/dl ≥ 140 and <200 ≥ 200 mg/dl

32. Maternal effects During pregnancy Abortions Preterm labor 20% Infections (UTI) Preeclampsia 25% Polyhydraminos 25-50% Maternal distress Diabetic retinopathy Diabetic nephropathy Ketoacidosis

33. Maternal effects During labor: Prolongation of labour due to big baby Shoulder dystocia Perineal injury Postpartum hemorrhage Operative interventions During Puerperium : Puerperal sepsis Lactation failure

34. Fetal hazards Congenital anomalies 3 times increased risk Caudal regression- 1.3/1000 Situs invertus Spina bifida, hydrocephaly, other CNS defects Anencephaly Cardiac anomalies: VSD, TGA, ASD, COA Anorectal atresia Renal anomalies: agenesis, cystic kidney, duplex ureter

35. Fetal hazards Unexplained stillbirth Hypoglycemia, hypocalcemia , hyperbilirubinemia , polycythemia Cardiomyopathies Inheritance of diabetes Shoulder dystocia Macrosomia IUGR RDS

36. Preconceptional counselling Preconception Counselling Risk of NTD ~1-2% Folic Acid 400µg/day Preconceptional glucose control using insulin. Fasting < 70-100 mg/dl, and PP <140mg/dl at the end of 1 hr and <120mg/dl at the end of 2hr.

37. Preconceptional counselling Normoglycemia prior to conception Ideally HBA1C 6% or less Team approach Glucose monitoring qid ACE inhibitors contraindicated Baseline HbA1C, 24h urine for protein Cr Cl , ophthalmology review Switch from OHA to insulin

38. Pregestational /Overt Diabetes Assess for end organ disease assess for nephropathy - inc risk of PIH Assess and treat retinopathy - may progress assess for neuropathy generally remains stable during pregnancy assess and treat vasculopathy CAD is a relative C/I for pregnancy

39. Maternal Surveillance - Blood pressure monitoring renal function every trimester urine culture monthly thyroid function BG control HB A1C every trimester

40. Fetal Surveillance USG for dating/viability ~ 8 weeks Transvaginal USG examination at 10-14 weeks Fetal anomaly detection nuchal translucency 11-14weeks maternal serum screen- free β HCG and PAPA-A MSAFP at 16w to screen for open Neural tube defect anatomy survey 18-20 weeks Fetal echo 22weeks Weekly biophysical profile, NST

41. Trimestric approach 1 st Trimester: Careful monitoring of glucose control is essential OHA to Insulin therapy 2 nd trimester: Maternal serum alpha fetoprotein at 16-20wks Targeted sonographic examination at 18-20wks Euglycemia with self monitoring is the goal Increased insulin requirement after 24wks 3 rd Trimester: Cesarean delivery to avoid traumatic birth

42. Admissions At 34-36 weeks in uncomplicated cases It facilitates Stabilisation of diabetes Less incidence of Preeclampsia, Polyhydramnios and Preterm labour Selecting time and mode of termination

43. Insulin therapy OHA not currently recommended for overt diabetes Maternal glycemic control with multiple daily insulin inj and adjustment of dietary intake S/C insulin infusion by calibrated pumps Self monitoring using glucometer recommended

44. Self monitored capillary BG goals Specimen Level (mg/dl) Fasting ≤ 95 Premeal ≤ 100 1 hr- postprandial ≤140 2 hr- postprandial ≤ 120 2-6hr ≥ 60 Mean (average) 100 Hb A1c ≤ 6

45. Management of diabetes in pregnancy insulin therapy Insulin Pump Allows insulin release close to physiologic levels Use short acting insulin 50-60% of total dose is basal rate 40-50% given as boluses Potential complications Pump failure Infection Increased risk of DKA

46. Management of diabetes in pregnancy insulin therapy Short acting Onset Peak Duration Regular Lispro Aspart 0.5 – 1 hr 20 mints 25 mints 2 – 4 hrs 0.5 – 1½ hr 30 – 1½ hr 4-6 hrs 3 – 4 hrs 3 – 4 hrs Intermediate acting NPH/ Isophane lente (Insulin zinc suspension 1 – 3 1 - 3 5 - 7 4 - 8 13 - 18 13 – 20 Long Acting Ultra lente / Protamine Glargine 4 – 6 1 – 4 14 – 18 Minimal peak activity 24 – 36 g 24hrs

47. Insulin therapy Regular and NPH are the most commonly used preparations Regular insulin/NPH combination- Slow absorption, administered 30min before meals Midmorning & midafternoon snacks necessary Rapidly acting insulin like Lispro prevent hypoglycemia

48. Insulin therapy Lispro and aspartate – should be taken immediately before meals Lispro and aspartate used for prandial insulin and insulin pump therapy

49. Insulin therapy Glargine- Longest acting Less episodes of nocturnal hypoglycemia Given in morning hours Detemir

50. Timing of Delivery Diet controlled Same as non diabetic Offer induction at 41 weeks if undelivered On Insulin/Type II/Type I If suboptimal control deliver following confirmation of lung maturity if <39 weeks Otherwise deliver by 40 weeks Generally do not allow to go post term DOC for initial tocolysis : Nifedipine

51. Mode of Delivery Macrosomic infants of diabetic mothers have higher rates of shoulder dystocia Cord is to be clamped immediately Reasonable to recommend C/S delivery if EFW is >4500g

52. Insulin requirement in labor Insulin requirements During induction of labor During elective caesarean section Usual insulin dose and meal on evening before surgery Overnight fast from 12 midnight Day before IOL Normal diet Normal insulin dose evening before IOL No overnight fast Day of IOL give half the morning dose of insulin before light breakfast Insert prostaglandin gel as early as possible Continuous CTG Start IV insulin infusion once labor establishes

53. Insulin therapy intrapartum CG Level Management 60-90 mg/dl 5%-10% DNS at 100 ml/hr 90-120mg/dl 0.9% NS or RL at 100ml/hr 120-140 mg/dl 5Uin 500ml 5% dex at 100ml/hr If >140 mg% then plain insulin sc by sliding scale: 140-180 mg/dl 4U 180 -250 mg/dl 8U 250-400 mg/dl 12U >400 mg% 16U CG and urinary ketone level should be measured every 2 hourly.

54. Contraception in DM Barrier methods are safe, inexpensive with fewer side effects OCPs cause insulin resistance due to progesterone component and there is high risk of thromboembolism, MI and CVA. IUCDs cause infection, glucose precipitates with Copper and thus reduction of efficacy. Permanent method are used in couples with complete family

55. Diabetic Ketoacidosis 5-10% of pregnant Type 1 patients Serious medical emergency Risk factors New onset DM Infection Insulin pump failure Steroids Fetal mortality 10%

56. Diabetic Ketoacidosis Diagnosis: BG conc > 250mg/dl Ketone bodies in urine and plasma Arterial pH <7.3 Serum bicarbonate < 15meq/L

57. Diabetic Ketoacidosis Management ABC’s and ABG Assess BG, ketones electrolytes Insulin 0.2-0.4U/Kg loading and 2-10U/h maintenance Begin 5% dextrose when BG is 250 mg% When potassium is N range begin 20mEq/h Rehydration isotonic NaCl 1L in 1 st hour 0.5-1L/h over 2-4h 6-8 L over 1 st 24 hours. 250cc/h until 80% replaced Replace Bicarb and phosphate as needed

58. Metabolic syndrome Definition (WHO) Diabetes, impaired glucose tolerance, impaired fasting glucose, insulin resistance+ atleast 2 of foll : Abdominal obesity Trigycerides > 150 mg/dl HDL < 40 mg/dl BP≥ 140/90 mm Hg Microalbuminuria > 20µg/min

59. Metabolic syndrome Definition (NCEPATP III) At least 3 of the following : Fasting plasma glucose > 110mg/dl Abdominal obesity (waist circumference> 35 in.) Triglycerides >150 mg/dl; HDL < 50mg/dl BP ≥ 130/85 mmHg

60. Indian experience Incidence of GDM is 3-5% Numbers are increasing 90% diagnosed cases are of GDM Fetal macrosomia 32% PIH 48% Hydramnios 4% IUD 12% Fetal malpresentation 16% Cesarean section 44% Maternal mortality 10 times

61. Medicolegal Pitfalls Congenital anomalies in infant- Explained to the mother Preventability by good glycemic control should be mentioned and recorded Birth injuries and Perinatal asphyxia USG should be done 2-3wks prior to delivery Offer cesarean section if EFW >4500gm

62. Take Home Message Preventing congenital anomalies is a challenge Maintaining euglycemia is the key Educating community is the cornerstone

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