Breech presentation
• 22% of births prior to 28 weeks' gestation
• 7% of births at 32 weeks' gestation
• 1-3% of births at term
Lie stable at 36 weeks
Types of breeches
• Frank breech (50-70%) - Hips flexed, knees extended
• Complete breech (5-10%) - Hips flexed, knees flexed
• Footling or incomplete (10-30%) - One or both hips extended, foot presenting
Aetiology /Associations
Uterine/placenta
• Uterine Anomalies ( bicornuate, Septate)
• lax uterus (multi parity)
• uterine Fibroids
• Placenta previa
• Polyhydroamnios
• Oligohydroamnios
Fetus
• Multiple praganancy
• Fetal congenital anomalies (hydrocephalus, anancaphaly)
• Intrauterine Death
• Prematurity
Management
• ECV
• If fail decide on mode of delivery ie. Vaginal Delivery Vs LSCS
Vaginal breech delivery Vs planned LSCS
Planned LSCS carries a reduced perinatal mortality compared with planned vaginal birth.
Favorable for Vaginal Delivery Unfavorable for vaginal breech birth
Good pelvimetry ( previous delivery of normal sized infant) Nulliparous / Clinically inadequate pelvis
EFW 2 – 3.8 kg 2kg >EFW >3.8 kg
Extended Breech/flexed Footling
Flexed Neck Hyper extended Neck
Normal liquor volume Oligohydroamnios/ polyhydroamnios
Previous Caserian section
Other contraindications to vaginal birth (e.g., placenta praevia, compromised fetal condition)
Intrapartum Management of vaginal breech Delivary
Maternal position : dorsal or lithotomy position
Stage 1 :
• VE ; exclude cord presentation, cord prolapsed (common in flexed breech)
• Adequate analgesia
Stage2:
• episiotomy to facilitate delivery of aftercoming head
• delivery of the leg : pinnard’s maneuver
• delivery of the shoulders : the Lovset maneuver
• delivery of head may be delivered with forceps, the Mauriceau-Smellie-Veit maneuver.
If conservative methods fail, symphysiotomy or caesarean section should be performed.
Complications of vaginal breech delivery
• Fetal hypoxia ;
cord prolapsed,
placental separation before delivery of head,
compression of umbilical cord,
premature inspiration of mucus obstructing the airways
• intracranial hemorrhage: rapid decent of the after coming head causing sudden compression followed by decompression leading to tentorial tear and ICB
• Entrapment of after coming head
• Trauma to the baby: Femur #, hip dislocation, damage to viscera, shoulder dystocia with humerus #
External cephalic version (ECV)
External cephalic version (ECV) is the manipulation of the fetus through the maternal abdomen to a cephalic presentation.
An overall success rate
40% for nulliparous,
60% for multiparous
Spontaneous reversion to breech presentation after successful ECV occurs in less than 5%
When should ECV be offered?
36 weeks in nulliparous women
from 37 weeks in multiparous women.
Contraindications for ECV
• antepartum haemorrhage within the last 7 days
• proteinuric pre-eclampsia
• major uterine anomaly
• scarred uterus
• placenta previa
• ruptured membranes
• oligohydramnios
• multiple pregnancy (except delivery of second twin
• IUGR
• major fetal anomalies
• abnormal cardiotocography
• unstable lie.
Complications
• placental abruption
• fetomaternal transfusion (rhesus sensitization of mother)
• uterine rupture /scar dehiscence
• cord prolapse,
• rupture of membranes
• Amniotic fluid embolism
• stillbirth
• transient abnormal fetal heart rate changes
• emergency cesarean delivery
Prerequisites for ECV/ procedure :
1. informed consent include
2. an ultrasound examination : to confirm fetal and placental position /liquor volume
3. CTG – Reactive CTG
4. Check rhesus status (anti-D immunoglobulin is normally offered to rhesus-negative women)
5. Facilities for rapid progression to LSCS, if necessary
Fasting 4-6 hours
beta-adrenergic receptor agonist (eg, salbutamol or terbutaline) to relax the uterus
apply powder (eg, cornstarch) over the patient's abdomen
breech is disengaged from the pelvis
version performed in a way that it favors flexion
Maximum 3 attempts
Post ECV
• CTG for at least 30 mins
• Check for PV bleeding or loss of liquor
• If rhesus negative, give anti D
• If unsuccessful repeat after one week or elective LSCS
Sunday, May 15, 2011
Wednesday, December 22, 2010
MENINGITIS
Meningitis
Causes:
| Infectious | Non Infectious |
| Viral § Commonest cause § Usually benign and self-limiting § Complete recovery w/o specific Rx is the norm. § Common organisms: echoviruses, mumps. Less commonly HSV & zoster, coxsackie Bacterial – high mortality & morbidity Fungal |
|
Causes of bacterial meningitis by population groups:
| Neonatal – 3months | 1. Group B strep 2. Gram negative bacilli (E coli, proteus) 3. Listeria monocytogenes |
| Pre-school child | 1. H. influenzae 2. N. meningitides 3. Strep. Pneumoniae 4. M. TB |
| Older child / Adults | 1. N. Meningitidis 2. Strep. Pneumoniae 3. M. TB |
| Elderly / DM/ debilitated | 1. Strep. Pneumoniae 2. N. Meningitidis 3. H. influenzae 4. L. monocytogenes 5. M. TB |
| Immuno-compromised | 1. Strep. Pneumoniae 2. N. Meningitidis 3. H. influenzae 4. L. monocytogenes 5. C. Neoformans 6. Toxoplasma gondii 7. S. aureus |
§ Meningococcus: Spread by air-borne route. May result in meningococcaemia.
~ Cxs of meningococcaemia: meningitis, purpuric rash, shock, DIVC, renal failure, peripheral gangrene, arthritis (rxtive or septic), pericarditis (rxtive or septic)
§ H. influenzae: a/w ottitis media
§ Pneumococcus: a/w ottitis media and pneumonia, esp in elderly, alcoholics & immunocompromised.
§ TB: chronic or acute on chronic, a/w chronic headache, isolated CN6 palsy due to ICP, and S/S of TB eg fever, nightsweats.
Risk factors:
| Environment | Overcrowded closed communities, schools, day care centres |
| Head injury | skull #, cranial or spine surgery |
| Septic site | pneumonia, mastoiditis, sinusitis, OM |
| Host | Complement or antibody deficiency Immunosuppression (CA, AIDS, hyposplenism, sickle-cell dz, hypogammaglobinaemia, DM |
| Foreign body | § CSF shunt/ VP shunt (prone to staph. Meningitis) |
Pathophysiology
Meningeal infection followed by bacteriemia
Host response to infection
Release of inflammatory mediators/ activated leucocytes
Endothelial damage
Cerebral edema/ raised ICP/reduced cerebral blood flow
1. Any acute infections eg malaria
2. Local infections causing neck stiffness
3. Encephalitis
4. Subarachnoid hemorrhage
S/S:
| Meningism | § Headache § Photophobia § Neck stiffness | § Kernig’s sign § Brudzinski’s sign (hip flexion on flexion of neck) § Opisthotonus |
| ICP | § Headache § Vomiting § Irritability § Drowsiness § ¯consciousness/coma § Focal neuro signs | § Fits § Bulging of fontanelle § Cushing’s reflex: BP & ¯pulse § Irregular respiration § Papilloedema |
| Septicaemia | § Malaise § Fever § Rash – petechiae/purpura suggests meningiococcus. | § DIC § ¯BP, pulse, tachypnoea § Arthritis § Odd behaviour |
ComplicationS
| Acute | chronic |
| · Seizures · Cerebral herniation · Increase in ICP · Cranial nv palsies · Subdural effusions ( H.influenza/strep.pneumonia) · Thrombosis of subdural sinuses · SIADH · Waterhouse Frederickson syndrome | · Neurological deficit · Deafness (damage to cochlear hair cells) · Aphasia · Ocular palsies · Cerebral palsy · Mental retardation · Brain abscess · Hydrocephalus/microcaphaly · Epilepsy · Diabetes insipidus |
Investigations:
| Blood | Full Blood Count | | |
| Blood C/S | | ||
| Acute Phase Reactants (CRP/ESR) | | ||
| BUSE/ creatinine | SIADH | ||
| Random Blood Glucose | | ||
| DIVC screen | Especially if meningococcaemia is suspected | ||
| LFT | | ||
| Urine Urine | UFEME | | |
| Urine C/S | | ||
| Lumbar puncture CSF | § Exclude ICP by CT head, fundoscopy & clinical signs. § Tubes
Cryptococcal antigen, bacterial antigens (S. pneumonia, N. meningitides, H. influenzae, GBS) Latex agglutination for bacterial antigens PCR ( herpes simplex) | ||
| CT head | Indications for CT scan in Meningitis (Mainly useful to detect complications) - Prolonged depression of consciousness - Prolonged focal or late seizures - Focal neurological abnormalities - Enlarging head circumference - Suspicious of subdural effusion or empyema Exclude ICP (eg cerebral abscess, head injury, brain tumour) pre-LP. Cerebral odema Hemorrhage Typical site of virus | ||
| CXR | If susupected TB | | |
Contra indication for lumbar puncture
- GCS<= 8
- Cardiorespiratory instability
- Increased in ICP
- Coma
- High BP
- Reduced HR
- Papilodema
- Tense fontanelle
- Focal neurological signs
- Caogulopathy
- Thrombocytopenia
- Local infections at the site of LP
Typical CSF in meningitis
| | Normal | Pyogenic | TB | Viral (‘aseptic’) |
| Appearance | clear | Turbid | Fibrin web forms on standing | Clear |
| Predominant cell | | Neutrophils | Lymphocytes | Lymphocytes |
| Cell count/ mm3 | 0-5/mm3 | 90-1000+ | 10-1000 | 50-1000 |
| Glucose | > 50% blood | ¯ (< 1/2 plasma) | ¯ (< 1/2 plasma) | N (> 1/2 plasma) |
| Protein (g/L) | 0.15-0.4 | (>1.5) | (1-5) | N (<1) |
| Culture / smear | | Positive | Usually not seen | Negative |
Treatment:
§ Monitoring: BP, pulse, RR, temp, SpO2, conscious level
§ Supplemental O2
§ ABx if bacterial (see below)
§ Antipyretics and antiemetics
§ Corticosteroids for ICP (controversial): 0.15mg/kg dexamethasone
Viral
§ Supportive treatment
§ Completer recovery without specific therapy is the norm.
Bacterial
§ IV penicillin stat on suspicion of bacterial meningitis
§ Modify ABx regimen according to CSF invx results
| Meningococcal | Benzyl penicillin (2.4g/4hr slow IV) |
| Pneumococcal | Ceftriaxone (2g/12 hrly IV) |
| H. influenzae | Ceftriaxone |
| GBS/ Gram negative bacilli | Ceftriaxone + Gentamicin + ampicillin (50mg/kg/6 hr IV) |
| L. monocytogenes | Gentamicin + ampicillin |
| M TB | Pyrazinamide, isoniazid, rifampicin, ethambutol 6-12 mths |
| C. neoformans | Amphotericin + flucytosine |
§ Treatment for pyogenic meningitis of unknown cause
| Neonate | Ampicillin + Ceftriaxone or gentamicin |
| Infant | Ampicillin + Ceftriaxone |
| Pre-school child | Ceftriaxone |
| Older child / adults | Penicillin G (400K units/kg/day) + Ceftriaxone |
| Elderly (>50YO) | Ampicillin + Ceftriaxone |
§ Prophylaxis for close contacts--meningococcus:
~ Children: 2 days of oral rifampicin (3-12mths 5mg/kg 12 hrly; >1yr 10 mg/kg 12 hrly)
~ Adults: single dose of 500mg ciprofloxacin OR rifampicin 600mg 12 hrly for 2 days.
§ Vaccination: available for groups A & C meningococci, but not group B.
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