43rd annual vail obstetrics and gynecology february · pdf file43rd annual vail obstetrics and...

43rd AnnualVail Obstetrics and Gynecology

FEBRUARY 19th-24th, 2017

CONFERENCEVail Marriot Mountain Resort & Spa - Vail, Colorado

Presented by:Department of Obstetrics and Gynecology University of Colorado School of Medicine

Sponsored by:University of Colorado School of Medicine Office of Continuing Medical Education



FridayFebruary 24th, 2017

Conference Schedule

FRIDAY, FEBRUARY 24TH, 2017

6:45 a.m. Breakfast with the Professors Nick Behrendt, MD & Shane Reeves, MD

7:15 a.m. What the generalist needs to know about fetal therapy Nick Behrendt, MD 7:45 a.m. Q&A

7:55 a.m. Prevention of Obstetric Lacerations Julie Scott, MD 8:25 a.m. Q&A

8:35 a.m. Implementing new HTN guidelines Shane Reeves, MD 9:05 a.m. Q&A

Adjourn Until 2018 February 18th-23rd, 2018

Visit CUVAILOBGYN.COM

What the Generalist Needs to Know about Fetal SurgeryNicholas Behrendt, MDAssociate Professor Maternal‐Fetal Medicine and Fetal Surgery

ObjectivesObjectives

• Identify fetal abnormalities that necessitate evaluation for fetal surgery

• Develop an understanding of fetal evaluations used to determine potential surgical intervention

• Care for patients after fetal surgical procedures

Overview

• Twin-to-Twin Transfusion Syndrome• Fetal Myelomeningocele Closure• Bladder Outlet Obstruction

Twin-to-Twin Transfusion Syndrome

Disease in which monochorionic twins (shared placenta) have communicating vessels that manifest a compromise in the pregnancy

The name is a misnomer – more likely a manifestation of a volume discrepancy between fetuses

• Can cause overload and cardiac compromise in one twin

Occurs in 15% of monochorionic twin pregnancies

Associated with at least an 80% risk of mortality if left untreated

Twin‐to‐Twin Transfusion Syndrome

5

Monochorionic‐DiamnioticThickness: Thin and hairlike# of Layers: 2“Insertion”: T‐signSingle PlacentaConcordant genders

The Key is Identification of the Chorionicity and Amnionicity

6

Dichorionic‐DiamnioticThickness: Thick (>2mm)# of Layers: 3‐4“Insertion”: Lamba SignMay have separateplacentas

• Best accomplished between 10‐14 weeks gestation• Some authors advocate for MFM consult for ALL suspected twin pregnancies

initially• Evaluate the thickness, number of layers, and “insertion” of the intertwin

membrane

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Evaluations every 2 weeks starting at 16 weeks through the duration of pregnancy*• ACOG Practice Bulletin 162 says to “consider”

Evaluate the following for sure:• Fluid maximum vertical pocket values for each twin• Presence or absence of bladders

Consider Evaluation of:• Middle Cerebral Artery Peak Systolic Velocities to evaluate for TAPS

Referral if there is any fluid discrepancy (even if it does not meet Quintero Staging)

Most MFM Practices would be happy to perform this surveillance if desired

Moldenhauer J, Johnson M. Diagnosis and Management of Complicated Monochorionic Twins. Clinical Obstetrics and Gynecology. 58(3) 2015. p 632‐642.

• Diagnosis:• Ultrasound and fetal echocardiography are used to Stage the Syndrome

Cincinnati Staging System

8

• Available from 16w to 26w6d• Fetoscopic Laser Photocoagulation has

become the standard treatment in advanced TTTS

• A small camera is inserted through the skin, through the uterus and into the amniotic sac

• Vascular “mapping” is done in order to only treat pathologic connections

• Yag laser from a 650 nm sheath treats the connections

Selective Fetoscopic Laser Photocoagulation

10

Selective Laser Photocoagulation

Outcomes vary amongst authors but overall:

• 80‐95% survival of one or both fetuses

• 60‐80% survival of both fetuses

• Outcomes vary depending on many factors

Laser Therapy

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Complications:• Chorioamnionitis• PPROM• Preterm Delivery

• Average latency around 8‐12 weeks from laser

• Average gestational age at delivery 31‐32 weeks

• Persistent TTTS or TAPS• Selective Intrauterine Growth

Restriction

Most authors recommend weekly ultrasounds:• Amniotic fluid checks• Doppler evaluations• Cervical length• Evaluation for TAPS

CFCC Protocol:• At least weekly ultrasounds (fluid, UA and DV Dopplers, MCA Dopplers)• Fetal echocardiogram every 2 weeks until resolution of cardiomyopathy• Growth ultrasounds every 4 weeks• Delivery at a hospital with a tertiary care center if any complications

Close Observation and Follow Up:

13

Fetal Myelomeningocele Closure

Open spinal cord defect that is normally not covered by skin

• Spectrum of diagnoses that all involve failure of the neural tube to close

Incidence estimated at 1:1000 live births

Usually isolated finding but may be part of a genetic disorder

• Amniocentesis recommended• Decreased recurrence with increase in

folic acid consumption by women

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• Parietal Bone Scalloping: “Lemon Sign”• Obliteration of the Cisterna Magna:

“Banana Sign”• Ventriculomegaly: Lateral ventricles

greater than 10 mm• Cystic lesion arising from the fetal

spine• Club feet

Initial Evaluation/Signs:

16

If any concern then refer for Maternal‐Fetal Medicine Evaluation

Combination of fetal ultrasound, echocardiogram, and MRI potentially

• Advanced technologies to detect the level of the lesion and effects of the lesion

Genetic testing due to increased incidence of genetic disorders

Evaluation for possible fetal closure

Depending on where you are, can have Neonatology, Neurosurgery, and OT/PT counselors available

Multidisciplinary Evaluation

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• Inclusion Criteria:• Lesion T1 through S1 with

hindbrain herniation, level of MMC confirmed by ultrasound and hindbrain herniation confirmed by MRI.

• Maternal age greater than or equal to 18 years.

• Gestational age 19 0/7 weeks to 26 0/7 at the time of prenatal surgery.

• Normal karyotype or FISH. • Normal fetal echocardiogram. • Singleton pregnancy.

Management of Myelomeningocele Study (MOMS Trial)

18

• Exclusion Criteria:• Other significant

anomaly• Kyphosis > 30 degrees• History of

incompetent cervix• BMI > 35• Infectious Disease• Uterine Anomaly• Maternal Medical

Issues• Previous hysterotomy

in active segment of uterus

• Improvements• Significant improvement in

Hindbrain Herniation• Decreased need for postnatal

ventriculoperitoneal shunt by 50%

• Improved neurologic function at 30 months of age

MOMS Trial Conclusions

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• Increased Risk:• Average Gestational age at

delivery 34 weeks (vs 35 weeks) with 50% delivering before 34 weeks

• 50% PPROM Rate• Oligohydramnios• Placental Abruption

• Abdominal incision 3 cm above the pubic bone and transverse

• Fascia opened vertically up to the umbilicus

• Retractor used for uterine exposure

• Placenta mapped with ultrasound• Uterine staplers to open the

uterus (see picture): In the active segment of myometrium

• Layers closed including 2‐3 layer PDS closure of the uterus

• Omentum sutured onto the uterine incision

20

In Utero Closure

Inpatient (CFCC Protocol):• Indocin x 48 hours• MgSO4 x 48 hours• Transition to PO Nifedipine• Daily ultrasounds• Daily Cervical length• Average stay 4 days

Close Observation and Follow Up:

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Outpatient: (CFCC protocol):• Nifedipine daily• Weekly Ultrasounds including

cervical length• Evaluation for PPROM, preterm

labor, and infection as needed

• Delivery by cesarean section if any concern for labor

• Uterine incision is through active portion of myometrium so treat as a classical incision

• Opening of abdomen is no different• If time from MMC closure to

cesarean section is relatively short then likely need to reopen the vertical fascial incision

• Depending on gestational age you can perform low transverse incision: Do not reopen uterine incision if possible

• Consider taking down the omental patch

Cesarean Section for Delivery:

22

• Future Pregnancies:• Need Cesarean sections for all

future pregnancies due to uterine incision

• Uterine rupture risk• No evidence that fertility is

effected• One known placenta accreta post

open fetal surgery

Bladder Outlet Obstruction

Congenital “blockage” of the genitourinary tract

Incidence estimated to be 1:5000 –1:25,000 live births

Usually a sporadic finding without a known genetic cause

Posterior Urethral Valves (PUV) is the most common cause

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• Large cystic abdominal mass in the fetal abdomen/pelvis

• “Keyhole Sign” (see image)• Abnormal Kidneys:

• Cystic• Bright and echogenic

• Abnormal amniotic fluid:• Usually normal until 16 weeks

gestation when fetus becomes main source of amniotic fluid

• If complete obstruction then usually anhydramnios by 18‐20 weeks

• Potter’s Sequence findings

Initial Evaluation/Signs:

25

Referral to Maternal‐Fetal Medicine if suspected

Combination of ultrasound, MRI, echocardiogram and invasive testing

Differential includes:• Sacrococcygeal teratoma• Prune Belly Syndrome• Other intraabdominal masses

Invasive testing to evaluate electrolytes:• Usually performed multiple times 24 hours apart• Some literature suggests it can help with predicting renal outcomes

Vesicoamniotic shunt is the fetal intervention available• Allow for restoration of amniotic fluid around the fetus relieving both external

and internal pressure on the fetal lungs• Does not improve renal function

Multidisciplinary Evaluation

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• No gestational age constraints but prime lung growth is between 18‐24 weeks

• Goal to create a channel between the fetal bladder and the amniotic sac to restore fluid around the fetus

• Complications:• PPROM• Preterm Labor• Infection

Vesicoamniotic Shunt Placement

27

• Vesicoamniotic Shunt Placement has a high rate of malfunction

• Occlusion• Dislodgement

• On average 2‐3 shunts are required over the course of the pregnancy

Bladder Outlet Obstruction Follow Up

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CFCC Protocol• At least weekly ultrasounds to evaluate AFI and shunt location (growth q 4 wk)• Antenatal testing• Multidisciplinary Planning:

• Urology and Nephrology due to high chance of bladder dysfunction and renal failure

• Neonatology consultation• Delivery planning

• Recommend delivery at tertiary center due to need for Pediatric subspecialty care

• Mode of delivery not modified• Ensure how many shunts were placed and account for each after delivery

• Harrison shunt can be seen on x‐ray

Bladder Outlet Obstruction Follow Up

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• Identification of fetal abnormalities is the key to evaluation for fetal intervention

• Referral to Maternal‐Fetal Medicine as soon as possible if a patient may qualify for fetal surgery

• Post‐surgical follow up involves frequent ultrasounds and office visits due to the high risk of complications or need for further procedures

• Referral to a Center with Multidisciplinary Care Available is sometimes necessary

• There are many other indications/options for fetal surgery beyond those presented during this lecture

30

Thank You!

43rd AnnualVail Obstetrics and Gynecology

FEBRUARY 19th-24th , 2017

CONFERENCEVail Marriot Mountain Resort & Spa - Vail, Colorado





CUVAILOBGYN.COM

Lecture Slides not available at time of printing

They will be available on the website.

Guidelines in Hypertension in pregnancy

Shane Reeves, MDColorado Institute for Maternal and

Fetal Health

November 2013

Which of the following is a diagnostic criteria for preeclampsia?

A. Blood pressure >140/90 on two occasions 2‐hours apart in a previously normotensivewoman

B. Protein/Creatinine ratio >0.3C. 24‐hour urine protein of >200 mgD. A shirt that smells of chamomile and

petunias

Diagnostic criteria

Which are severe features of preeclampsia?

A. Platelet count <100,000B. Cr >0.9C. Elevated AST and ALT 1.5 times above normalD. 5 grams or more of proteinuria in a 24‐hour

urine collectionE. A fetus measuring at <5th percentile for EFW

Severe Features – Do not need Proteinuria

Changes with Protein and Severe Criteria

• 24‐hour urine >300 mg still valid– Can be timed and extrapolated

• Protein/Cr of >0.3 (in mg/dL)• Massive proteinuria (>5g) removed from severe criteria

• IUGR removed from severe criteria• BPs now 4 hours apart rather than 6 hours apart

Predictors of Preeclampsia

• sFLT• Uterine Artery Doppler• Biochemical markers

“These tests are not yet ready for clinical use”

A 26 y.o. G2P0101 presents at 10 weeks of pregnancy. She has a history of severe preeclampsia at 34 weeks in a prior pregnancy. What therapy would you recommend to prevent preeclampsia in this pregnancy?

A. 1000 mg of Vitamin CB. Low Salt Diet with <100 mEq/LC. Strict Bed restD. Baby Aspirin 81 mg per dayE. Cytotec 800 mcg per vagina q24 hours for 2

doses

Prevention of Preeclampsia

• History of preeclampsia– 60‐80 mg of baby aspirin beginning in late first trimester

• Vit C and E– Does not prevent

• No restriction of salt• Bed rest does not prevent

Quick Definitions and Key

• GHTN = gestational hypertension• PreW/o = Preeclampsia without severe features

• PreW/ = Preeclampsia with severe features• CHTN = Chronic hypertension• CHTN S/I Pre = CHTN with superimposed preeclampsia

A 19 y.o. G1P0 at 34 weeks 0 days has a blood pressure of 152/98. Repeat evaluation in triage shows 145/80. What would be the MOST appropriate next step in patient evaluation?

A. I would step on your face you sadistic CadB. Administer antihypertensive therapyC. Place the patient on strict bed restD. Send off protein/Cr ratio and HELLP panelE. B, C, and D above

Management PreW/O and GHTN

• BP <160/110– Do not administer blood pressure medications

• Strict bed rest for PreW/O and GHTN NOT recommended

• Hospitalization for PreW/O and GHTN not required

A 32 year old G1 presents at 32 weeks with blood pressures of 140‐152/90‐105. A 24 hour urine protein is 2000mg, HELLP panel is normal, and she has no headache or pulmonary edema. You deem her stable for outpatient management. What will the appropriate management strategy be?

A. Repeat a 24‐hour urine weeklyB. Blood pressure evaluation twice weeklyC. HELLP panel weeklyD. All of the AboveE. Both B and C aboveF. Beat the person who writes these confusing

multiple choice questions

Monitoring of PreW/O and GHTN

• PreW/O– Twice weekly BP assessment– HELLP panel weekly– No need for repeat proteinuria assessment

• unless BPs normalize and first one in question

• GHTN– Weekly office BP and protein assessment– Weekly BP check at home in addition to office assessment

After your decision to manage a preeclampticwithout severe features as an outpatient, what type of fetal surveillance would you perform?

A. Serial growth ultrasoundsB. No assessment. We are putting the “M” back

in “MFM”C. Antenatal fetal monitoring D. A and C above

Fetal Assessment

• Serial fetal growth assessment is recommended– If IUGR – UmA Doppler recommended

• Antenatal monitoring is recommended

25 y.o. G2P1 presents at 37w3d with BP 140/92. Repeat in 4 hours is still elevated. HELLP panel is normal. Pr/Cr is 0.28. Pt denies symptoms of HA and visual changes. Fetus has EFW at the 25th percentile. What is the recommendation from ACOG?

A. Expectantly manage with serial protein assessments and HELLP panels. Deliver at 39 weeks.

B. Move towards deliveryC. Treat with antihypertensives and send home with a

24‐hour urine collectionD. Start magnesium sulfate administration and assess

if the patient is a candidate for expectant management

Delivery Timing

• PreW/O and GHTN <37 weeks– Expectant management recommended– Maternal and fetal assessment

• PreW/O and GHTN >37 weeks– Delivery recommended

• PreW/ – Deliver >34 weeks if maternal condition is stable

Which of the following are indications for delivery of preeclamptic patients after 34 weeks gestation?

A. Oligohydramnios with an AFI <8B. EFW at the 8th percentileC. BPP of 8/10D. Ruptured membranesE. The inability to reach one’s toenails for a pedicure

Delivery is indicated with preeclampsia if:

• 37 weeks or more of gestation• Abruption• 34 weeks +

– Labor or rupture of membranes– EFW <5th percentile– Oligohydramnios with AFI <5 cm– Persistent BPP of 6/10 or less

34 y.o. G2P0010 at 35 weeks presents with blood pressures of 160‐170/100‐110. She has a Pr/Cr of 1.2. HELLP panel is otherwise normal. Ultrasound shows the fetus is in the breech presentation. What is the next step?A. Admit the patient for expectant management

until 37 weeksB. Perform cesarean section and start magnesium

post‐partumC. Start magnesium drip and continue this through

the cesarean sectionD. Prescribe moxibustion therapy

Magnesium Sulfate

Not Recommended• BP <160/110• PreW/O• GHTN

Recommended• BP >160/110• HELLP• Eclampsia• PreW/• Intra‐operative

administration recommended

23 y.o. G1P0 at 28 weeks 3 days presents with BP 170/102 with repeat in 15 minutes at 180/112. No HA, visual changes, RUQ pain, or SOB. HELLP is normal. Pr/Cr 1.5. What would your next step be:A. Admit to the hospital, start magnesium, move

towards deliveryB. Send home with a 24 hour urine protein assessmentC. Start magnesium, give steroids and move toward

deliveryD. Start magnesium, give steroids, give labetolol, and

assess if you can expectantly manage until 34 weeksE. Sip on some coffee and let the deck dock handle it

Preeclampsia with severe features

• Expectant management <34 weeks• Antihypertensives if >160/110• Corticosteroids recommended for lung maturity <34 weeks– Delay delivery by 48 hours

• At Gestational age prior to viability– Delivery recommended

A 19 y.o. G1P0 at 28 weeks has blood pressures of 160‐170/110, LDH of 500, AST of 100, ALT of 150, and PLT count of 80,000. She has no headache or visual changes. Her fetus is reactive and cephalic. What would ACOG recommend you do?A. Give BMZ and wait 48 hours prior to induction

of labor. B. Move immediately toward delivery with

induction and magnesium sulfate. C. Manage expectantly until 34 weeks.D. Run for the Border ‘cuz your Jonesin’ for a bean

burrito

Can Wait For 48 Hours After Steroids

• PPROM• Labor• PLT <100,000• Elevated LFT• IUGR

– A/REDF• Oligohydramnios (AFI <5)• Renal dysfunction

Don’t Wait 48 Hours For Steroids

• Uncontrollable severe HTN• Eclampsia• Pulmonary edema• Placental abruption• DIC• Non‐reassuring fetal status• IUFD

HELLP

• Magnesium recommended• Can wait for 24‐48 hours after steroids• Steroids can help to improve platelet count.

Post Partum

• All patients with GHTN or Preeclampsia– BP monitored for 72 hours (Inpatient or equivalent outpatient)

– Follow up BP assessment 7‐10 days– Avoid NSAID therapy in the first few days

• Discharge instructions– Signs and symptoms of preeclampsia – Highlight the importance of reporting information to the health care provider

Post partum HTN

• HTN with Symptoms of headache or blurred vision– Administer magnesium

• Preeclampsia with severe blood pressure– Administer magnesium– Treat hypertension

• Duration of magnesium administration is not mentioned

• BP >150/100 on two occasions 4 hours apart should prompt therapy

Chronic Hypertension

40 y.o. G3P2 at 10 weeks presents with a history of chronic hypertension. She currently takes Losartan and has no history of kidney or cardiac disease. Blood pressure is 128/72. What steps would be best?A. Start baby aspirin, continue LosartanB. Start baby aspirin, discontinue Losartan,

check a 24‐hour urine protein, reassess BP in 1 week to guide antihypertensive therapy

C. Continue Losartan with blood pressure target of <110/70

D. Place her on strict bed rest.

CHTN

• Refer to a specialist if secondary hypertension suggested

• Home blood pressure monitoring recommended

• Rule out white coat hypertension• Extremely low Na Diet (<100 mEq/d) NOT recommended

• Continue moderate exercise

When to refer to a specialist for workup of CHTN

• HTN resistant to medications• Hypokalemia• Elevated serum creatinine• Strong family history of kidney disease

When choosing an antihypertensive, which one should be avoided?A. CaptoprilB. LabetalolC. NifedipineD. Methyldopa

CHTN Blood Pressure Control

• DO NOT TREAT if:– BP <160/105– No evidence of end‐organ damage

• TARGET– 120‐160/80‐105– Over‐treatment can result in IUGR

• DRUGS of CHOICE– Labetolol, nifedipine, methyldopa

CHTN Treatment

• Drugs to AVOID– ACE‐IN– Angiotensin receptor blockers– Renin inhibitors– Mineralocorticoid receptor antagonists

• Begin baby aspirin in the late first trimester to prevent preeclampsia

Chronic Hypertension Monitoring

• Fetal growth assessment with ultrasound– If IUGR, UmA Doppler

• Antepartum monitoring if:– Need for medication– IUGR– Superimposed preeclampsia– Other medical conditions increasing the risk of fetal death

CHTN Delivery Timing

• Not recommended at <38 weeks if no evidence of preeclampsia or other complications

• Deliver earlier if other complications arise or if superimposed preeclampsia

36 y.o. G3P2 at 36 weeks 3 days has a history of obesity, CHTN, and GDM controlled with glyburide. She has been controlled with labetolol 400 BID and has a baseline Cr of 1.1 and 24‐hour urine protein of 360 mg. Today, she has new symptoms of HA, visual changes and blood pressure is 200/110. She has 3+ proteinuria and PLT count of 80,000. What would your next step be:A. Start magnesium and move toward deliveryB. Start magnesium, give betamethasone, wait 48

hours and move toward deliveryC. Give labetolol 20 mg IVD. Stress the importance of weight loss and initiate

a high‐protein diet.E. A and C

CHTN with SI Pre

• Administer steroids if <34 weeks• Magnesium if severe features• Deliver at 37 weeks if no severe features• Deliver at 34 weeks if severe features present

Treatment of Acute Hypertension

• Hypertension that is severe (160 SBP OR 110 DBP) that persists >15 minutes is an emergency

• SBP is more concerning for risk of stroke and cerebral hemorrhage

• Goal is to achieve SBP of 140‐150 and DBP 90‐100– Not to normalize

First Line Therapy

• Labetalol– Avoid in asthma, heart disease, or CHF

• Hydralazine– Highest rate of maternal hypotension

• Oral Nifedipine– Risk for neuromuscular blockade is very low when used with Magnesium

– Higher rates of maternal hypotension, dizziness, and headache

• Magnesium is not an antihypertensive but should be used for seizure prevention

Salient Points

• Start with Labetalol– 20 mg, 40 mg, 80 mg (10 minutes between doses)– Hydralazine added

• Start with Hydralazine– 10 mg, 20 mg (20 minutes between doses)– Labetalol added

• Start with Nifedipine (Only Oral)– 10 mg, 20 mg, 20 mg (20 minutes between doses)– Labetalol Added

Second Line Therapy

• Labetalol • Nicardipine infusion pump• Sodium nitroprusside reserved for extreme emergencies

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