Fetal Monitors

Ibrahim Machiwala asked:


• The definitive treatment of pre eclampsia is delivery to prevent development of maternal or fetal complications from disease progression.

• Mild pre-eclampsia — At term, women are induced if there are no contraindications to vaginal birth. This minimizes the risk of progression to severe disease and its complications — There is no reason to delay induction of women who are at least 37 weeks of gestation and have a favorable cervix (Bishop score greater than 6).

• Hospital Admission — Close maternal monitoring upon diagnosis is important for disease severity and the rate of progression. Hospitalization is useful for making these assessments & facilitates rapid intervention in the event of fulminant progression to eclampsia, hypertensive crisis, abruptio placenta, or HELLP syndrome.

• Lab Follow up — platelet count, serum creatinine, serum ALT and AST should be repeated once or twice weekly.

• Assessment of fetal well-being & fetal growth – Ultrasound Doppler and Biophysical profile.

• Antenatal corticosteroids — to promote fetal lung maturity should be administered to women less than 34 weeks of gestation.

Expectant Management of Pre Eclampsia:

In women with severe preeclampsia remote from term, the decision to continue pregnancy beyond that interval required for the administration of corticosteroids depends upon daily maternal and fetal assessment with continual review of the ongoing risks of conservative management versus the benefit of further fetal maturation. Such women should be cared for in a hospitalized setting and by, or in consultation with, a maternal-fetal medicine specialist.

• Hospitalize until delivery.

• Keep the patient at bed rest, except for bathroom privileges.

• Monitor blood pressure every 2 to 4 hours while awake.

• Assess maternal symptoms every 2 to 4 hours while awake.

• Strict recording of fluid intake and urine output.

• Complete blood count, electrolytes, and liver and renal function tests twice weekly.

• Antenatal corticosteroids if not previously given.

• Regular assessment of fetal wellbeing.

• Elective delivery after 34 weeks.

Management of Pre Eclampsia:

• Sodium restriction and diuretics have no role in routine therapy.

• L-arginine supplementation lowered blood pressure or improved kidney function in pre eclamptic women. Effect of L-arginine therapy on the glomerular injury of preeclampsia:

— a randomized controlled trial Hladunewich MA; Derby GC; Lafayette RA; Blouch KL; Druzin ML; Myers BD Obstet Gynecol. 2006 Apr;107(4):886-95

• Anti Hypertensive Treatment — initiating antihypertensive therapy in pre-eclamptic/eclamptic women when the systolic blood pressure is >150 mm Hg & diastolic >100 mm Hg.

• Acute Therapy:

• Labetalol – Intermittent or continuous infusion fall in blood pressure begins within 5 to 10 minutes and lasts from 3 to 6 hours.

• Hydralazine — The fall in blood pressure begins within 10 to 30 minutes and lasts from 2 to 4 hours.

• Calcium channel blockers – Nifedipine & Nicardipine.

• Diazoxide – used when BP control is not archived with Labetalol & Hydralazine

Drugs contraindicated in pregnancy:

• Sodium Nitroprusside

• ACE Inhibitors

• ARB’s

Target blood pressures:

• Systolic b/w 130 to 150 mmHg

• Diastolic b/w 80 to 100 mm Hg

Breastfeeding mothers:

Beta-adrenergic blockers & calcium channel blockers enter breast milk; but considered “compatible” with breastfeeding by the American Academy of Pediatrics.

ACEi & ARB’s are generally avoided during lactation in the neonatal period. Diuretics reduces milk volume.

Effects of BP Control on Fetus:

A 10 mmHg fall in mean arterial pressure was associated with a 176 g decrease in birth weight. This effect was unrelated to the type of hypertension or choice of medication.

Most experts agree that severe hypertension should be treated to prevent maternal vascular complications. However, there is no consensus as to the optimal blood pressure threshold for initiating therapy. We initiate antihypertensive therapy in adult women at systolic pressures between 150 and 160 mm Hg and diastolic blood pressures between 100 and 105 mm Hg.

Complications of Pre-eclampsia:

Outcome measure Normal blood pressure, (percent) Mild preeclampsia (percent) Severe preeclampsia (percent)

Maternal

Outcome measure, Normal blood pressure, (percent), Mild preeclampsia (percent), Severe preeclampsia (percent)

Maternal

Liver dysfunction, 0.2, 3.2, 20.2

Kidney dysfunction, 0.3, 5.1, 12.8

Placental abruption, 0.7, 0.5, 3.7

Induced labor, 12.1, 41.5, 58.7

Cesarean delivery, 13.3, 30.9, 34.9

Delivery

Juanita

Ken Wilson asked:


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Juan

Prof G M Wani asked:


PREGNANCY DIAGNOSIS IN ruminants

1 Introduction

Rectal palptation in small ruminants is of little value due to the size of the pelvis. (Wani, 1981). The caudal artery monitoring, bloatment, non-return to oestrus, udder development and other tests tried have had little success, (Wani & Sahni,1980). The more recent interest in early pregnancy 3. diagnosis of small ruminants is of academic and economic importance (Mellado,2003). A highly valued zygote or embryo when transferred to a less valued surrogate mother (recipient) needs to be closely monitored and the early detection of conception helps in repeated use of baren females. Proper management of pregnant animals also prevents embryonic losses. The method applied should be safe to both offspring and dam and needs to be cheap and easily applied. A review of various methods and techniques used for early pregnancy diagnosis in small ruminants. (sheep and goats) is presented.

.2 Early Signs of Pregnancy

2.1. Maintenance of a functional corpus luteum

It was evident that conception prolongs the life of the CL and prolongation and maintenance of a functional CL is triggered by the developing conceptus. These signals ensure the maintenance of the structural integrity of the CL. Corpus luteum produces progesterone, which maintains the uterine endometrium in a state permitting embryonic development, implantation and foetal-placental development (wani,1984b) . The formation and regression of the corpus luteum (CL) in Muzzaffarinagri ewes and Jamunapari goats was monitored at 3 days intervals for an entire oestruous cycle. Laparotomy and laparoscopic methods were used in these experiments.

The Endometrium undergoes tissue remodeling. This change in Extra cellular Matrix (ECM ) components is needed for successful implantation. Cytokinens 8,18 and 19 have been detected in the caprine endometrium during early pregnancy using immunofluorescence. Thus the presence of these cytokinen at approximately day 15 post conception is indicative of pregnancy in goats.

The implantation process in goats starts around day 18 post mating. During this phase intense type I collagen staining was detected throughout the uterine caruncular and intracaruncular stroma. For embryonic trophoblastic adhesions with endometrium, local control of protease activity is suggested. (Guillomot, 1999).

The earliest signs of pregnancy is the non-regression of the cyclic CL, which can be observed by the following methods:

i. Laparoscopy and Laparotomy approximately day 18-25 post mating. (Wani, 1982, 1988, 1984b,Wani & Buchoo, 1990, Wani & Buchoo, 1993, Cuellar et al, 1990, Wani et al, 2003).

ii. Serum Progesterone values higher than 1 ng/ml e.g 2 to 3 ng/ml. (Wani, 1989; Shreif, 1997, Boscas et al, 2003, Al-Merestani et al, 1999, Zarkawiet et al, 1999). Diagnosis of Pregnancy accurately (100%) predicted on the basis of serum progesterone P4 values around 17-19 days post mating .

iii. Pregnancy associated ovine glycoproteins recorded approximately post mating indicate pregnancy in sheep. (Karen et al, 2003; Verberckmoes, et al, 2004) or secretion of 17 & 22-24 K Da proteins on day 17 post mating in the caprine conceptus. (Guillomot et al, 1998).

iv. Non-return to oestrus (Mellado, 2003)

Some of the other early pregnancy signs detected by various methods are set out in Table 1.

3 Non-rejection of early conceptus

Progesterone maintains the uterine endometrium in a state which allows for embryonic development, implantation and foetal placental development. Details of foetomaternal relationships have been described (Mufti, 1997, Mufti et al, 2000)and are shown illustrated in Fig 1to 5. The presence of an early conceptus prolongs the life of corpus- luteum. These pregnancy signals are secreted as proteins. (Heap et al, 1990). Some of these proteins have been identified as ovine Trophablast protein I (OTP-1) in sheep which prevents the release of PGF2 alpha and thus helps in the maintenance of the corpus luteum. In cyclic ewes (non-pregnant) PGF2 alpha pulses are released in response to oxytocin with receptors being in the endometrium. The earliest signal of pregnancy is detected by a marked reduction in the endometrial oxytocin receptor numbers. The OTP-1 may inhibit synthesis of endometrial receptors for oestrogen and oxytocin. This possibly prevents luteolysis and maintains the dominance of theuterus by progesterone which is pre-requisite for the establishment and maintenance of pregnancy. (Bretzlaft and Romano, 2001; Wani, 1996; Ala cam et al, 1988).

The expression of progesterone receptors (PR) in the caprine uterus markedly increases during the peri-implantation period and estrogen –(ER) receptors do not increase in relation to PR, thus signaling the non-rejection of the early conceptus. (Flores et al, 2001). Progesterone in milk too can be found during early fertilization and conception (Cough et al, 1989).

Caprine H-type I antigen expression is unregulated during peri-implantation and progesterone P4 level stimulate it. It may be a useful marker to signal uterine preparations for receiving and retaining pregnancy in goats. (Powell et al, 2000). The caprine pregnancy related glycoprotein (Ca PAG) may help the conceptus to develop and is found around 18-19 day post mating . (Garbayo et al 2000). Endometrial tissue the undergoes remodeling to retain the conceptus in gravid small ruminant females. (Guillomot, 1999)

The dephosphorylated state of caprine uterine myocin in early pregnancy may help the conceptus to grow. Changes in the expression of native myocin, myosin heavy chains (MHCS) and myosin light chains (MLCS) were observed. (Kumar and Katoch, 1997).

For the development of the blastocyst, a proper uterine environment is essential. Besides the maintenance of the corpus luteum, production and availability of progesterone, the non-rejection of conceptus (blastocyst) is another critical feature of this period. The embryo produces interferons (embryo-IFN). This embryo IFN is homologous with - interfersons ( ? –IFN) and Ovine Trophoblast Interferons (OTI) of early pregnancy.

Purified OTP and recombinant OTP (r-oTP) produced in yeast exhibit antiviral activity and these r-OTP and OTP inhibit the release of endometrial PGF2 ? . This helps in the non-regression of the CL and indirectly maintains the early conceptus. Intra uterine r-OTP administered at a dose of 340 µg/ day for a week maintained the C.L in cyclic ewes for a month or so of . The inter- oestruos interval in 80% of the ewes was about a month or more. This dose r-OTP was as a effective as 14-16 day old conceptus. OTP was found to be immunosuppressive in several in-vitro and in-vivo assays. An assay on phytohaemagglutinin A revealed both OTP and r-OTP to be immunosuppressive. This was further verified by the inhibitory activity of r-OTP in Graft Versus Host Reaction. (GVH assays). Trophoblast interferons play a strategic role in the prevention of early pregnancy loss as it inhibits CD + blastogenesis. The role of CD + cells and as helper T lymphocytes and delayed+ Type hyper sensitivity mediators (DTHS) would explain this immuno- suppressive rate of OTP. (ILeri et al, 1996; Karen et al, 2003; Wani, 1996).

3.4 Oestrogen: – Pregesterone ratio (E:P ratio)



The role of oxytocin in inducing uterine PGF2 alpha was discussed earlier. However, the release of PGF2 under the action of oxytocin depends on or is controlled by progesterone and oestradiol. It was further indicated that ewes with a high E:P ratio may generate stronger luteolytic signals. It was demonstrated that low progesterone and high oestradiol combination record the largest and sustained increase in PGF2 alpha following oxytocin injection. Trophoblast interferons act locally to suppress the uterine oxytocin receptors in sheep.(Karen et al, 2003 ).

5 Maternal recognition of pregnancy

The maternal recognition of pregnancy in sheep and cattle is centered around the production by the trophoblast of type I x interferon (tINF). This tIFN then suppresses uterine oxytocin receptor concentrations (OTr). The oxytocin receptor (OTr) occupancy is associated with oxytocin induced PGF2 alpha release. OTr inhibition may represent the principal antiluteolytic mechanism of tIFN and secretion of the conceptus secretory proteins or bovine recombinant IFN to the uterus reduces OTr. Concentrations in intact and ovarectionized steroid treated ewes . A relationship between the conceptus secretory proteins and the metabolic products and those in the peripheral blood of the dam exists. ( Mufti; 1996; Mufti et al, 2000). There are conflicting reports making the action of oestradiol on oxytocin receptor concentration. (Powell et al, 2000). Trophoblastic cells contain interferon on day 14-17 after mating. During maternal recognition of pregnancy goat interferon was detected on day 18 post mating, its absence signifies pregnancy maintenance has been taken over by the corpus luteum. Thus a very thin line exists between maternal recognition of pregnancy and its maintenance or sustenance by the CL. (Gillomot et al, 1998).

6 The Reliability Pregnancy tests

Various methods used for correctly predicting pregnancy in sheep and goats during gestation have been summarized in Table 2. The accuracy varies from 70 to100% with different ultrasonic equipment. Different models as well as principles involved have been extensively reviewed (Wani, 1991; Wani et al,1998) and other methods of pregnancy detection during this stage e.g serum progesterone determination, vaginal cytology, laparotomy, estrone sulphate are summarized (Table-2). Various techniques were also evaluated in assessing mid-gestation. The various pregnancy signs as quoted by

various researchers using ultrasonography are summarized in Table 3. Of late certain anatomical features in the live, developing conceptus in vivo have been reported. This is reviewed and a summary is presented (Table 4). Various live foetal measurements like Biparietal diameter, Amniotic vesicle diameter, foetal radius and Tibia lengths are reviewed and shown (Table 5). Various pregnancy related images, histological sections and morphology of endometeruim have recently be published (Wani et al 2007, 2006 abc) where images are presented 6-15

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Nellie

doctor_76 asked:


We bought one from Wal-Mart and tried it out. It is pretty neat hearing the little thumps and bops of the baby moving around but as of yet, no heartbeat… My wife is 19 weeks as of today, anyone have any idea how soon we may be able to hear it with the monitor?

Marion