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UPSC MainsMEDICAL-SCIENCE-PAPER-II202110 Marks
Q34.

Outline the strategy for managing a severely growth restricted pregnancy diagnosed at 26 weeks of gestation. This female has no living issues and has a past history of undergoing Caesarean Section at 32 weeks of pregnancy.

How to Approach

This question requires a systematic approach to managing a complex obstetric case. The answer should focus on a multidisciplinary approach, considering the gestational age, fetal growth restriction, maternal history of Cesarean section, and absence of living issues. Key areas to cover include detailed fetal assessment, maternal health optimization, timing and mode of delivery, and postpartum care. The answer should demonstrate an understanding of the risks and benefits of various interventions. A structured approach using headings and subheadings will enhance clarity.

Model Answer

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Introduction

Severe growth restriction (SGR) in pregnancy, defined as an estimated fetal weight (EFW) below the 10th percentile for gestational age, poses significant challenges to both mother and fetus. Diagnosed at 26 weeks, this case necessitates a meticulous management strategy to optimize fetal well-being and minimize maternal morbidity. The patient’s history of a prior Cesarean section further complicates the situation, increasing the risk of uterine rupture and placental abnormalities. Given the absence of living issues, the emotional and psychological aspects of potential fetal loss must also be addressed. This answer will outline a comprehensive strategy for managing this complex case, balancing fetal maturity with maternal safety.

I. Initial Assessment and Confirmation of Diagnosis

The diagnosis of SGR at 26 weeks requires confirmation with serial ultrasounds. This includes:

  • Detailed Anatomy Scan: To rule out structural anomalies contributing to growth restriction.
  • Doppler Studies: Umbilical artery Doppler (UAD) and middle cerebral artery (MCA) Doppler to assess placental function and fetal hemodynamics. Increased UAD resistance and decreased MCA resistance suggest fetal compromise.
  • EFW Estimation: Using multiple biometric parameters and appropriate growth charts.
  • Amniotic Fluid Volume: Oligohydramnios is common in SGR and further indicates fetal compromise.

II. Fetal Surveillance

Intensive fetal surveillance is crucial to monitor fetal well-being:

  • Non-Stress Tests (NSTs): Performed 2-3 times per week to assess fetal heart rate reactivity.
  • Biophysical Profile (BPP): Combining NST with ultrasound assessment of fetal breathing movements, body movements, tone, and amniotic fluid volume. A BPP score of <4/8 indicates fetal compromise.
  • Cardiotocography (CTG): Continuous fetal heart rate monitoring to detect decelerations suggestive of fetal distress.

III. Maternal Assessment and Optimization

Maternal health needs to be optimized to support fetal growth as much as possible:

  • Nutritional Assessment: Ensure adequate caloric and protein intake. Consider nutritional supplementation if needed.
  • Blood Pressure Control: Manage any pre-existing hypertension or gestational hypertension.
  • Diabetes Screening: Rule out or manage gestational diabetes.
  • Assessment for Antiphospholipid Syndrome (APS) and other thrombophilias: These conditions can contribute to placental insufficiency.
  • Corticosteroid Administration: Betamethasone or dexamethasone should be administered between 24 and 34 weeks gestation to enhance fetal lung maturity, anticipating potential preterm delivery.

IV. Timing and Mode of Delivery

The decision regarding timing and mode of delivery is complex and depends on several factors:

  • Gestational Age: Delivery is generally recommended if the fetus reaches a viable gestational age (typically >26 weeks) and fetal surveillance indicates compromise.
  • Doppler Abnormalities: Persistent abnormal Doppler studies (UAD notching, reversed end-diastolic flow) indicate severe placental insufficiency and warrant delivery.
  • Non-Reassuring Fetal Status: Persistent non-reactive NSTs or low BPP scores necessitate delivery.
  • Mode of Delivery: Given the prior Cesarean section, a repeat Cesarean section is generally recommended to avoid uterine rupture. However, a vaginal birth after Cesarean (VBAC) may be considered if the previous uterine incision was low transverse and there are no contraindications. A thorough risk-benefit analysis is essential.

V. Postpartum Care

Postpartum care should focus on maternal recovery and emotional support:

  • Monitoring for Postpartum Hemorrhage: SGR pregnancies are associated with an increased risk of postpartum hemorrhage.
  • Thromboprophylaxis: Consider thromboprophylaxis, especially if there are risk factors for thromboembolism.
  • Emotional Support: Provide counseling and support to the mother, especially given the absence of living issues and the potential for fetal loss.

VI. Multidisciplinary Approach

Effective management requires a multidisciplinary team including:

  • Obstetrician
  • Maternal-Fetal Medicine Specialist
  • Neonatologist
  • Ultrasound Technician
  • Counselor/Psychologist

Conclusion

Managing a severely growth-restricted pregnancy at 26 weeks with a history of prior Cesarean section demands a meticulous and individualized approach. Prioritizing comprehensive fetal surveillance, maternal optimization, and careful consideration of delivery timing and mode are crucial. A multidisciplinary team is essential for optimal outcomes. While the prognosis can be challenging, proactive management can improve fetal well-being and minimize maternal morbidity. Continued research into the etiology and management of SGR is vital to improve outcomes for affected pregnancies.

Answer Length

This is a comprehensive model answer for learning purposes and may exceed the word limit. In the exam, always adhere to the prescribed word count.

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Additional Resources

Key Definitions

Estimated Fetal Weight (EFW)
An ultrasound-based estimation of the fetus's weight, used to assess growth and identify potential growth restriction. It is expressed in grams.
Oligohydramnios
A condition characterized by a low volume of amniotic fluid, often associated with fetal growth restriction and placental insufficiency.

Key Statistics

Approximately 5-10% of pregnancies are affected by fetal growth restriction (FGR). (Source: American College of Obstetricians and Gynecologists (ACOG), 2023 - knowledge cutoff)

Source: ACOG Practice Bulletin No. 223

Babies born with SGR have a significantly higher risk of neonatal morbidity and mortality, including respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. (Source: National Institutes of Health, 2022 - knowledge cutoff)

Source: NIH website - Eunice Kennedy Shriver National Institute of Child Health and Human Development

Examples

Placental Insufficiency

A 30-year-old woman with pre-existing hypertension is diagnosed with SGR at 28 weeks. Doppler studies reveal absent end-diastolic flow in the umbilical artery, indicating placental insufficiency. Delivery is planned at 32 weeks to mitigate fetal risk.

Frequently Asked Questions

▶What is the role of fetal intervention in SGR?

Fetal interventions, such as selective fetal reduction in twin pregnancies or intrauterine transfusion for fetal anemia, may be considered in specific cases of SGR, but are generally reserved for highly specialized centers and are not routinely recommended.

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