Eva L. Feldman, M.D., Ph.D.

• Department of Neurology
• University of Michigan
• Ann Arbor, MI

The transport team that has invested several hours at a bedside keratin intensive treatment phenytoin 100 mg amex, stabilizing a newborn with medical or surgical issues chapter 7 medications and older adults buy phenytoin in india, may be spending time in a facility that is not ideal treatment sciatica purchase 100 mg phenytoin free shipping, has a limited number of skilled personnel symptoms xanax is prescribed for 100 mg phenytoin order otc, and has minimal backup symptoms appendicitis 100 mg phenytoin sale, thus prolonging the transport process and potentially putting that individual patient at risk (Chen et al, 2005; Haji-Michael, 2005). However, the patient and the system are at risk because the valuable resource of specialized neonatal transport personnel is not available for another patient. Ideally, care delivery would be the same at referral and receiving centers; the development of practice guidelines can be helpful in that regard. Guidelines that are evidence based, developed by regional and local experts, and disseminated to referring locations and transport teams will help to standardize and enable consistent care across variable locations. It is necessary, however, to assess and reassess the quality of the guidelines and the competency of their use to ensure optimal results from this process. It is clear that identification of those events, discussion with families (where appropriate), and root cause analysis are imperative. Ligtenberg et al (2005) noted that one third of patients had an adverse event, and 50% of those resulted from not following the advice of the medical command physician. In a review of the London Neonatal Transfer Service, Lim and Ratnavel (2008) noted that 36% of their patients had greater than or equal to one adverse event, and two thirds of those were due to human error; half of those occurred before the team arrived at the referral center, and their major etiologies included preparation and communication. A neonatal transport service must determine if maternal transport is part of their purview. Developing appropriate criteria for transporting women in preterm labor may help to direct the optimal use of resources required with maternal transfer. Identifying the appropriate time to transport women in preterm labor, as well as those with other preterm medical issues, will help in developing appropriate criteria and limit resource utilization for maternal transfers. It is important to note that significant work regarding neonatal and maternal transport and regionalization of care in the United States, United Kingdom, Australia, Europe, and other areas has already been accomplished. There are, however, multiple opportunities to improve transport on an individual and regional basis in these developed countries and in other developing countries. A quality medical director and program director, often a nurse or respiratory therapist, are essential to understand the potentially complicated and challenging environment of transport medicine. These leaders should be instrumental in identifying expectations, roles, and responsibilities for the process; this includes access through a communication center and developing and disseminating referral center expectations. These expectations include stabilization and preparation of the patient before transport, making an appropriate decision to transfer, choosing the appropriate transport process and destination, obtaining consent from the family for transport, discussing plans for stabilization and intervention with the medical command physician, and initiating that plan as able. Referral centers must be able to be direct when they believe that the suggested interventions are inappropriate or beyond their scope. The referring team also needs to be available to participate in transition care to the transport team and the receiving service. The receiving and transport team responsibilities include being immediately available for case discussion, having the ability to rapidly accept the patient if capacity is available, offering clear and concise expert recommendations, ensuring preparation of the environment and the staff both for the transport and arrival of the patient, organizing additional diagnostics and interventions, and providing available and accessible neonatal advice throughout the process. Most important, the team needs to ensure that appropriate skills and therapy are available and delivered throughout the process, from referral call through definitive placement, and ensure seamless transition at each point of care. Multiple disciplines have organizations with transport focus and expertise, including the American Academy of Pediatrics Section on Transport Medicine, which includes executive committee representation from neonatology, pediatric critical care, and emergency medicine physicians, as well as a broad membership from other subspecialties and disciplines. The American Academy of Pediatrics Transport Section published its most recent Guidelines for Neonatal and Pediatric Transport in 2007; they also host a listserv at transmedaap@listserve. These keys include integrity, professionalism, preparation, anticipation, education, competency, critical evaluation of current and new practices, the ability to critically assess the quality of care being delivered at every point along the way, and looking for opportunities to improve access, efficiency, and delivery of care. An area that is vital for appropriate transport care is the assurance of competency of the providers (American Academy of Pediatric Committee on Fetus and Newborn and Bell, 2007). As noted, providers can come from many different backgrounds and bring different skills from their clinical and training experience. It is imperative for the transport system and leadership to ensure that the skills required are present in their personnel. This responsibility includes initial education, continuing education, and competency assessment. A team may decide to have individuals who are experts in defined areas of care, such as a physician who manages airways and the pneumothorax, a nurse who manages intravenous access and medication delivery, and a respiratory therapist who is responsible for airway and ventilatory support, whereas another team may choose to have all team members competent in all skills. Specific procedures may be useful or needed in transport that are not as common in the hospital environment or to the hospital-based providers. However the team is structured, there must be clear and concise guidelines for ongoing training and assessment of the personnel. High-fidelity simulation models offer additional opportunities to assess and potentially improve technical and cognitive capabilities (LeFlore and Anderson, 2008). The American Academy of Pediatrics Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients (available at The true quality of a transport service is sometimes difficult to determine, because many teams and services have been developed independently and are not part of larger regional systems. It is difficult to compare and contrast systems in different areas for which different patient populations are transported (Berge et al, 2005; Cornette and Miall, 2006; Craig, 2005; Doyle and Orr, 2002; Khilnani and Chhabra, 2008; Van Reempts et al, 2007). One avenue for potential standardization of the transport environment is by assessment and accreditation by the Commission on Accreditation of Medical Transport Systems, which was initiated in 1990 as a direct response to the number of air medical accidents in the 1980s. This certification is voluntary in some areas and required in others, and it serves to assure providers, stakeholders, and the public of adherence to quality of care and transport safety standards. The Commission on Accreditation of Medical Transport Systems is an independent organization, supported by 16 member organizations, which publishes standards and arranges reviews of interested air and ground transport programs. In addition, the logistics of travel must include a safe environment, including helmets and fire-retardant suits for those who fly in helicopters, three-point restraints, and appropriate ambulance seating arrangements. There should not be an occasion when providers put themselves at risk by being unrestrained or being in an area where unsecured debris or inappropriately placed equipment may damage a provider or a patient. Adherence to rules and regulations of air and ground transport is imperative as well (Clawson, 2002; Greene, 2009; King and Woodward, 2002b; Levick et al, 2006; National Highway Traffic Safety Administration, 2009). It is imperative to recognize that there is risk with both air and ground transport. The air transport industry has seen an acute spike in tragic and fatal air accidents (Greene, 2009; National Transportation Safety Board Accident Database, 2009). Requirements such as duty hours for pilots, weather restrictions, flight under instrument, flight rules with terrain avoidance equipment, and night vision goggles can to help minimize the risk for these transports. Although ground ambulances are used much more frequently, and the risk of injury and death is evident, the fatality rate is lower in ambulance accidents than it is in aircraft accidents (Becker, 2003; Becker et al, 2003; King and Woodward, 2002b). It is necessary, however, that the vehicles be maintained and operated in a safe manner. Many systems do not allow ambulances to exceed posted speed limits and use lights and sirens only as a way to identify an emergency response, not to enable the vehicle to circumvent or ignore standard traffic laws (Clawson, 2002). It is evident from the transport and pediatric literature that patient outcomes are improved with specialty providers. There have been multiple studies to examine this particular issue (Belway et al, 2006; Mullane et al, 2004). Perhaps the most compelling is the study by Orr et al (2009), which examined transports provided by variable providers within the same system. This study compared outcomes in patients whose care was delivered by specialized pediatric critical care teams with those whose care was delivered by general providers. Patient outcomes were worse for those whose care was not delivered by specialty teams, and much improved for those who were. One challenge, however, with transport teams is that differentiation of medical resources, such as a neonatal specialty team, likely means that there may be a scarcity and potential need for rationing of those resources. It is possible to develop teams with a variety of personnel with complementary cognitive and procedural skill sets and work toward appropriate triage of transport requests to ensure the proper level of onsite skill provision. There have been multiple attempts to develop triage tools for pediatric and neonatal care providers, including the Mortality Index for Neonatal Transport, the Modified Clinical Risk Index for Babies, and the Risk Score for Transported Patients, which are noted in the bibliography (Broughton et al, 2004a, 2004b; Markakis et al, 2006). Families who have been formally surveyed appreciate the opportunity to participate in the care of their child. In neonatal transport, however, there are times when there are two patients who may require care in two disparate locations. A mother who has had a cesarean section and has delivered an acutely ill child in need of care in a higher facility is one such example. Transport teams need to be sensitive to the challenges and opportunities for the family and include them in the process when possible. It is evident that when parents attend or accompany transport team members on critical care transports, they are not there to assess the medical skill set of the provider, but to provide support to their child. It is also a great opportunity for the transport team to demonstrate to the family that their patient is in focused, professional, caring, and capable hands. Discussion of patients should not take place in a public area or via public communication airways where non­patient-related personnel or bystanders could overhear information about a specific patient. Patients cannot be transferred if they are unstable and the ability to further stabilize them is available at the initial site of care. If a patient must be transferred for care while in an unstable condition-a frequent scenario for critically ill patients who need care not available at the referring institution-consent must be obtained from the family, which acknowledges their understanding of the potential risks and benefits of the process. In practice, there are often patients in unstable condition who are transferred from lower to higher levels of care, because the level of care that can be provided at the referring or initial center is not optimal for the child. This reason is appropriate for transfer as compared with transferring patients because of financial or other economic drivers. Before the referring center calls regarding the patient and the center of referral has accepted care, the entire medical responsibility lies with the referring provider. Once the receiving team has accepted the patient and offered advice, medical liability is a shared process. The referring physician maintains the majority of the liability, as well as medical control of the patient, throughout the process until the transport team has left the referring hospital. It is important to recognize that most transport teams and personnel do not have privileges at referring hospitals and are working under the guidance and supervision of the referring physician team. Transport teams that act independently, or referring physicians who are not available when the transport team arrives, put both the referring provider and the transport team at risk if there is disagreement or inappropriate care delivered to the patient. There will be times, however, when there is disagreement regarding the optimal care to be delivered. For example, a child with a hypoplastic left heart syndrome and an open ductus arteriosus may be given a low-dose prostaglandin infusion and be in stable condition. A transport team can insist on intubation before a long air transport, whereas the referral physician might believe that intubation is not required and that it poses a risk to that particular patient. The appropriate way to handle a situation that cannot be easily mitigated is to involve the medical command physician with a telephone call to the referring physician in a discussion at a peer-topeer level. Transport teams have been known to comply with the wishes of the referring providers to not perform advanced procedures at the referring hospital, only to perform those procedures in the ambulance, which is a much less desirable location. Ideally, all disagreements and considerations of different therapies are discussed in a collegial fashion in the appropriate environment to enable the safe care and transport of the child to the receiving center. As noted previously, documentation of all information received and advice offered is imperative. If there is future review or challenge to the care delivered during transport, as with any other care delivered in the hospital, clear and appropriate documentation should stand alone as an excellent defense. The use of recorded lines with frequent review, for educational and quality assurance purposes, can be invaluable. Review with legal advisors can help to define the length of time the recorded materials should be maintained for quality improvement or patient record addendum. The team initiates and provides much of the same level of complex neonatal care as the receiving hospital, but in a changing environment. It is this changing environment that poses unique challenges for both patient and caregiver. These issues would be amplified in the case of a disaster with care and transfer required for premature infants (Gershanik, 2006). Limit of Viability the incidence of premature births has been increasing in the United States. The longterm outcome for many of these small infants is often unknown for months to years after leaving the hospital. In some instances, the long-term results have not been ideal (Donohue et al, 2009; Tyson and Saigal, 2005). Human viability is currently limited by the physiology of pulmonary development and its ability to exchange gases. Unfortunately, for transport teams and the care givers at referring hospitals, it is difficult to determine which infants born at the margins of viability should be resuscitated and provided with aggressive neonatal care and which should be allowed to die (American Academy of Pediatrics Committee on Fetus and Newborn and Bell, 2007; Buchanan, 2009). These decisions are best made collaboratively with the family, transport team members, and the referring and receiving physicians (Ahluwalia et al, 2008; Gunderman and Engle, 2005; Tyson et al, 1996) and may ultimately result in a patient transport, even when the likelihood for survival is minimal. Thermoregulation Problems in neonatal thermoregulation continue to be a major contributor to neonatal morbidity and mortality worldwide and can be especially problematic in neonatal transport (World Health Organization, 1996). During transport, neonates often cross into and out of multiple different environments with wide temperature and humidity variations. Preterm infants, although as sensitive to temperature as term infants, lack sufficient brown fat to sustain a response when exposed to a cold environment (Baumgart, 2008). Silverman et al (1958) demonstrated that using a higher incubator temperature, even without additional humidity resulted in improved premature survival rates. Although elevated temperatures in neonates occur with increased metabolic rates, prolonged seizures, dehydration, or infection, the most common cause of neonatal hyperthermia is high ambient air temperature and humidity (Baumgart, 2008). In a review of a subset of patients referred for a trial of hypothermia for hypoxic ischemic encephalopathy, patients with an elevated body temperature had poorer neurologic outcomes than those with normal body temperatures (Laptook et al, 2008; Yager et al, 2004). The importance of delivering humidified gas to neonates receiving mechanical ventilation is widely acknowledged (Sousulski et al, 1983). There is a linear correlation between incubator temperature and the humidity generated by heated humidity systems (Fassassi et al, 2007). Whereas ventilator complications can be reduced and thermoregulation can be improved by providing exogenous heat and humidity to the gases, active heated humidification systems are used infrequently during neonatal transport. Passive hygroscopic heat and moisture exchangers have been used for short-term conventional mechanical ventilation and with some types of high-frequency ventilation (Fassassi et al, 2007; Schiffmann, 1997; Schiffmann et al, 1999). Surfactant Surfactant replacement has had a significant effect on newborn intensive care. Numerous systematic reviews have demonstrated the benefit of surfactant administration in reducing oxygen needs and ventilation requirements, as well as ventilator complications such as pneumothorax and pulmonary interstitial emphysema (Horbar et al, 1993; Liechty et al, 1991; Schwartz et al, 1994).

The situations that indicate the use of the vacuum and the requirements that must be fulfilled for its correct use are identical to those for the obstetric forceps treatment 4 ringworm generic phenytoin 100 mg buy. The device consists of a metal or plastic cup (flexible or semirigid) that is applied to the fetal vertex symptoms rectal cancer purchase generic phenytoin on line. Care is taken in its application to ensure that an adequate seal has been created pretreatment order phenytoin 100 mg without prescription, and that no maternal soft tissue is trapped between the suction device and the fetus treatment bacterial vaginosis phenytoin 100 mg buy with visa. Traction is then applied to the fetal head in the line of the birth canal in an effort to assist delivery treatment impetigo phenytoin 100 mg purchase visa. It is generally advised that no more than three detachments occur before attempts at vacuum extraction are abandoned (Ali and Norwitz, 2009). In a laboratory experiment, Duchon et al (1988) compared the maximum force at suggested vacuum pressures (550-600 mm Hg) prior to detachments for different types of vacuum devices. They found that the average force of traction exerted before detachments ranged from 18 to 20 kg (Benedetto et al, 2007). This result is interesting to bear in mind when one considers the older data of Wylie who estimated the average tractive force required for delivery of infants weighing 15. Tage Malmström was a discshaped stainless steel cup attached to a metal chain for traction. Because of technical problems and lack of experience with this instrument, vacuum devices did not gain popularity in the United States until the introduction of the disposable cups in the 1980s. The soft cup is a pliable, funnel- or bellshaped cup, which is the most common type used in the United States. The rigid cup is a firm mushroom-shaped cup (M cup) similar to the original metal disc-shaped cup and is available in three sizes. For example, the risk of scalp laceration with the rigid Kiwi OmniCup (Clinical Innovations, Murray, Utah) was reported to be 14. These and other authors concluded that handheld soft bell cups should be considered for more straightforward occiput-anterior deliveries, and that rigid M cups should be reserved for more complicated deliveries, such as those involving larger infants, significant caput succedaneum (scalp edema), occiput-posterior presentation, or asynclitism. The vacuum extractor is widely used in the United States, but is not free of preventing neonatal injury. Other than superficial scalp lacerations or abrasions, which usually heal without incident, as well as local soft tissue swelling or bruising, the use of the vacuum has been associated with cephalhematoma and subgaleal hemorrhages. Cephalhematoma occurs when the force created by the vacuum results in the rupture of diploic or emissary vessels between the periosteum and outer table of the skull; this fills the potential space that exists between the two with blood. Although cephalhematomas are often cosmetically alarming, they are limited to traveling along one cranial bone, because the firm periosteal attachments limit further extravasation of blood across suture lines. Thus large amounts of blood cannot usually collect in this space, and serious neonatal compromise from this bleeding is rare. In a randomized trial of continuous and intermittent vacuum application, Bofill examined factors associated with increasing the risk of cephalhematoma; they found that only asynclitism and traction time were independently related to this complication (Hartley and Hitti, 2005). There was a clear relationship between increasing time of vacuum application (up to 6 minutes) and cephalhematoma. Interestingly, Hartley and Hitti did not find a significant independent association of neonatal injury with continuous versus intermittent vacuum, or with decreasing gestational age or increasing birthweight. These results were further corroborated by Teng who conducted a prospective observational study of 134 vacuum extractions and found that only increasing total duration of vacuum application was associated with neonatal injury (Feingold et al, 1988). Much of the literature about this rare complication of vacuum extraction was published in the 1970s and early 1980s, with few recent studies to detail associated risk factors. Plauche, in his classic paper on vacuum related neonatal injury, identified only 18 cases of subgaleal hematomas among 14,276 cases of vacuumassisted births, in contrast to a mean incidence of cephalhematoma of 6% (Keith et al, 1988). These morbidity Subcutaneous edema estimates are derived from data that are approximately 30 to 40 years old; nevertheless, Teng noted an incidence of cephalhematoma of 8%, and 0. A recent study from Australian investigators evaluated 37 cases of subgaleal hemorrhage at a single tertiary care center accrued over a period of 23 years, with an estimated prevalence of 1. The finding was that this complication occurred most often in primigravidae, and that a large proportion of these infants (89. Yet as outlined previously, there are definite neonatal risks associated with the use of vacuum extraction. Food and Drug Administration has suggested that infants delivered with the vacuum have close monitoring for subgaleal or subaponeurotic hematoma, and that a high index of suspicion be maintained for this rare complication. It must be emphasized that the overall risk of adverse events attributable to the vacuum is extremely low, because the U. Food and Drug Administration estimated five serious complications per year of recent use during a time period when 228,354 vacuum deliveries were performed. However, it is likely that sequelae related to vacuum extraction often go underreported (Menacker and Martin, 2008). The choice of which instrument to use, forceps or vacuum, is usually determined by the obstetric care provider depending on the skill level and experience with either method. The Cochrane Library has pooled the results from 10 randomized trials comparing neonatal morbidity and successful vaginal delivery between these two devices (Roberts et al, 2002). However the overall serious complication rate was low, and there was no difference in long-term morbidity between groups (Johnson and Menon, 2003). The greatest danger in the use of either vacuum or forceps comes in the combination of both instruments together. Towner showed that the use of one instrument after the other had failed and carried a neonatal intracranial injury risk of 1 per 256, significantly greater than that of either modality alone (Learman, 1998). This finding was further supported by the work of Gardella et al, (2001), who matched 11,223 women (a third of whom had combined instruments, vacuum alone, or forceps alone, respectively) to an equivalent number of spontaneous vaginal deliveries. These investigators found no statistically significant difference in intracranial hemorrhage when a single instrument was compared to spontaneous vaginal delivery; however, the combined use of both instruments markedly increased the risk of intracranial hemorrhage, seizures, and low 5-minute Apgar scores (Ron-El et al, 1981). The overall risk of nerve and scalp injury was greater when single-instrument delivery was compared with spontaneous delivery, but the overall incidence of each complication is rare. The vacuum extractor is an acceptable instrument if used judiciously and in the proper circumstances, carrying an overall minimal risk of serious neonatal complications. Its safety is comparable to the obstetric forceps, although it has a higher incidence of cephalhematoma, but a lower potential for facial nerve injury. The chance of failure is greater with the vacuum, which could then potentially tempt the health care provider to subsequently use the forceps. The use of both forceps and vacuum after one instrument has failed carries a higher risk of adverse outcomes, and it should be undertaken only with an understanding of the higher likelihood of neonatal morbidity. The problem posed by this entity is that although it is highly anticipated, it is unpredictable and can appear despite the most cautious measures taken to prevent it. Shoulder dystocia is defined as the delivery of the fetal head with an impaction of the fetal shoulder girdle or trunk against the pubic symphysis, making subsequent delivery either difficult or impossible without performing auxiliary delivery maneuvers. In some cases the posterior shoulder may be lodged behind the sacral promontory-a bilateral shoulder dystocia. Once shoulder dystocia occurs, a series of maneuvers-which have never been tested in a prospective fashion, because of the sporadic and unpredictable nature of this complication-are used to resolve it. The first step is usually the McRoberts maneuver, which consists of hyperflexing the maternal thighs onto the abdomen. This maneuver flattens the pubic symphysis and sacral promontory and facilitates delivery of both the anterior and posterior shoulders. If unsuccessful, this maneuver is usually followed by suprapubic pressure to remove the anterior shoulder from its impacted state behind the pubic symphysis. If these two maneuvers fail, either rotational maneuvers or extraction of the posterior fetal arm are usually tried. It is often necessary to perform an episiotomy to have sufficient room in the vagina to accomplish this maneuver. An alternative maneuver to fetal manipulation is the all-fours position, or Gaskin maneuver. With this maneuver, the mother is moved from the lithotomy position to a hands and knees position. If the dystocia continues unresolved, the Zavanelli maneuver or cephalic replacement can be performed. After the fetal head is rotated from occiput transverse to occiput anterior, it is flexed and pushed back in the birth canal, and the child was delivered by emergent cesarean section. McRoberts maneuver, suprapubic pressure, or both will relieve greater than 50% of instances. Recent data have focused on enhanced practitioner training for shoulder dystocia by means of simulation. It is estimated that almost 50% of currently practicing obstetric birth attendants have never successfully performed maneuvers other than the McRoberts maneuver and suprapubic pressure. The prevalence of shoulder dystocia varies depending on the population studied and the presence of various risk factors known to predispose women to this obstetric emergency. Maternal obesity, fetal macrosomia, history of prior shoulder dystocia, and maternal diabetes mellitus are the most common associated variables, but are not of sufficient prognostic power to be clinically useful in predicting should dystocia (Ali and Norwitz, 2009; Benedetto et al, 2007; Herbst and Källén, 2008). Because shoulder dystocia has the potential to cause significant neonatal morbidity and mortality, efforts have been made to predict its occurrence; unfortunately, no clinical guidelines have been clinically tested or proved. Ultrasound examination is commonly used in patients with suspected fetal macrosomia or diabetes to detect large birthweight in infants who might be more likely to suffer shoulder dystocia. Third-trimester sonographic examination has an accuracy of 10% to 15% in the prediction of fetal weight, and is thus not highly reliable (Feingold et al, 1988; Hillier and Johanson, 1994; Keith et al, 1988). In addition, if ultrasound examination were completely reliable, the fetal weight cut-off that would prompt an elective cesarean section has not been determined. Lipscomb evaluated the deliveries of 227 mother-infant pairs at their institution with birthweights greater than 4500 g and found a shoulder dystocia rate of 18. Therefore the occurrence of brachial plexus injury at birth does not necessarily guarantee permanent neurologic morbidity. Gherman et al (2006) reviewed 285 cases of shoulder dystocia and found that 77 (24. The requirement of additional fetal manipulative procedures increased the risk of humeral fracture only and not clavicular or brachial plexus injury. A prospective investigation evaluated the natural history of recovery following a birth-related brachial plexus injury of infants referred to a tertiary care, multidisciplinary neurological center. Enrollment required identification of injury in the newborn period, initial evaluation at the center between 1 and 2 months of age, and lack of antigravity movement in the shoulder or elbow persisting until 2 weeks of age. In this group of children subject to ascertainment bias (as those injuries resolving before 2 weeks of age would not have been included in the results), complete neurologic recovery was documented in 66%, and only 14% had persistent, severe weakness (Learman, 1998). In the best systematic review of brachial plexus injury to date, the risk of permanent brachial plexus impairment, if recognizable at birth, was 15% to 20% (Pondaag et al, 2004). Rouse et al (1996) elaborated further on these concepts in their decision analysis, which showed that if one chose to perform an elective cesarean section for all women without diabetes and with sonographically predicted macrosomia (estimated fetal weight >4000 g), 2345 cesarean sections would need to be performed to prevent one permanent brachial plexus injury. If the 4500-g cutoff were selected, 50% more cesarean deliveries would be needed to prevent one permanent brachial plexus injury. In the mother with diabetes, if one chose a cut-off of 4500 g or greater, 443 cesareans would need to be done to prevent one permanent injury (Keith et al, 1988)-a tradeoff that most practitioners now believe is acceptable. Therefore at present there is no universally accepted method to prevent shoulder dystocia. Studies have shown that operative vaginal delivery, especially vacuum delivery, of a fetus suspected to have macrosomia either clinically or sonographically could increase the risk of shoulder dystocia (Ron-El et al, 1981). It seems wise to avoid difficult forceps or vacuum delivery if a patient is thought to have an infant weighing more than 4000 g, especially if she has diabetes or a past history of shoulder dystocia. The documentation of the events surrounding shoulder dystocia are important, as is the discussion of current status and future status of an infant delivered with a birth injury after shoulder dystocia. Both obstetric and pediatric providers should debrief the shoulder dystocia event immediately after the delivery. In the case of fetal injury, it is optimal for both obstetric and pediatric providers to discuss the delivery events and subsequent newborn treatment plans with the mother before discharge. The footling breech has one (single footling) or both (double footling) lower extremities presenting. The frank breech with buttocks presenting has a lower risk of these adverse events occurring, and thus could potentially deliver vaginally. The complete breech presentation will convert to frank or footling during labor, and the appropriate management scheme for delivery depends on which leading fetal part will descend. In the absence of urgent fetal indications, the singleton breech is allowed to deliver passively with maternal expulsive efforts until the infant has been delivered past the umbilicus. At this point the legs are gently reduced, and the trunk and body are gently rotated to bring the sacrum anteriorly. With the appearance of the scapula below the maternal symphysis, the arms are then delivered by gently sweeping them across the chest. Every effort is then made to keep the neck from extending during the delivery of the aftercoming head; this is accomplished during delivery of the body by an assistant exerting suprapubic pressure on the fetal head to keep it flexed. Once the body has delivered, the delivery of the head is accomplished by either the Mariceau-Smellie-Veit maneuver, in which one hand extends along the posterior neck and occiput and applies pressure to prevent hyperextension, while the other hand gently applies downward traction against the maxilla to flex the head forward as the head is delivered, or with Piper forceps directly applied to the fetal vertex. The feasibility of vaginal breech delivery and its safety have been the subject of much debate throughout the past half century. With the advent of safe, expedient cesarean delivery in the United States, many obstetricians have favored the operative approach as the method of choice for management of the breech presentation at term. The literature to support this point of view has produced conflicting conclusions, and its interpretation is consequently difficult. There has been an extensive body of literature over the past half century examining this issue. Unfortunately, there are only two randomized trials that have explored the question of which delivery route is best for the term singleton frank breech fetus (Ali and Norwitz, 2009; Benedetto et al, 2007), but there are several large retrospective series describing neonatal outcomes with the vaginal approach, most of which suggest that vaginal delivery in carefully selected patients carries a low risk of long-term neonatal morbidity and mortality. Diro et al (1999) evaluated 1021 term singleton breech deliveries occurring at their institution over a 4-year period.

These facts became publicly known and led to a national controversy that eventually reached the Oval Office treatment 197 107 blood pressure cheap 100 mg phenytoin. It was difficult to decide which action should be taken medications derived from plants order 100 mg phenytoin otc, because the federal government has no jurisdiction over child abuse and neglect; it is the domain of the states medicine to prevent cold 100 mg phenytoin order with visa. The federal government oversees civil rights enforcement pure keratin treatment purchase phenytoin online pills, however medications with acetaminophen order genuine phenytoin online, and the Reagan administration devised a legal strategy that defined not treating babies with Down syndrome or other congenital anomalies as discrimination against people with disabilities, rather than medical neglect. These signs proclaimed that withholding treatment on the basis of disability was a federal civil rights violation (Annas, 1984) and that federal investigative squads could review medical records to determine whether discrimination had taken place. A diluted version of the original Baby Doe guidelines was eventually incorporated into the federal Child Abuse and Treatment Act (Annas, 1986; Kopelman, 1988). That law, however, is primarily a funding mechanism to channel federal funds to state child protection agencies; it is not a regulation that can be enforced for physicians or hospitals. The Baby Doe regulations do not exist today and have not existed since 1984; however, they still hold symbolic power. The mention of Baby Doe strikes fear in the hearts of pediatricians who lived through the events, in part because pediatricians had made pediatricians into villains in the societal battle over child protection. The original goal-to decrease the range of cases in which withholding treatment of newborns is permissible-did not need federal input. Many diseases that used to be considered incompatible with life or that were seen as leading to an unacceptable quality of life were being treated routinely. With few exceptions (hypoplastic left ventricle being one of the best recognized), these advances have been relatively uncontroversial. Once sufficient data are gathered to demonstrate moderate efficacy, the innovations are widely and rapidly adopted. There is still controversy when treatments enable survival but have a high likelihood, or certainty, that survival will be accompanied by severe neurologic impairment. Second, what is the likelihood that the child will have the most severe possible impairment The prognostic spectrum of Down syndrome is broad, but few infants with trisomy 21 are severely impaired. In contrast, almost all infants with trisomy 13 or 18 either die in infancy or are left with profound neurologic impairment. The outcomes for these chromosomal anomalies can be used to define the spectrum within which clinical decisions are made. For babies whose outcomes are likely to be similar to those seen in trisomy 21, it is no longer permissible to withhold life-sustaining treatment. For babies whose outcomes are likely to be similar to babies with trisomy 13, it is permissible to withhold or withdraw life-sustaining treatment and offer palliative care instead. The calculus becomes more complex in conditions associated with a wider range of outcomes, such as extreme prematurity or high myelomenigocele with hydrocephalus. The capacity to repair Arnold­Chiari malformation and duodenal atresia existed long before it was applied to children with myelomeningocele and Down syndrome. What has changed the mood of the country is a growing recognition that disability is as much a social construct as a medical construct, although it is always both and not one or the other. After all, patients can have do-not-resuscitate orders or receive palliative care rather than intensive care. They write, "If this legislation were enforced, respondents predicted more aggressive resuscitation potentially increasing risks of disability or delayed death. The hope is that such centers will allow more timely, and therefore more effective, intervention for babies with congenital heart disease, congenital diaphragmatic hernia, or other anomalies. The medical effectiveness of fetal centers will depend on two distinct developments. First, on a population basis, these centers will only be as effective as fetal screening and diagnosis. The existence of these centers will almost certainly create an expectation and a demand for better fetal screening. Such screening is likely to include both better imaging and better screening tests that can be performed on maternal blood; both will lead to earlier diagnosis of fetal anomalies. These diagnoses will create more complex dilemmas for perinatologists and parents who will need to decide, in any particular case, whether to terminate the pregnancy, offer fetal therapy, or offer either palliative care or interventions after birth. Ironically, better fetal diagnosis may increase the likelihood of pregnancy termination, even when postnatal treatment is possible, such as in hypoplastic left heart syndrome. Second, the effectiveness of fetal centers will depend on the effectiveness of fetal interventions. Perhaps surprisingly, other than in utero transfusion for Rhesus disease or vascular ablation for twin-twin transfusion syndromes- neither of which are particularly new and neither of which is performed by pediatric surgeons or pediatricians-there is little evidence that any fetal intervention has had any effect on any neonatal outcome. This lack of demonstrated effectiveness has, thus far, not suppressed the proliferation of fetal intervention centers. There may be other factors, including institutional prestige, finances, and recruitment of "desirable" patients. Such screening is under the purview of states, rather than the federal government, and there is wide variation in the number of tests that are performed. In 1995 the average number of tests per state was five (range: zero to eight disorders). Between 1995 and 2005 most states added tests, so that the average number of screening tests done by 2005 was 24 (Tarini et al, 2006). For rare conditions, the percentage of positive tests that are false positives is increased. Thus, the more rare conditions that are added to a newborn screening panel, the more false positives there will be. False positives are associated with considerable parental anxiety and can lead to potentially dangerous and unnecessary diagnostic procedures or treatments. Interestingly, the tests themselves are astoundingly inexpensive, which is why policy makers are tempted to add more to the panels. However, the follow-up counseling and testing after positive tests are expensive, and without such followup the screening programs will not work. Consequently, for infants who receive resuscitation in the delivery room, birthweight-specific mortality and morbidity are unlikely to change much in the near future. Nonetheless, three developments may change the way we think about newborns, and consequently shift the terrain of neonatal bioethics. Finally, there is the potential for discrimination against patients for whom documented heterozygous carrier status conveys no recognized medical infirmity, but social or psychological stigma may be real. The recommendations purport to reflect the traditional paradigm that data drive policy. Certainly not because the Dutch, Canadians, or Oregonians have forgotten how to resuscitate small infants. Perhaps it is non-maleficence­the fear that survival with permanent neurologic morbidity may be cruel to the child, the family, or society at large. If the fear of a permanent crippling neurologic injury is the driving force, we should not be resuscitating 26 or 27 weekers, since many more of them will survive, and survive with disability. The approach in the Netherlands is consistent; there is a limited budget and a communitarian ethic. There is a certain rationale behind spending money on all pregnant women, instead of 1% of micro-premies. The United States appears ambivalent­we value individuals over community, are fascinated with high-technology, and claim to prize our children. On the other hand, we will not spend money to prevent unwanted teen pregnancy or to provide visiting nurses for new mothers. We appear quite comfortable calling delivery-room resuscitation of 24 weekers "optional," based on gestational age alone. Only 24,000 infants of 4 million births die each year in the United States, and half of these will die within fewer than 7 days. Born-Alive Infants Protection Act of 2001: Report together with additional and dissenting views of the House Committee on the Judiciary, 107th Congress, 1st Session, August 2, 2001. Johnson S, Fawke J, Hennessy E, et al: Neurodevelopmental disability through 11 years of age in children born before 26 weeks of gestation, Pediatrics 124:E249-E257. Lantos J: Baby Doe five years later: implications for child health, N Engl J Med 317:444-447, 1987. Meadow W, Lagatta J, Andrews B, et al: Just in time: ethical implications of serial predictions of death and morbidity for ventilated premature infants, Pediatrics 121:732-740, 2008. Intensive care for extreme prematurity: moving beyond gestational age, N Engl J Med 358:1672-1681, 2008. Regions and countries that have the highest maternal mortality rates also have the highest child mortality rates (Table 4-1). At the current rate, the target of fewer than 5 million annual child deaths will not be met until 2045. The regions with the highest numbers of child deaths are Sub-Saharan Africa (which has high fertility rates and the highest child mortality rates [144 deaths per 1000 live births], and 4. Sub-Saharan Africa accounts for 51% of all deaths among children younger than 5 years, followed by Asia with 42% (You et al, 2009). In 2008, 75% of deaths in children younger than 5 years occurred in only 18 countries, and 40% occurred in only three countries: India, Nigeria, and the Democratic Republic of the Congo. Of the 34 countries with mortality rates exceeding 100 per 1000 live births in 2008, all were in Sub-Saharan Africa, except for Afghanistan (You et al, 2009). More than 70% of deaths in children younger than 5 years are caused by newborn problems, pneumonia, and diarrhea. Pneumonia results in death for more than 2 million children younger than 5 years each year, or approximately 20% of child deaths worldwide. More than 95% of all new pneumonia cases, representing an estimated 150 million episodes of pneumonia annually, occur in children younger than 5 years in developing countries. Sub-Saharan Africa and South Asia together have more than half the total number of pneumonia cases. Sazawal and Black (1992) suggested that community-based acute respiratory infection case management might reduce mortality by more than 20% in children younger than 4 years. Failing prevention, prompt diagnosis and treatment are necessary to improve pneumonia mortality and morbidity; however, prompt diagnosis and effective treatment of pneumonia and hypoxemia are often not available. Radiology, laboratory tests, and pulse oximetry, which can predict response to antibiotic therapy in cases of severe pneumonia (Fu et al, 2006), are not available in most first-level. Randomized controlled trials of parenteral antibiotic treatment in hospitals compared with home-based treatment have demonstrated the safety and efficacy of treating pneumonia with oral antibiotics outside of a hospital setting in older children. New evidence regarding home treatment of severe pneumonia is changing concepts about the need for hospitalization. The first randomized trial to compare outcomes of hospital treatment of severe pneumonia, without underlying complications, with home-based oral antibiotics in Pakistan demonstrated that home-based antibiotics are safe and effective. Of 2037 children with severe pneumonia aged 3 to 59 months, randomized to either parenteral ampicillin for 48 hours followed by 3 days of oral ampicillin or home-based oral amoxicillin for 5 days, there were equal numbers of failures in the hospitalized group (8. A small percentage (approximately 2% to 3%) of severely ill children will still require early community detection and transport to a hospital for evaluation of hypoxia, infection, pneumonia, malaria, and parenteral antibiotics with or without oxygen (Mwaniki et al, 2009). Worldwide, diarrhea accounts for 18% of deaths among children younger than 5 years, or an estimated 1. Children in poverty are especially prone to diarrheal diseases after the introduction of complementary feeding, because diarrhea is spread by poor hygiene and sanitation facilities; contaminated water, formula, food, or utensils; low rates of vitamin A supplementation; low zinc intake; and limited access to rotavirus immunization. Research has demonstrated that homemade fluids that contain lower concentrations of sodium and glucose, sucrose, or other carbohydrates. Undernutrition is another major factor in mortality of children younger than 5 years; it is responsible for 7% of the total disease burden in any age group, making it the highest of any risk factor for overall global burden of disease (Black et al, 2008b). Maternal or child undernutrition is a complex intergenerational problem that includes intrauterine growth restriction, severe wasting, and stunting. Wasting (weight-for-height Z score less than ­2) is associated with acute weight loss. An estimated 178 million children younger than 5 years have stunting-almost one third of children in low- to middle-resource settings. Ninety percent of them (160 million) live in just 36 countries and represent almost half of the children in those countries. This urgent problem must be solved, because the period between birth and 24 months old is critical. If children do not grow appropriately before 2 years old, they are more likely to be short as adults, have lower educational achievement and economic productivity, and give birth to smaller infants who repeat the cycle in the next generation. Although the problem of undernutrition has been overshadowed by concerns over obesity, there is no evidence that rapid weight or linear growth in the first 2 years of life increases the risk of chronic disease in adults (fetal origin of adult disease), even in children with poor fetal growth (Victora et al, 2008). A recent review of interventions that affect maternal and child undernutrition suggested that counseling about breastfeeding and supplementation with vitamin A and increased zinc intake have the greatest potential to reduce the burden of child morbidity and mortality (Bhutta et al, 2008a). The promotion of breastfeeding has had an effect on the improved survival of infants and young children, but its effect on stunting has been negligible. Among populations with inadequate food, food supplements are beneficial with or without educational interventions (increased height-for-age Z scores by 0. In populations with sufficient food, complementary feeding education increased height-forage Z scores by 0. Recommended micronutrient interventions for children include strategies for vitamin A supplementation, zinc supplements to prevent and treat diarrhea and lower respiratory tract infections, iron supplements in areas where malaria is not endemic, and universal promotion of iodized salt (Bhutta et al, 2008a). A subsequent metaanalysis of neonatal vitamin A supplementation concluded, on the basis of six trials in the developing world, that there was no evidence for a reduced risk of mortality and morbidity during infancy and thus no justification for neonatal vitamin A supplementation as a public health measure to reduce infant mortality and morbidity in developing countries (Gogia and Sachdev, 2009). The efficacy of zinc supplementation in reducing overall mortality in neonates has been questioned as well (Sazawal et al, 2007). Existing interventions designed to improve nutrition and prevent related disease may reduce stunting at 36 months old by as much as 36% and mortality between birth and 36 months old by approximately 25%. Growth (length, height, and weight) should be monitored routinely and regularly in view of its importance as a marker for undernutrition and stunting (Victora et al, 2009). The nutrition of the children of India and Sub-Saharan Africa are of greatest concern. In Africa, neonates are born with normal birthweight, but develop stunting and wasting because of poverty and civil unrest. Although exclusive breastfeeding protects the neonate, providing adequate amounts of nourishing food in early infancy is critical to the future of children from these two continents. In contrast, little progress has been made in reducing maternal and neonatal deaths in the developing world, where the disparity is large and growing (Lawn et al, 2005) and the average neonatal mortality rate (deaths in the first 28 days of life per 1000 live births) in 2000 was 33, with a range of 2 to 70.

It might not be an option for some women; therefore primary prevention should be the focus for reducing the risk of multiple fetuses treatment 2 purchase phenytoin 100 mg without prescription. Multiple gestations are associated with increased maternal medicine 8 letters 100 mg phenytoin purchase with visa, fetal medications with weight loss side effects generic phenytoin 100 mg buy online, and neonatal complications that generate a medical medicine to increase appetite buy phenytoin 100 mg on line, psychological treatment strep throat generic 100 mg phenytoin amex, and economic burden to families and society. Primary prevention of multiple fetuses by limiting the number of embryos transferred or canceling an overstimulated ovulation induction cycle is optimal; however, in reality multifetal pregnancies continue to occur. First developed in the 1980s, selective termination of one or more fetuses is performed to reduce the final fetal number. The majority of patients reduce to twins, followed by singletons; few reduce to triplets (Stone et al, 2008). Success rates correlate with both beginning and ending fetal number (Evans et al, 2001). Loss rates are higher after reducing to a singleton versus reducing to twins, but twins overall have higher morbidity than do singletons (Evans and Britt, 2005, 2008; Evans et al, 2001; Stone et al, 2008). Reduction of twins to singletons may be considered given a lower loss rate after reduction versus continuing with twins (Evans et al, 2004). Practice Committee of the American Society for Reproductive Medicine: Multiple pregnancy associated with infertility therapy, Fertil Steril 86(Suppl 1): S106-S110, 2006. Thurin A, Hausken J, Hillensjo T, et al: Elective single-embryo transfer versus double-embryo transfer in vitro fertilization, N Engl J Med 351:2392-2402, 2004. Mollen ll ll ll An infant with hydrops has an abnormal accumulation of excess fluid. The condition varies from mild, generalized edema to massive edema, with effusions in multiple body cavities and with peripheral edema so severe that the extremities are fixed in extension. Fetuses with severe hydrops may die in utero; if delivered alive, they may die in the neonatal period from the severity of their underlying disease or from severe cardiorespiratory failure. The first description of hydrops in a newborn, in a twin gestation, may have appeared in 1609 (Liley, 2009). Ballantyne (1892) suggested that the finding of hydrops was an outcome for many different causes, in contrast to the belief at that time that hydrops was a single entity. Potter (1943) first distinguished between hydrops secondary to erythroblastosis fetalis and nonimmune hydrops, by describing a group of infants with generalized body edema who did not have hepatosplenomegaly or abnormal erythropoiesis. With the nearly universal use of anti-D globulin and refinement of the schedule and doses for its administration, the occurrence of immune-mediated hydrops has steadily declined, such that later studies found that immune-mediated causes accounted for only 6% to 10% of all cases of hydrops (Heinonen et al, 2000; Machin, 1989). The reported incidence of nonimmune hydrops in the general population has been highly variable, ranging from 6 per 1000 pregnancies in a high-risk referral clinic in the United Kingdom between 1993 and 1999 (Sohan et al, 2001) to 1 in 4000 pregnancies (Norton, 1994); other published rates are 6 per 1000 pregnancies (Santolaya et al, 1992), 1. However, all the published studies come from single institutions, with the at-risk populations ranging from that of a highrisk pregnancy clinic to infants in a neonatal intensive care unit. No study has monitored all pregnant women in one geographic area to calculate the true population incidence of nonimmune hydrops, especially monitoring infants who died in utero. Geography also affects the incidence; several causes of nonimmune hydrops, such as -thalassemia, are more common in certain areas of the world. Finally, the incidence of nonimmune hydrops may be rising because of the more routine use of ultrasound investigation in the late first trimester of pregnancy (Iskaros et al, 1997). Anemia, resulting in high-output cardiac failure Decreased lymphatic flow Capillary leak the actual pathophysiology of hydrops for many of the conditions in Table 8-1, however, is still not understood. The most common causes of nonimmune hydrops are chromosomal, cardiovascular, hematologic, thoracic, infectious, and related to twinning (Abrams et al, 2007; Bellini et al, 2009; Wilkins, 1999). As with reported incidence rates, the relative contribution of these causes varies by study. Studies from Asia have noted a higher percentage of cases from hematologic causes, probably because of the higher rates of -thalassemia in the population (Lin et al, 1991; Nakayama et al, 1999). The percentage of infants with "idiopathic" hydrops, or hydrops of unknown etiology, varies from 5. Yaegashi et al (1998) used enzyme-linked immunosorbent assay and polymerase chain reaction techniques to improve the detection of parvovirus infection. In both their own institution, and in eight other series of patients, these investigators found evidence of parvovirus infection in 15% to 19% of all infants previously diagnosed with idiopathic hydrops. It is likely that, as there is increased understanding of and testing for many of the conditions listed in Table 8-1, the number of infants diagnosed with idiopathic, nonimmune hydrops will continue to decline. To understand the pathogenesis of hydrops, the clinician must consider the forces underlying normal fluid homeostasis. The regulation of net fluid movement across a capillary membrane depends on the Starling forces, which were first described by E. Although an abnormality of any of the components of this equation may, in theory, result in the accumulation of edema fluid, the fetal-placental unit presents a unique physiologic condition that effectively eliminates two of the factors, assuming unimpeded fetal-placental flow and an appropriately functioning maternal-placental interface. Arrows represent net effect of movement of fluid across the capillary membrane for each factor under normal conditions. Pc, Capillary hydrostatic pressure; Pt, interstitial hydrostatic pressure or tissue turgor pressure; Op, plasma oncotic pressure as determined by plasma proteins and other solutes; Ot, interstitial osmotic pressure. Any condition resulting in elevated fetal capillary hydrostatic pressure or low plasma colloid oncotic pressure would likely cause the net flow of water from fetal villi in the placenta to the maternal blood stream, where it can be effectively eliminated. This elimination of fluid would counteract the accumulation of interstitial fluid by the fetus. Although the placenta of a fetus with hydrops is also edematous, these changes are believed to occur with, and not before, fetal fluid accumulation. Others have reviewed these potential mechanisms (Phibbs et al, 1974), which remain among the central hypotheses addressed by investigators in this area. Infants with alloimmune hydrops (and several of the nonimmune hydrops conditions as well) have significant anemia. It has been proposed that anemia leads to congestive heart failure with increased hydrostatic pressure in the capillaries, causing vascular damage that results in edema. However, the hematocrit values of infants with and without hydrops overlap significantly, suggesting that anemia alone is not the complete explanation. A rapidly lowered hemoglobin concentration results in greater cardiac output to maintain adequate oxygen delivery. This output results in higher oxygen demands by the myocardium, which may be difficult to meet because of the anemia. The hypoxic myocardium can become less contractile and less compliant, with ventricular stiffness causing increased afterload to the atria. In addition, reduced compliance of a right ventricle may result in flow reversal in the inferior vena cava, which may in turn cause end-organ damage to the liver, with consequent hypoalbuminemia and portal hypertension enhancing formation of both edema and ascites. Hydrops has been produced in fetal lambs (Blair et al, 1994) in which the hemoglobin content was lowered in 12 fetuses through exchange transfusion using cell-free plasma; six became hydropic. In the most severely anemic fetuses, it is probable that decreased oxygen transport causes tissue hypoxia, which in turn increases capillary permeability to both water and protein. These changes in capillary permeability also likely contribute to the development of hydrops. Infants who have erythroblastosis and hydrops seem to demonstrate a correlation between serum albumin concentration and the severity of hydrops (Phibbs et al, 1974). Initial therapy after birth, however, tends to rapidly raise the serum albumin value toward normal, and with diuresis the albumin concentrations normalize. This finding suggests that hypoalbuminemia may be the result of dilution rather than the cause of hydrops. To elucidate the role of isolated hypoproteinemia in the genesis of hydrops, Moise et al (1991) have induced hypoproteinemia in sets of twin fetal lambs. One twin from each set underwent serum protein reduction through repeated removal of plasma and replacement with normal saline; the other twin served as the control. Over 3 days, plasma protein concentrations were reduced by an average of 41%, with a 44% reduction in colloid osmotic pressure, in experimental subjects. No fetuses became edematous, and total body water content values were similar in experimental and control animals. Thus hypoproteinemia alone was insufficient to cause hydrops fetalis over the course of the study. Transcapillary filtration probably increased with hypoproteinemia, but was compensated by lymphatic return. Human fetuses with hypoproteinemia as a result of nephrotic syndrome or analbuminemia rarely experience hydrops, further supporting the hypothesis that hypoproteinemia alone is not sufficient to cause hydrops. Hypoproteinemia may, however, lower the threshold for edema formation in the presence of impaired lymphatic return or increased intravascular hydrostatic pressures. Both of these mechanisms may then contribute to interstitial accumulation of fluid. Watson and Campbell (1986) found that two thirds of prenatally diagnosed cases were discovered on routine ultrasonographic examinations, and one third was referred for evaluation because of suspected polyhydramnios. Graves and Baskett (1984) reported that hydrops was more commonly discovered after referral for polyhydramnios, fetus large for dates, fetal tachycardia, or pregnancy-induced hypertension. Despite the underlying cause of hydrops or the clinical presentation, the prenatal diagnosis is made via the ultrasonographic finding of excess fluid in the form of ascites, pleural or pericardial effusions, skin edema, placental edema, or polyhydramnios. Several definitions for ultrasonographic diagnosis based on quantity and distribution of excess fluid have been proposed. One widely accepted set of criteria consists of the presence of excess fluid in any two of the previously listed compartments. Because this definition is based on the presence of excess fluid alone, the degree of severity is generally subjective. Swain et al (1999) outlined a multidisciplinary approach to the evaluation and management of the mother and fetus with hydrops. Patient history should focus on ethnic background, familial history of consanguinity, genetic or congenital anomalies, and complications of pregnancy, including recent maternal illness and environmental exposures. Maternal disorders such as diabetes, systemic lupus erythematosus, myotonic dystrophy, and any type of liver disease should also be noted. Rapid evaluation is necessary to determine whether fetal intervention is possible and to estimate the prognosis for the fetus. Many conditions, such as arrhythmias, twin-twin transfusion, large vascular masses, and congenital diaphragmatic hernias and other chest-occupying lesions, are discovered during the initial ultrasonographic evaluation (Coleman et al, 2002). If the initial ultrasonic examination is not helpful in identifying a cause, it may be helpful to repeat it at a later date to reassess fetal anatomy, monitor progression of the hydrops, and evaluate well-being of the fetus. Fetal echocardiography should also be performed to evaluate for cardiac malformations and arrhythmia. In diagnoses in which therapy is futile, the goal is to avoid unnecessary invasive testing and cesarean section. The prognosis should be discussed frankly with the parents, who should be given the option of terminating the pregnancy. Digoxin is most commonly administered, although other antiarrhythmics have been used, such as sotolol or flecainide, because transplacental transfer of digoxin may be impaired in the setting of hydrops. In extreme circumstances, such as fetal tachyarrhythmia refractory to maternal treatment, direct fetal administration of antiarrhythmic agents via percutaneous umbilical blood sampling or intramuscular injection, although untested and highly risky, has met with some success. If anemia is the cause of hydrops, transfusions of packed red blood cells may be administered to the fetus. Often a single transfusion reverses the edema, although serial transfusions may be necessary. Parvovirus B19 (Anand et al, 1987) and fetal-maternal hemorrhage are examples of diagnoses that are amenable to this therapy. Other diagnoses involving anemias that are refractory to transfusions, such as -thalassemia, may require neonatal stem cell transplantation. Transfusions should be given, with the use of ultrasonographic guidance, into the intraperitoneal space or umbilical vein. If uptake of intraperitoneal blood is incomplete, treatment for the hydrops is less successful; degeneration of the remaining hemoglobin may create a substantial bilirubin load, necessitating phototherapy or exchange transfusion after the infant is delivered. Surgery continues to evolve as a promising therapy for select cases of fetal hydrops (Azizkhan and Crombleholme, 2008; Kitano et al, 1999). These results highlight the fact that fetuses with lung lesions leading to hydrops have high mortality rates. Maternal morbidities related to fetal intervention ranged from uterine wound infection with dehiscence to mild postoperative interstitial pulmonary edema, which was treated with diuretics. High morbidity and mortality rates in severe twintwin transfusion with associated hydrops led to multiple international trials of laser photocoagulation of interfetal vascular connections. Although the trials met with varying results, metanalysis involving the three major trials demonstrates improvement in perinatal and neonatal outcomes. However, the current level of evidence is limited in the reported effect on neurodevelopmental outcomes in survivors. A 2008 Cochrane review recommends considering treatment with laser coagulation at all stages of twin-twin transfusion (Roberts et al, 2008). Fetal intervention has met with some success in other diagnoses with associated hydrops. Thoracoamniotic shunts for large unicystic lesions and pleuroamniotic shunts for hydrothorax have reportedly enhanced survival in extreme cases. Similarly, in cases of massive urinary ascites, urinary diversion via peritoneal shunts has been reported, but with a poor long-term prognosis (Crombleholme et al, 1990). However, as with other invasive interventions, there are potential risks with fetal surgery. A review of the reproductive outcomes of future pregnancies after a pregnancy complicated by maternal-fetal surgery found a complication rate of 35%: 12% affected by uterine dehiscience, 6% with uterine rupture, 3% requiring hysterectomy; and 9% with hemorrhage requiring transfusion (Wilson et al, 2004). These longer-term complications suggest that the potential benefit of fetal surgical intervention must be balanced by the potential complications of the procedure experienced by the mother. In cases in which the cause can be corrected by appropriate care at the time of delivery, such as elimination of a chorioangioma, and in cases in which no cause can be ascertained, close observation for fetal demise is the focus of prenatal management. It is difficult to decide whether to attempt tocolysis and delay delivery so as to allow the potentially beneficial administration of steroids before birth or to deliver the fetus immediately. If tocolysis is possible, expectant management should include usual biophysical testing, although fetal decompensation may be difficult to measure.

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