Acute renal failure was not predictive of late renal dysfunction or decreased long- term survival [104] proven 100mg avanafil. Cardiac arrhythmias cheap avanafil generic, especially atrial arrhythmias such as atrial fibrillation buy avanafil 100mg amex, commonly develop in the perioperative period with an incidence of 25% in one study with resulting increase in length of hospital stay and increased 1-year mortality buy 200 mg avanafil otc. Risk factors for their development included older age, diagnosis of pulmonary fibrosis, right ventricular dysfunction, right ventricle enlargement and elevated right atrial pressure, left atrial enlargement diastolic dysfunction, and history of coronary artery disease [105]. In one series of lung transplant recipients, the incidence of deep venous thrombosis and pulmonary embolism was reported to be 8. This complication was believed to be related to alterations in coagulability leading to a hypercoagulable state or hypercoagulability due to their underlying disease [107,108]. However, despite these improvements, numerous complications, many of which are managed by critical care professionals, can arise in this group of patients, and the unique aspects of their care are important. Chiumello D, Coppola S, Froio S, et al: Extracorporeal life support as bridge to lung transplantation: a systematic review. Javidfar J, Brodie D, Iribarne A, et al: Extracorporeal membrane oxygenation as a bridge to lung transplantation and recovery. Horai T, Shigemura N, Gries C, et al: Lung transplantation for patients with high lung allocation score: single-center experience. Sommer W, Kuhn C, Tudorache I, et al: Extended criteria donor lungs and clinical outcome: results of an alternative allocation algorithm. Minambres E, Coll E, Duerto J, et al: Effect of an intensive lung donor- management protocol on lung transplantation outcomes. Boffini M, Ricci D, Bonato R, et al: Incidence and severity of primary graft dysfunction after lung transplantation using rejected grafts reconditioned with ex vivo lung perfusion. Perrin G, Roch A, Michelet P, et al: Inhaled nitric oxide does not prevent pulmonary edema after lung transplantation measured by lung water content: a randomized clinical study. Ardehali A, Laks H, Levine M, et al: A prospective trial of inhaled nitric oxide in clinical lung transplantation. Struber M, Fischer S, Niedermeyer J, et al: Effects of exogenous surfactant instillation in clinical lung transplantation: a prospective, randomized trial. Cohen J, Singer P, Raviv Y, et al: Outcome of lung transplant recipients requiring readmission to the intensive care unit. Riera J, Baldirà J, Ramirez S, et al: Gastroparesis following lung transplantation: risk factor for pneumonia. Ferdinande P, Bruyninckx F, Van Raemdonck D, et al; Leuven Lung Transplant Group: Phrenic nerve dysfunction after heart–lung and lung transplantation. Jacques F, El-Hamamsy I, Fortier A, et al: Acute renal failure following lung transplantation: risk factors, mortality, and long-term consequences. Raghavan D, Gao A, Ahn C, et al: Contemporary analysis of incidence of post-operative atrial fibrillation, its predictors, and association with clinical outcomes in lung transplantation. Fourteen years passed before the first successful heart–lung transplant was performed on March 9, 1981. Heart–lung transplantation established the potential for lung transplantation as a viable therapeutic option, and the first successful single-lung transplant was performed in 1983 [1]. The waiting list for heart transplant has steadily grown because more patients are added than removed every year. Subsequently, the number of heart transplants has been increasing since 2004, with roughly 2,500 performed annually in the United States. It could also be an individual who has a mechanical assist device in place and either right or left ventricular support that is beginning to malfunction. It also includes individuals who are on continuous mechanical ventilation or on high-dose inotropic support that cannot be weaned. Status 2 candidates are individuals who need heart transplantation but have not been defined as being in the most urgent status. These patients typically are at home, still active, and taking heart- failure medications while awaiting transplantation. The number of transplantations increased for patients with cardiomyopathy and congenital heart disease, 34% and 28%, respectively. Cardiac retransplantation represents approximately 4% of the adult heart transplant population annually. Most patients who received a transplant had private insurance; however, the proportion of insured versus those on Medicare decreased between 2002 and 2012 [2]. Patient Selection Many of the specific critical care problems seen in thoracic organ recipients can be reduced by careful patient selection. The other 10% to 20% are individuals who are critically ill and undergo an urgent transplant evaluation. The recipient assessment consists of a general evaluation, an assessment of the functional and hemodynamic status, and a psychosocial evaluation. For those patients who are capable of performing this test, there are excellent data which demonstrate that a peak oxygen consumption of less than 12 mL/kg/min is associated with a very poor 1-year survival rate without transplant. Individuals with a peak oxygen consumption of less than 15 mL/kg/min should be considered for listing [3,4]. The patient’s medical history is examined to try to determine the cause of the patient’s heart disease. Individuals who have a creatinine clearance of less than 50 mL per minute do have a significant increase in the need for postcardiac transplantation dialysis and have lower rates of survival than those with near-normal renal function. Individuals with severely abnormal creatinine clearance would be excluded from heart transplant or considered for heart-and-kidney transplantations. Individuals with diabetes need further end-organ evaluation prior to listing to understand the full scope of their risk. The hemodynamic evaluation consists of an echocardiogram to evaluate function and anatomy, and a cardiac catheterization. The cardiac catheterization includes evaluation of heart function by a right heart catheterization as well as a coronary angiogram. In this assessment, the patient’s coronary anatomy is examined for potential intervention, and any abnormalities in the filling pressures, pulmonary capillary occlusion pressure, or pulmonary vascular resistance are identified. Patients with heart failure and secondary pulmonary hypertension are a group who are of special interest. Pulmonary arterial and capillary wedge pressures are measured to determine the degree to which a patient has secondary pulmonary hypertension and whether or not it is reversible. The patient’s hemodynamics should be optimized in the catheterization laboratory in an attempt to decrease the pulmonary arterial pressures to normal levels, and 100% oxygen, nitric oxide, and other pulmonary vasodilators can be used to test the reactivity of the pulmonary vasculature. Individuals with values outside these values would then be listed for heart–lung transplant, or be given a trial of pulmonary vasodilators. The psychosocial evaluation should be centered on evaluating not only the transplant recipient, but also the family support for the patient. This needs to be performed by a qualified professional experienced in social work and, when indicated, other mental health professionals who have a keen understanding of the demands made on a postoperative cardiac transplantation patient. Patients need to be medically compliant, have adequate neurocognitive function for the postoperative regimen, and adequate social support. Once the evaluation has been completed, the patient is evaluated for any relative or absolute contraindication for heart transplantation. Those relative contraindications include: age greater than 70 years, previous chronic substance abuse, limited social support, limited adaptive ability, mild renal dysfunction, active peptic ulcer disease, cachexia, obesity, and cigarette smoking. It should be noted that to receive a heart transplantation, individuals who smoke are required to go through a smoking-cessation program, and many transplant programs require them to sign a contract stating that they will not resume smoking prior to or after the transplantation. Absolute contraindications to cardiac transplantation include: ongoing substance abuse, refractory psychiatric conditions, suicidal behavior, severe personality disorder, issues with ongoing medical noncompliance, inadequate neurocognitive ability, irreversible hepatic or renal dysfunction, severe peripheral or cerebral vascular disease, systemic disease that limits rehabilitation, insulin-dependent diabetes with severe end-organ damage, or evidence of severe, fixed, secondary pulmonary hypertension [8–10]. With an assist device implanted, patients who would otherwise not survive long enough to receive a heart transplantation are now living independently at home with reasonably good quality of life until a suitable organ becomes available. This has impacted the number of patients reliant on inotropes at the time of transplant, with a decrease from 43. There are two broad categories of devices in use based on pump mechanism: pulsatile devices that employ some type of pneumatic pump, and continuous, or axial flow devices that involve a spinning propeller. The cycles of the pulsatile device are measured in beats per minute (bpm) and that of the continuous-flow pumps in revolutions per minute (rpm). Each device has an inflow cannula through which the patient’s blood is drawn from the heart and into the pump and an outflow cannula that directs the blood back into the patient’s circulation. For both pulsatile pumps and continuous-flow pumps, there are two more classifications that can be described on the basis of the location of the pump when implanted: intracorporeal, wherein the entire pump is implanted inside the body with the exception of the drive-line that powers the device and passes through an exit site on the abdomen; the other is paracorporeal, or extracorporeal, wherein the pump sits outside the body and the inflow and outflow cannulae enter and exit the skin on the upper abdomen just below the costal margin. The Levitronix CentriMag (now owned by Thoratec) is approved for temporary right ventricular assistance up to 30 days and its inflow cannula may be placed in either the right atrium or the right ventricle.

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Coagulation parameters (prothrombin time order generic avanafil from india, partial thromboplastin time buy generic avanafil line, thrombin time) need to be carefully monitored because of frequent coagulopathy order avanafil 50mg with visa, most likely related to intraoperative blood loss and temporary ischemic damage of the revascularized new liver buy cheap avanafil 100mg on line. Normalization of these values, along with improvement in mental status and renal function, are valuable indicators of good graft function. Most liver transplant recipients have a reduced intravascular volume as a result of insufficient correction of intraoperative bleeding, ongoing postoperative hemorrhage and/or fluid shifts through third spacing. In contrast to nontransplant critical care patients, liver transplant recipients may benefit more from blood transfusions and albumin [28]. The osmotic effect of blood and colloids promotes the shift of fluids from the extravascular space into the circulation, thereby improving organ perfusion while reducing graft congestion. Potassium may be elevated because of poor renal function, residual reperfusion effect, or immunosuppressive medications. Diuretics may be required to remove excess fluid acquired intraoperatively, but may result in hypokalemia and may not be effective in patients with acute kidney injury or for those with a history of hepatorenal syndrome. Magnesium levels should be kept above 2 mg per dL to prevent seizures, particularly in the presence of tacrolimus, which may lower the seizure threshold. Nasogastric suction can usually be discontinued during the first postoperative day; patients with a choledochojejunostomy may need more time. Given the magnitude of the operation, the often poor pretransplant medical status, and the need for immunosuppression, it is not surprising that more than 50% of liver recipients develop some type of infection. Close attention must be given to all invasive monitoring lines, which should be removed or changed every 5 to 7 days. Aggressive clearance of respiratory secretions is needed, because the lung is a common site of postoperative infection. Signs of hepatic function include good texture and color of the graft, evidence of bile production, and restoration of hemodynamic stability. The patient who rapidly awakens from anesthesia and whose mental status progressively improves likely has a well-functioning graft. Laboratory values that corroborate good function include normalization of the coagulation profile, resolution of hypoglycemia, and clearance of serum lactate. Hemolysis of transfused and recycled blood, and ischemia– reperfusion injury may lead to postoperative hyperbilirubinemia in the presence of a functioning graft. Adequate urine production and good output of bile through the biliary tube (if present) are also indicators of good graft function. Serum transaminase levels will usually rise during the first 48 to 72 hours following transplant secondary to preservation injury, and then should fall rapidly over the subsequent 24 to 48 hours. Many programs use a triple immunosuppressive regimen based on a calcineurin inhibitor (cyclosporine or tacrolimus), antimetabolite (mycophenolate mofetil or azathioprine), and prednisone. Some centers also use antibody induction such as antilymphocyte antibody or Rituximab [29], either for all recipients or only for those with renal dysfunction. Other humanized monoclonal antibodies such as basiliximab and daclizumab are also being used as part of steroid sparing protocols or to reduce calcineurin inhibitors dose [30]. Surgical complications related directly to the operation include postoperative hemorrhage, problems with any of the anastomoses (five vascular and one biliary), and wound complications. Biliary Complications Biliary complications are considered the technical “Achilles heel” of liver transplantation because of their morbidity and frequent occurrence. In early reports, morbidity rates of up to 50% and related mortality rates of up to 25% to 30% were reported [31,32]. Recent improvements in organ selection, preservation, immunosuppression, and standardization of the methods of biliary reconstruction have all contributed to reduce the incidence of these complications. The main risk factors for biliary complications include: small size of bile ducts, hepatic artery thrombosis, older donor age, prolonged ischemic times, and immunologic response (e. An endoscopic strategy is the first choice for biliary complications; treatment of biliary stricture with endoscopic modalities has a success rate of 57% [33]. Biliary Leaks Biliary leaks typically occur early and are diagnosed by the presence of a biliary fistula or on a routine cholangiography. The majority of bile leaks are seen either in the first month after liver transplant or after T- tube removal. Risk factors for biliary leak include small size of bile ducts, discrepancy between donor and recipient ducts size, ischemic injury, and devascularization of the bile duct. Because of this concern, many transplant centers have stopped using T-tubes, although this change in practice has not been demonstrated to decrease the incidence of biliary leakage (4. In some cases, a primary surgical revision is indicated, particularly with early leaks (<1 to 2 weeks after liver transplant), large defects, or if bile duct necrosis is suspected. Duct-to-duct repairs are not always feasible and a bilioenteric anastomosis is often required, especially in the case of periductal infection and/or bile duct necrosis [37]. Available therapeutic approaches (endoscopic dilation/stenting, hepatico-jejuno anastomosis, liver resection, or retransplantation) are performed only when complications are already present. Severe and long anastomotic strictures are usually not amenable to endoscopic treatment, requiring surgical correction instead. Endoscopic sphincterotomy is the treatment of choice and is effective in the vast majority of patients [42,43]. Vascular Complications Vascular complications following liver transplantation include bleeding, thromboembolic events, and anastomotic failures (stenosis and thrombosis). Bleeding Despite advances in surgical technique and anesthetic management, extensive bleeding is still very common during and after liver transplantation. Because of changes in procoagulant and anticoagulant pathways with cirrhosis, cirrhotic patients are at increased risk both of bleeding and of thromboembolic events. The most common source of bleeding after liver transplantation is from the vascular anastomosis, but it can also arise from varices, the retroperitoneum, or the liver anastomoses. The incidence of posttransplantation abdominal bleeding, defined as any hemorrhage requiring radiologic intervention or laparotomy within the first month, is 9%, occurring at a mean of 6. Active bleeding is controlled by endovascular interventional techniques for 39%, by surgical ligation or vascular reconstruction for 46%, or by sequential combinations of endovascular intervention and surgery for 15% [49]. Recent literature has challenged this dogma, showing that the coagulation system of cirrhotic patients is dysfunctional and also associated with hypercoagulability tendency [53–55]. The biliary ducts are exclusively supplied by arterial blood [58], and interruption of arterial blood leads to ischemic cholangiopathy, which leads to biliary strictures, abscesses, biliary cast formation, and potentially sepsis [36]. Treatment of these complications has traditionally involved reexploration, surgical thrombectomy, and anastomotic revision. More recently, catheter-based and medical anticoagulant or thrombolytic interventions are available, but the results are inferior. Conventional risk factors for wound infections are all present in liver transplant recipients, including longer operative times, contamination with bowel or biliary contents, need for transfusion of blood products, poor nutritional status prior to transplantation, and steroid administration for immunosuppression to prevent rejection. Wound infections typically develop after the first week following liver transplantation, often presenting with fever, chills, erythema, and purulent drainage from the wound. Given the presence of immunosuppression, signs and symptoms of infection may be subtle, with the absence of typical features of inflammation. Management includes opening the wound to allow appropriate drainage of collections, frequent dressing changes, and allowing healing by secondary intention. Intravenous antibiotics may be necessary in the presence of significant cellulitis, deeper involvement, or systemic symptoms. Complicated skin and soft tissue infections, including necrotizing fasciitis, have been reported and require rapid, aggressive debridement together with appropriate selection of intravenous antibiotics. Medical complications in the early posttransplant period may involve almost any organ system (Table 58. Outcomes are typically better if retransplantation is performed as early as possible, before the development of significant multiorgan dysfunction [73]. Rejection Graft rejection affects up to 30% of liver transplant recipients at some point posttransplantation. Rejection typically manifests as elevation of serum bilirubin and/or transaminase levels, occasionally with mild fever and malaise. The differential diagnosis of rejection includes vascular thrombosis, bile leaks, and underlying infection. Mild episodes may be managed by increasing the baseline level of immunosuppression, whereas moderate or severe rejection episodes usually require treatment with a pulse of high-dose intravenous corticosteroids. Neurologic Complications Neurologic complications are relatively common posttransplant, affecting 15% to 30% of liver transplant recipients.

As the name implies discount 50 mg avanafil with amex, this is a genetic disorder associated with recurrent serositis primarily of the abdominal cavity generic avanafil 100mg mastercard, but it can also result in pleuritis and pericarditis safe avanafil 100 mg. The molecular basis for this disease is loss of pyrin order generic avanafil, a protein important for the regulation of inflammasomes. Given increasing prevalence of obesity and the sedentary lifestyle of our population, pulmonary emboli are an increasing concern. Also, patients who have been at prolonged bed rest are at increased risk of thrombus formation in the calves. When emboli are small, they may not result in respiratory complaints and may simply present as fever. These patients often complain of neck pain and, on physical examination, have a tender and edematous thyroid reflecting ongoing inflammation. Consider factitious fever in the female health care worker with a medical textbook at the bedside and recurrent polymicrobial bacteremia. In many of these cases, fever spontaneously resolved over 3 to 6 months without harmful consequences. A review of all symptoms associated with the illness needs to be periodically updated. Symptoms often are transient and are recalled by the patient only after repeated questioning. Family history must also be thoroughly reviewed to exclude genetic disorders, such as cyclic neutropenia and familial Mediterranean fever. Social history needs to include animal exposure (pets and other domestic or wild animals), home environment, and occupational exposure. Travel history should explore travel to areas endemic for malaria and other parasites, typhoid, coccidiomycosis, histoplasmosis, and tick-borne illnesses. A list of all medications, including over-the-counter and natural organic remedies, must be compiled to exclude the possibility of drug fever. Particular attention should be paid to the skin examination, looking for embolic or vasculitic lesions or evidence of physical manipulation. Particular attention should be paid to the nail beds, where small emboli can become trapped in the distal capillaries of the fingers and toes, resulting in small splinter-shaped infarcts. Careful eye examination should be repeated, looking for conjunctival petechiae, conjunctivitis, punctate corneal lesions, uveitis, optic nerve changes, and retinal or choroidal abnormalities. Thorough palpation of all lymph nodes needs to be repeatedly performed, documenting the consistency, size, and tenderness. Cardiac examination should be repeated daily, listening for cardiac murmurs and pericardial rubs. The abdomen also should be palpated daily to detect new masses, areas of localized tenderness, and hepato- or splenomegaly. Medical history of infectious diseases and family history should be carefully reviewed. Epidemiology history should include animal exposure, outdoor camping, insect bites, and travel to developing countries or the Southwest United States and the Ohio River valley. Abdominal examination should assess liver and spleen size and should palpate for masses and areas of tenderness. Tests should be directed toward specific complaints and abnormalities found on preliminary testing. In recent years, rather than insufficient studies being the norm, clinicians have erred on the side of excessive and uninformative testing. Each patient’s diagnostic workup must be tailored to personal history and physical findings. An iterative rather than a shotgun approach to testing is the most effective course of action. Willy Sutton was a famous bank robber, who, when finally captured, was asked by newspaper reporters, “Willy, why do you rob banks? This exercise requires a seasoned clinician with over 10 years of experience who has developed the pattern recognition and intuitive expertise to differentiate between those abnormalities that have the potential to lead to a definitive diagnosis and those that represent false clues that have the potential to waste both time and money. Alternatively, a interferon γ release assay can be performed to assess latent tuberculosis. The use of skin tests to detect histoplasmosis and coccidiomycosis is not generally recommended. In general, no more than six blood cultures should be drawn during the entire course of the illness. However, they may be repeated periodically or if a significant change occurs in the fever pattern. Because of the possibility of fastidious slow-growing bacteria, all blood cultures should be held for 3 weeks. Multiple urine samples should be obtained and cultured for tuberculosis in addition to more conventional bacteria. Aerobic, anaerobic, mycobacterial, and fungal cultures should be ordered on virtually all samples. Viral cultures or quantitative polymerase chain reaction may also be considered in specific cases in which cytomegalovirus or Epstein–Barr virus is suspected. A single titer simply demonstrates a history of exposure; a rising titer indicates recent infection. Antibody titers may be useful in cytomegalovirus, Epstein–Barr virus, Toxoplasma, Rickettsia, Chlamydia, and Brucella infections. If liver functions are abnormal, hepatitis serology should also be ordered (see Chapter 8). Results to look for are mediastinal enlargement (suggestive of lymphoma), micronodular interstitial changes (“millet seed” pattern, suggestive of miliary tuberculosis), or nodular lesions or infiltrates (can be seen in many infectious diseases, connective tissue diseases, and neoplasms). Tests That Should Be Ordered Depending on the Patient’s Symptoms and Signs—In patients who are suspected of having a chronic infection, radionuclide scans may be helpful in localizing the site. Another tracer molecule that accumulates in areas of inflammation and in 18 malignant tumors is F fluorodeoxyglucose. Unlike other scans, which require that the patient be scanned during a period of 24-36 hours, positron 18 emission tomography with F fluorodeoxyglucose is completed within a few hours. In patients with a heart murmur and persistent fever, cardiac echo should be considered. Transesophageal echo is the test of choice; it has a greater than 90% sensitivity for detecting cardiac vegetations, and it is also helpful in detecting myocardial abscess and atrial myxoma. Ultrasound of the lower abdomen may be helpful in cases in which pelvic lesions are suspected. When other tests are unrevealing, upper gastrointestinal barium study with small bowel follow- through should be ordered to exclude regional enteritis. Radiographs of all joints should be ordered in any patient with persistent joint complaints to document anatomic defects. Invasive Procedures—Laparoscopic guided biopsy improves the yield by allowing biopsies to be taken in areas where abnormalities in the external capsule are seen; however, this surgical procedure is rarely used. Bone marrow biopsy is also recommended as a routine invasive test if all noninvasive studies are negative and has a yield of nearly 25%. Hematologic malignancies are most commonly identified, particularly malignant lymphoma and less commonly acute leukemia. Infectious diseases can also be identified, and the bone marrow should be cultured (see the earlier subsection titled “Cultures”), because disseminated tuberculosis, histoplasmosis, coccidiomycosis, and other fungal and mycobacterial infections often seed the bone marrow. Use of other invasive procedures will depend on the diagnostic findings, history, and physical findings to that point. It should be kept in mind that, because skip lesions are common in temporal arteritis, a long sample of the temporal artery should be obtained and multiple arterial sections examined. In addition to a complete series of cultures, all biopsy specimens should undergo Brown–Brenn, Ziehl–Neelsen, methenamine silver, periodic acid Schiff, and Dieterle silver staining in addition to routine hematoxylin and eosin. Frozen sections should be obtained for immunofluorescence staining, and the remaining tissue block should be saved for additional future studies. It should be emphasized that, when symptoms, signs, or a specific diagnostic abnormality is found, all other scheduled diagnostic tests should be delayed and Sutton’s law applied. Clinicians need to apply Baye’s theorem and predict the pretest and posttest probability of the particular disease.

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Obstet Gynecol ultrasonography and magnetic resonance imaging in 2014;123:1185–1192 buy avanafil in united states online. Prediction of complete uterine rupture by sonographic International standards for fetal growth based on evaluation of the lower uterine segment purchase generic avanafil pills. Am J Obstet serial ultrasound measurements: the Fetal Growth Gynecol 2009;201:320 order avanafil master card. Gestational uterine segment thickness to predict uterine rupture age at delivery and special educational need: during a trial of labor in women with previous retrospective cohort study of 407 discount avanafil 200 mg line,503 schoolchildren. Planned birth before 39 weeks and child of unexplained stillbirths using clinical practice development: a population‐based study. Update on the diagnosis and Effectiveness of detection of intrauterine growth classification of fetal growth restriction and proposal retardation by abdominal palpation as screening test of a stage‐based management protocol. The Investigation and Management of the Small‐for‐ Customised antenatal growth charts. Value of changes in Doppler and biophysical parameters as of a single early third trimester fetal biometry for the severe fetal growth restriction worsens. Ultrasound prediction of birth weight deviations in a low risk Obstet Gynecol 2001;18:571–577. Than Award Lecture: Recognition of placental failure is Screening for fetal growth restriction with universal key to saving babies’ lives. Placenta 2015;36(Suppl 1): third trimester ultrasonography in nulliparous women S20–S28. Arch Gynecol Obstet formal fetal movement counting and risk of antepartum 2016;294:673–679. Customised versus Predicting poor perinatal outcome in women who population‐based growth charts as a screening tool present with decreased fetal movements. J Obstet for detecting small for gestational age infants in Gynaecol 2009;29:705–710. Clinical Practice Guideline for the 65 Oros D, ueras F, Cruz‐Martinez R, Meler E, Management of Women who Report Decreased Fetal Munmany M, Gratacos E. Umbilical and fetal middle cerebral in computerized fetal heart rate analysis antepartum. Fetal perception of reduced fetal movements: a prospective biophysical profile scoring: a prospective study in cohort study. Best Pract Res Clin Obstet Doppler ultrasound in predicting the perinatal Gynaecol 2017;38:12–23. Biophysical adverse pregnancy outcome: systematic review and profile for fetal assessment in high risk pregnancies. Doppler ultrasonography in 71 American College of Obstetricians and Gynecologists’ high‐risk pregnancies: systematic review with meta‐ Committee on Practice Bulletins—Obstetrics. Changes definition of macrosomia through an outcome‐based in fetal Doppler indices as a marker of failure to reach approach in low‐ and middle‐income countries: a growth potential at term. Stillbirth in gestation, increased intrapartum operative intervention diabetic pregnancies. Placental syndromes: getting to 64 Cruz‐Martinez R, Savchev S, Cruz‐Lemini M, Mendez the heart of the matter. Intrapartum clinical, sonographic, and perinatal outcome in small‐for‐gestational‐age fetuses. Ultrasonographic weight estimation in large for the value of ultrasound in the prediction of successful gestational age fetuses: a comparison of 17 sonographic induction of labor. Ultrasound 89 Garcia‐Simon R, ueras F, Savchev S, Fabre E, Obstet Gynecol 2013;41:398–405. Performance of the outcome after labor induction for late‐onset small‐for‐ ultrasound examination in the early and late third gestational‐age fetuses. Ultrasound Obstet Gynecol trimester for the prediction of birth weight deviations. Validation of Induction of labour at or near term for suspected fetal models that predict Cesarean section after induction macrosomia. Prior to this the fetus relies on placental trans­ able to cross the placenta and stimulate the fetal thyroid fer of maternal thyroid hormones. It has been estimated that (T3) increase with advancing gestation, from 14–16 weeks neonatal thyrotoxicosis occurs in 2–10% of babies born onwards [1,2]. The T3 concentrations are lower than adult levels throughout placenta is more permeable to IgG in the second half of pregnancy. As a result, of the fetal pituitary–thyroid axis is independent of the fetal hyperthyroidism usually develops in the second half mother. Disruption of normal 1) Euthyroid, not on medication, but who has previously thyroid function, if unrecognized and untreated, can received antithyroid drugs: the risk of fetal/neonatal therefore have significant long‐term sequelae. More commonly it occurs second­ 2) Euthyroid, previously treated with radioactive iodine ary to maternal thyroid disease and/or its treatment. High concentrations of antibodies identify mass, such as cystic hygroma, cervical teratoma and hae­ a pregnancy at risk of fetal hyperthyroidism. The goitre may repre­ should be measured again in the third trimester to sent fetal hyperthyroidism or hypothyroidism. There may be tachycardia or bradycar­ can cause hyperextension of the fetal neck resulting in dia and in severe cases complete heart block. Fetal hypo­ in polyhydramnios with its associated risk of preterm thyroidism is often unrecognized and should be consid­ labour. Management Ultrasound can detect fetal goitre, which is the earliest Management ultrasound feature of fetal thyroid dysfunction and If fetal hypothyroidism is secondary to maternal antithy­ appears before fetal tachycardia. Colour flow the fetal thyroid should be carried out at no greater than Doppler may help differentiate between a hyperthyroid fortnightly intervals to ensure reduction in size, which is and a hypothyroid goitre. Hyperthyroidism is associated usually noted within 2 weeks of reducing therapy [8]. In at‐risk pregnancies monthly used and 250–500µg of T4 at 7–10 day intervals is a ultrasound should be carried out from around 20 weeks’ proposed regimen [9]. If the fetal condi­ Cordocentesis is the only direct method of assessing tion deteriorates despite treatment, cordocentesis is fetal thyroid function. Treatment by maternal administration of antithyroid ● Fetal goitre, present on ultrasound, indicates fetal drugs is both safe and effective in the management of thyroid dysfunction if other differential diagnoses fetal hyperthyroidism. If the ● It should be possible to distinguish fetal hyperthy- mother is euthyroid she may require thyroxine supple­ roidism from hypothyroidism on clinical grounds in mentation. Fetal hypothyroidism Worldwide, iodine deficiency is the leading cause of fetal hypothyroidism. Five enzymes are responsible for the conversion of tibodies can cause fetal hypothyroidism. Anti‐thyroper­ cholesterol to cortisol, and a defect in any one of these oxidase antibodies cross the placenta in the third will cause precursors to be diverted to the production of trimester but have little effect on fetal thyroid function. Androgen excess in utero leads to virilization of a echocardiography are the main diagnostic techniques. Androgen reader is referred to other literature for a more compre­ excess does not affect development of fetal male genitalia. The aim of therapy is to prevent virilization of a female Irregular fetal heart rate fetus. The fetal adrenal gland can be suppressed by maternal administration of dexamethasone. A minimum This is typically described as a ‘missed beat’ and is usually dose of 20 µg per kilogram pre‐pregnancy weight in two due to atrial extrasystoles. These extrasystoles are more divided doses is the recommended regimen and therapy common in the third trimester and are detected in 1. Occasionally (2–3% of cases) a sustained tachycardia develops and it is wise to auscultate Approach to management the heart regularly to ensure this does not occur. Atrial fibrillation and chaotic atrial tachycardia are much ● Discontinue dexamethasone in all male fetuses and all less common and ventricular tachycardia is extremely rare unaffected female fetuses. Information regarding longer‐term effects is lim­ Atrial flutter ited and parents must be made aware of this when the atrial rate is very fast at 350–500 bpm. Fetal dysrhythmias Management options These comprise irregular fetal heart rhythm, fetal tachy­ the fetus with a sustained tachycardia is at risk of devel­ cardias and fetal bradycardias. Delivery, followed by postnatal therapy, is an interval and this cannot be detected on routine ultra­ option if close to term, but it is recognized that pharma­ sound. In utero therapy is effective until an impulse is blocked; this results in an irregular in restoring sinus rhythm and is the preferred option for rhythm but the fetal heart rate may be normal.