Cardiovascular Disease in Pregnancy Part IV: Pulmonary Hypertension, Marfan's, and Bicuspid Aortic Valve

Pulmonary Hypertension 

• What is PH? 

  • Elevation in mean pulmonary arterial pressure (PAP) >/= 25 mmHg upon right heart catheterization 

  • PAH or pulmonary arterial hypertension = subset of PH characterized by LV filling pressure </= 15 mmHg and a pulmonary vascular resistance > 3 Wood Units 

  • Why is it important in pregnancy? 

    • Mortality remains high in women with PH (9-28% mortality) 

    • There is a recommendation to avoid pregnancy, and termination should be discussed 

    • Greatest risk = during labor and immediately postpartum 

    • Causes of death most commonly are pulmonary hypertensive crisis, pulmonary thrombosis, and right heart failure 

  • What to do if they get pregnant

    • Echocardiography to evaluate heart function 

    • Right heart catheterization is recommended if diagnostic uncertainty 

    • Multidisciplinary team to care for mother in a tertiary care center 

    • Consider anticoagulation as thrombo-embolism is a major risk 

    • Diuretics if heart failure 

  • Delivery 

    • Multidisciplinary delivery team 

    • Vaginal delivery can be associated with volume changes during contractions → can pose a problem to women with pulmonary hypertension because they have a limited capability to increase their cardiac output 

    • Remember: cardiac output increases 30% in first stage of labor and >50% in second stage of labor 

    • Planned cesarean may be a better choice - but we need to monitor hemodynamic arterial and central venous pressure

    • Postpartum - also need to observe closely due to fluid shifts. Continue to record strict I/Os and optimize RV function

• Marfan’s Syndrome 

  • Overall risk is aortic dissection associated with pregnancy → ~3% 

  • Aortic size is a major determinant of risk, but even women with aortic root of <40 mm, risk of dissection is 1% 

  • Pregnancy should be avoided in Marfans if aortic root is >45 mm → increased risk of dissection 

  • If 40-45mm, other factors like rate of growth and family history should be considered 

• Bicuspid Aortic Valve 

  • Can also lead to aortic dilatation; occurs in less than 50% of patients with a bicuspid aortic valve 

  • The dilatation can be in the distal ascending aorta which cannot be seen well with echo 

  • Risk of dissection is overall small, but pregnancy should be avoided if aorta diameter is >50 mm 

• General considerations in the antepartum 

  • Testing for mom 

    • EKG 

    • Echo - with unexplained or new cardiovascular signs or symptoms, or known cardiac disease in pregnancy 

    • Exercise testing 

    • Other tests 

  • Genetic testing and counseling 

    • Prepregnancy counseling of course, and risk assessment with the mWHO classification of maternal risk 

    • High risk patients should be treated by a multidisciplinary pregnancy heart team  

    • Genetic counseling should be considered if congenital heart disease or congenital arrhythmias, cardiomyopathies, aortic disease, or genetic malformation associated with CVD 

      • Why? Increased risk of fetal congenital heart disease in moms with these issues (baseline 1% goes up to 3-5%) 

  • Labor and delivery

    • Vaginal delivery is generally recommended as first choice for most patients unless the have the following, at which point cesarean should be considered: 

      • Dilatation of the ascending aorta >45 mm, severe aortic stenosis, preterm labor while on oral anticoagulants, PH, Eisenmenger’s syndrome, or severe heart failure 

    • IOL should be considered by 40 weeks at the latest 

    • Postpartum: discussion of birth control and prevention of next pregnancy 

    • Postpartum testing of maternal cardiac status 

  • Fetal assessment 

    • Fetal echo when there is an elevated risk of fetal abnormalities 

    • Consideration of growth ultrasounds as there is higher risk of FGR 

    • Consideration of fetal testing 

Cardiovascular Disease in Pregnancy Part III: Septal Defects and Maternal Congenital Cardiac Disease

We continue our series on cardiovascular diseases with part III this week. Check out Part I and Part II if you haven’t already!

Atrial Septal Defects (ASDs) + Ventricular Septal Defects (VSDs) 

• ASD: Repaired vs. unrepaired 

  • Repaired = WHO class I - if no significant residual disease, have very low maternal cardiac risk in pregnancy.

  • Unrepaired = WHO class II 

    • Depends on size; if small → generally uncomplicated, will tolerate pregnancy well 

    • However, those with unrepaired ASDs also can have risk for supraventricular arrhythmias, like atrial flutter 

      • Remember that if there is an ASD, DVTs can travel to the systemic circulation → stroke (paradoxical embolus).

    • Also, if ASD is large and associated with significant pulmonary vascular disease, pregnancy should be avoided due to high risk of maternal and fetal mortality 

• VSD: Repaired vs. unrepaired 

  • Repaired = WHO Class I. If small VSD with shunt ratio <1.7 with normal pulmonary pressure and preserved aerobic function → no increased risk to mom or fetus during pregnancy.

    • Shunt ratio briefly: pulmonary flow/systemic flow 

    • Basically, when there is L → R shunt, because there is a backleak of blood from the left side to the right side, the pulmonary flow will always be more than the systemic flow.

      • So a large shunt ratio implies significantly more pulmonary flow compared to systemic flow.

  •  Unrepaired: if large VSD shunts, history of arrhythmia associated with shunt, ventricular dysfunction, or pulmonary hypertension → higher risk of developing cardiovascular complications in pregnancy 

    • Complications include arrhythmias and heart failure.

    • Surveillance during pregnancy for pulmonary hypertension.

• Atrioventricular septal defect 

  • After ASD repair, pregnancy is usually well tolerated (WHO Class II - III) 

  • Arrhythmias and worsening AV regurg have been described 

Tetralogy of Fallot 

• Most common cyanotic congenital heart defect. Remember PROV:

  • Pulmonary stenosis (RV outflow tract obstruction)

  • RV Hypertrophy (concentric)

  • Overriding aorta 

  • VSD 

• How to remember all this: 

  • Think this way: The aorta and the pulmonary artery trunk are next to each other in the heart. Aorta comes from the LV and the pulmonary artery from the RV. Imagine if the aorta just became really big and took over the real estate of the pulmonary artery. What has to happen? 

    • Overriding aorta 

    • Aorta takes over the real estate and therefore breaks through the ventricular septum → VSD 

    • The pulmonary artery is now super small, and therefore the pulmonic valve must be super small → RV outflow tract obstruction 

    • RV now has to work harder → RV hypertrophy 

      • So really, it’s just one thing that went wrong! 

• Repaired Tet = WHO Class II - generally good outcomes if no severe hemodynamic abnormalities before pregnancy  

  • Complications can include arrhythmias (6.4%) and heart failure (2.4%) 

  • Fetal complications = premature delivery, SGA, recurrent CHD of any type, and very small risk of fetal and perinatal mortality (0.5% and 1.4% respectively) 

  • Remember that there is a higher risk of 22q11.2 microdeletion in offspring 

    • Approximately 15% of patients with ToF and other conotruncal defects have chromosome 22q11.2 microdeletion, and genetic testing should be offered in the prenatal setting 

  • Follow up every trimester by cards, but if severe pulmonary regurg, monthly or bimonthly follow up 

• Unrepaired Tet = WHO Class III, and pregnancy is not recommended 

  • Would need close f/u with cardiology 

More rare stuff 

• Ebstein’s Anomaly 

  • What is it: Tricuspid valve is placed too low on the right ventricle → enlargement of R atrium and non-functioning tricuspid valve. 

  • Again, if uncomplicated, pregnancy is well tolerated (Who Class II) 

  • But if there is cyanosis (usually due to ASD) or heart failure → counsel against pregnancy  

• Transposition of the Great Arteries 

  • What it is: the left side of the heart pumps to the pulmonary artery and right side of the heart pumps to the aorta (basically, aorta and pulmonary artery are switched) 

  • Adults will have it corrected = arterial switch, and can usually tolerate pregnancy well if there is good clinical function pre-pregnancy 

  • Again, there is higher risk of heart failure and arrhythmias and should have good cardiology follow up 

• Fontan Circulation 

  • What is it:

    • Basically it is a palliative surgical procedure performed in patients with a functional or anatomic single ventricle 

    • Some common reasons: hypoplastic left heart syndrome, tricuspid atresia, pulmonary atresia with intact ventricular septum, etc. 

  • Essentially diverts systemic venous return to the lungs without a pump, driven by central venous pressure. The single ventricle does pump blood to the systemic circulation.

  • For this to work, the person must have a low pulmonary arteriolar resistance, and relatively normal function of the single ventricle.

  • Prior to pregnancy, those with Fontan circulation should discuss with their cardiologist and have preconception counseling with MFM 

  • Those with poor functional capacity, history of heart failure, or ventricular function <40%, arrhythmias, etc should not get pregnant due to risk of complications 

  • Complications during pregnancy: arrhythmias, thrombotic and bleeding events, ventricular dysfunction, and edema 

  • Increased risk for SAB and premature birth as well as FGR 

  • PPH has been documented in up to 50% of pregnancies 

Labor and Delivery 

• In most of these cases, patients should have telemetry intrapartum and 24 hours pp due to higher risk of arrythmias 

• Strict I/Os

• Depending on severity of case, but should consider early epidural

• Vaginal delivery is not contraindicated, but should be assessed on a case by case basis

Hidradenitis Suppuritiva

• Admittedly we are not dermatologists… but hydradenitis suppuritiva (HS) affects a substantial number of our patients and because of the locations it affects, OB/GYNs are often the first to see it.

What is HS?

• Chronic, recurrent inflammatory disease of apocrine sweat glands

  • Also known as acne inversa 

  • Located usually in axillae, groin, genitals, perineal, buttocks, and inframammary areas 

  • Women tend to be more affected than men  

• Prevalence 

  • 1%-4%, onset usually between puberty - 40 years of age, usually in second or third decade of life 

• Why do we care?

  • Can cause significant pain, issues with scarring 

  • May have huge impact on self-esteem and quality of life can be severe, thus importance of early diagnosis and treatment 

  • Very rarely, squamous cell carcinomas develop within sites of HS 

How do we recognize it and diagnose it? 

View fullsize

JAAD 5/2020

Pathogenesis 

• Follicular occlusion is most likely the even that is responsible for the initial development of HS lesions; may be due to ductal keratinocyte proliferation  → hyperkeratosis and plugging 

• There is then follicular rupture → formation of sinus tracts

• Associated factors

  • Genetics

  • Mechanical stress (ie. pressure, friction, etc.),

  • Obesity (maybe...but it’s also present in those without obesity),

  • Smoking (strong correlation; majority of affected patients are smokers),

  • Hormones (some people may experience perimenstrual flares)  

• History and Physical exam 

  • Typical lesions, typical locations, relapses and chronicity 

  • Inflammatory nodules - first lesion is single, painful, deep-seated inflamed nodule in the intertriginous area; diagnosis is usually missed at his stage; can be diagnosed as a “boil” or furunculosis 

    • After some time, the nodule can progress to form an abscess → may open to skin surface spontaneously 

    • Pain usually improves after drainage 

  • Sinus tracts - skin tunnels; can happen if HS is persistent for months or years; can release blood-stained, seropurulent, malodorous discharge periodically 

  • Comedones - can appear with longstanding HS 

  • Scarring - healed areas can have individual, pitted, acneiform scars; may be atrophic or keloidal 

• Lab studies - usually not needed, but if you’re uncertain, can do skin biopsy → r/o squamous cell carcinoma 

• Differential Diagnosis 

  • Folliculitis, acne vulgaris, pilonidal disease, Crohn disease 

Stage II disease — image courtesy of Wikimedia commons.

Stage III disease with active infection ongoing -- image courtesy of Wikimedia Commons.

What is the Hurley Staging System? - divides patients with HS into three disease severity groups:

• Stage I: Abscess formation (single or multiple) without sinus tracts and cicatrization/scarring 

• Stage II: Recurrent abscesses with sinuses tracts and scarring, single or multiple widely separated lesions 

• Stage III: Diffuse or almost diffuse involvement, or multiple interconnected sinus tracts and abscesses across the entire area.
  

How do we manage HS, and when should we refer out? 

• Goals

  • Reduce formation of new areas, sinus tracts, and scarring 

  • Treat existing lesions and reduce symptoms 

  • Minimize psychological morbidity 

• For all patients 

  • Education, psychological support if needed - it’s a chronic disease, not due to poor hygiene. Course can vary from person to person 

  • Wound and skin care techniques 

  • Pain management - NSAIDS usually, but discuss opioid analgesia if needed 

  • Treat associated symptoms and conditions 

  • Encourage smoking cessation if they smoke 

• Stage I - Aim is to reduce burden of disease  

  • Topical clindamycin - can reduce inflammatory lesions; usually applied 2x/day 

  • If fail topical therapy → oral therapy

    • Oral tetracyclines: 100 mg doxycycline daily or BID

      • If oral antibiotic therapy achieves good disease control, patients can stop and continue with topical clindamycin for maintenance

    • Antiandrogenic agents - spironolactone and finasteride; can be used, but they should NOT be given if there is possibility patient is pregnant  

    • Oral contraceptives - very small study that showed some improvement 

    • Metformin - can help promote weight loss, which can help HS

  • For acute symptomatic lesions - warm compress 

    • May want to refer out for this: possibility of intralesional corticosteroid injections 

    • Unroofing the area over the nodule 

    • I&D - not advised for routine treatment. It can lead to immediate relief, but can promote lesion recurrence and scarring 

• Stage II and III - Can try everything above, but if not working, usually this is when we would say you should refer out for other treatments 

  • If they don’t achieve good control with antibiotics, metformin or antiandrogenic therapy, may require oral retinoids, dapsone and biologics 

    • We’ll mention some, but we won’t go into detail, since we don’t really do this stuff as Ob/Gyns 

  • Oral retinoids - may only have limited benefit 

  • Oral dapsone - sulfone drug with immunomodulatory and antibacterial properties 

  • Adalimumab - FDA approved treatment for moderate to severe HS 

  • Acute symptomatic lesions: oral glucocorticoids may also be used 

  • For severe, refractory disease 

    • Wide excision - extensive surgical intervention can get to greatest likelihood for resolution of active inflammation, but can be disfiguring and involve a prolonged recovery time.

Intrahepatic Cholestasis of Pregnancy

Further reading for today: SMFM consult series #53 — it’s free!

And check out the ObG Project’s summary too!

What is cholestasis?

• ICP or IHCP is a strange condition occurring in the 2nd and 3rd trimesters of pregnancy, and is characterized by two primary things: intense pruritis, and elevated serum bile acid levels.

  • The intense itching is the characteristic symptom -- rashless, unrelenting, and affecting even the palmar surfaces of the hands and the soles of the feet.

• Women at risk of ICP include women who have had a history of ICP, women with hepatic disorders such as hepatitis C, nonalcoholic cirrhosis or pancreatitis, and women with gallstones and cholecystitis. 

  • Recurrence risk in subsequent pregnancy may be as high as 90%, but there’s limited data on this risk overall. 

  • ICP is also associated with multiple gestations, advanced maternal age, and there is likely a familial component to ICP as well. 

• Incidence of ICP is around 0.3 - 0.5%, but has been reported as affecting up to 15% of pregnancies.

• It seems silly to care about a disorder that causes itching in pregnancy, and ICP really doesn’t seem to affect the mother otherwise -- however, ICP is associated with severe adverse perinatal outcomes, particularly stillbirth, meconium-stained fluid, and preterm birth.

Many other conditions can cause itching in pregnancy!

• Differential diagnoses include atopic eruption of pregnancy (AEP), polymorphic eruption of pregnancy (PEP), and pemphigoid gestationis (PG). 

  • AEP is associated with an eczematous rash that breaks out on the face, eyelids, neck, antecubal and popliteal fossa, trunk, and extremities -- think of the terrible eczema you saw in kids on your pediatrics rotation, but now put it on a pregnant woman!  

  • PEP, or it’s former name PUPPS (pruritic urticarial papules and plaques of pregnancy, or PUPPS), is also associated with a rash that often breaks out in plaques on the abdomen and thighs, but will spare the arms generally. This is the most common dermatosis of pregnancy.

  • Finally, PG is super rare, but as you might remember from your dermatology rotations or Step 1 studying, “pemphigus” is derived from  the Greek word meaning pustules. The characteristic skin change of this disorder are vesicles and bullae, and though rare, requires consultation with dermatology immediately!

  • There are even other conditions that can cause itching without a rash in pregnancy - renal failure, HIV, multiple sclerosis, and psychiatric disease include just a few of the broad differential. 

    • However, any patient with generalized pruritis in the 2nd or 3rd trimester should receive an evaluation for possible ICP.

How do we evaluate for ICP?

• There shouldn’t be a rash!

  • The exam should also look for potential other hepatic causes that might raise bile acids - dark urine, jaundice or scleral icterus, abdominal pain and colic are not common with ICP.

• Bile acids are the laboratory of choice to evaluate for cholestasis of pregnancy.

  • Total serum bile acids > 10 micromol/L is the general cutoff for diagnosis of ICP.

  • Some labs will ask for a fasting draw, which can be impractical for a pregnancy evaluation. Trials reviewing this have demonstrated that differences in random and fasting bile acid levels are pretty small in pregnant women, so feel free to draw away at the time of suspicion!

    • This also helps because many times, bile acid measurements occur at specialty labs and take a few days to return. 

• Evaluation should also look at transaminases as these may also be elevated in ICP. 

What is the antenatal management of ICP?

• The primary adverse outcome we’re trying to avoid is stillbirth. Stillbirth risk seems to correlate with increasing bile acid levels:

  • Diagnosis is called with BA > 10 micromol/L;

  • BA > 40 micromol/L has been demonstrated to have a higher incidence of stillbirth in some studies, as well as higher risk of other poor neonatal outcomes such as meconium, respiratory distress, and preterm birth; 

  • A large meta-analysis demonstrated the highest risk for stillbirth and other adverse outcomes seems to exist for women with BAs > 100 micromol/L. 
    

• For maternal benefit, the drug of choice is ursodeoxycholic acid, or ursodiol. 

  • Ursodiol is effective in improving laboratory abnormalities (i.e., BAs, LFTs) and itching while not increasing any adverse fetal effects.

    • However, ursodiol likely does not decrease adverse fetal outcomes in ICP, so even though the bile acids will go lower, the peak value is still important to keep in mind. 

  • Dosing of ursodiol should be 10-15mg/kg per day, divided into 2-3 daily doses. 

    • This often comes out around 300mg BID or TID, or 500mg BID. 

  • Alternative medications for maternal benefit to reduce bile acid levels include cholestyramine and S-adenosyl-methionine (a dietary supplement in the US, sold as “SAMe”). 

  • Symptomatic treatment of itching can safely be targeted with oral antihistamines.

    • Topical antipruritics are likely unhelpful given the widespread nature of the itching!

  • Serial testing of bile acids is not necessarily recommended, but might be considered on a case-by-case basis as peak values are what have been reported in studies as being most significant with respect to stillbirth risk. 

    • It’s worthwhile to note that it’s not uncommon for pruritis in ICP can precede rising bile acid levels by even a few weeks! So in women who initially have a negative test, repeat bile acids and transaminase levels are very reasonable. 

      • Some may also practice in this particular scenario by diagnosing ICP clinically, and starting ursodiol empirically even in the absence of elevated bile acids. SMFM notes this is a reasonable approach, but certainly be aware of your differential diagnosis and keep an open eye for other pathologies.
        
        

• For fetal benefit, our only defense against stillbirth is the use of antenatal testing! 

  • Antenatal testing should begin with diagnosis of ICP, at a gestational age when delivery would be performed in response to an abnormal test.

  • SMFM notes that most obstetric providers will perform some sort of antenatal testing, though the optimal frequency is unknown and even the effectiveness of testing is uncertain:

    • The mechanism for stillbirth in ICP is thought to be a sudden event, rather than a chronic placental vascular process -- so surveillance doesn’t necessarily predict stillbirth well.

  • Considerations for an antenatal testing schedule should be gestational age, severity of cholestasis (i.e., peak bile acid level), and patient values.

• Ultimately to avoid stillbirth, delivery should be undertaken at an earlier gestational age:

  • In women with a clinical diagnosis of ICP (i.e., no bile acid elevation), delivery should not occur at less than 37 weeks.

  • In women with ICP and bile acids less than 100, delivery is reasonable between 36’0 - 39’0.

    • Data here is more challenging and less convincing on risk of stillbirth and when it occurs. It’s reasonable to consider managing women with lower values (ie., < 40) towards the later end of this window, and women with higher values (i.e., > 40) towards the earlier end.

  • In women with ICP and bile acids > 100, delivery can be offered as early as 36’0.

    • This is based on data suggesting in this high risk group, the risk of stillbirth substantially increases past this gestational age. 

    • SMFM even mentions in this group delivery between 34’0 - 36’0, provided that one of the following criteria is met:

      • Excruciating pruritis unremitting to pharmacotherapy;

      • History of ICP-associated stillbirth < 36 weeks in prior pregnancy;

      • Preexisting or acute hepatic disease with clinical or lab evidence of worsening hepatic function.

    • SMFM does advocate for the use of steroids for fetal lung maturity prior to delivery at 37’0 or earlier!

External Cephalic Version (ECV)

Background / Intro

• Breech presentation occurs in about 3-4% of term pregnancies, with a significant number of these patients delivery ultimately by cesarean. 

• Previously on the podcast, we covered considerations for singleton breech vaginal delivery. While that was a fun one to talk through, as we mentioned then, breech delivery is NOT the standard of care. So how do we avoid cesarean?

• External cephalic version is the answer! Essentially, using pressure on the pregnant person’s abdomen to achieve movement of the fetus to cephalic presentation. 

• In order to offer this service, ACOG recommends an evaluation of presentation beginning at 36’0 weeks. Check out PB 221 for more reading.

Considerations prior to ECV

• Patients who are good candidates for ECV are:

  • At least 37’0 and EFW > 2500g. 

    • Spontaneous version after this GA is less likely.

    • Risk of reversion to breech is significantly lower after this GA or lower than this EFW.

    • If complications arise, the infant is term and can be delivered emergently with less concern regarding sequelae of prematurity. 

  • Of higher parity

    • Multiple studies have reported positive associations between multiparity and success of ECV. 

  • In transverse or oblique presentations

    • While breech is not a contraindication by any means, traveling a little less far makes it easier!

  • With less cervical dilation, and of higher station

    • Babies lower in the pelvis are tough to turn!

• Things you might think make a difference, but actually are less important:

  • Placental location

    • Studies are mixed in this regard; some authors have found improved success with posterior placentation, while others have found no association. 

  • Amniotic fluid volume

    • This was one I always heard about in residency!

    • While it makes intrinsic sense that higher levels of fluid would lower success rates, studies have not actually demonstrated this conclusively. 

  • Maternal obesity

    • Another controversial topic where studies have been mixed in terms of predictors of success. 

  • Obesity

    • Some authors 

  • TOLAC candidates

    • The most recent interaction of the ECV bulletin addressed this question, noting there’s limited evidence for women with a preexisting uterine scar on ECV. However, in four trials, no cases of uterine rupture from ECV were reported, so it’s reasonable to offer. 

  • Ongoing labor

    • There is also limited evidence that ECV can be successful during early labor, lowering cesarean delivery rates and reducing hospital length of stay. 

Counseling for a procedure - risks and benefits

• Benefits

  • Certainly one benefit is the option of avoiding cesarean delivery! There is a significant reduction in cesarean birth rate for women who have successful ECV in randomized studies. 

    • Interestingly, the risk is still higher for cesarean in the ECV population compared to those who present with a fetus in cephalic presentation.

  • This also comes with the benefits of greater likelihood of vaginal delivery - most notably, fewer hospital days and lower odds of endometritis and sepsis. 

  • The success rate of ECV in trials is about 60% -- so a little better than 50/50. 

• Risks

  • Discomfort certainly is the biggest consideration -- we’re going to mash on your abdomen now! Pain medications parenterally or the use of epidurals can help reduce this element. There even is evidence that epidural anesthesia may increase success rates.

    • This should particularly be considered for women who have an unsuccessful ECV at 37 weeks, but wish to retry at 39 weeks. A placement of an epidural, followed by ECV attempt, which if unsuccessful provides anesthesia for cesarean delivery. 

  • Fetal heart rate abnormalities - fortunately, these are often transient decelerations that resolve with a pause or cessation in the procedure. 

  • Additional serious risks - placental abruption, umbilical cord prolapse, membrane rupture, stillbirth, and fetal-maternal hemorrhage have all been reported after ECV; however, all occur at rates of less than 1%. 

  • Need for emergent delivery - because of the rare risks above, women should be counseled that there is the very rare possibility of emergent delivery when ECV is attempted. ECV should only be performed in places where cesarean is readily available. 

After consenting your patient, prepare yourself for a procedure!

• Step 1: get an NST!

  • Certainly a non-reactive or suspicious NST pre-procedure would be a reason to re-consider doing something that might cause the fetus to react poorly. 

• Step 2: consider a cervical exam

  • If your patient has advanced cervical dilation, and you end up in the sticky situation of causing membrane rupture, it’s good to know if that 3cm cervix might drop a cord! 

  • Additionally, if you’re doing an ECV at 39+ weeks, this will let you consider what to use for induction subsequently. 

• Step 3: ultrasound

  • Do a quick survey. Take a look at a number of things, including:

    • True presentation: frank vs complete breech, transverse, oblique. 

      • What are frank and complete breech?

        • Frank we remember this as “Frank smells his feet.” This is the “pike” presentation where the fetus is maximally extended legs and flexed at the hips.

        • Complete this is the classic cross-legged sitting position.

    • Fluid volume

    • Placental location

• Step 4: orders!

  • Medications for ECV:

    • Pain medications -- as we mentioned above, can be considered in the form of parenteral meds or epidural anesthesia. If IV meds are given, be aware of the consequences on fetal heart rate of the med you’re giving. 

    • Tocolytics -- classically terbutaline, the B2-agonist. With relaxing the uterus, a randomized trial found that terbutaline doubled the chances of a successful ECV. 

      • There’s not much data regarding other uterine relaxants, but be aware that the beta-agonist effect of terbutaline often causes tachycardia -- so avoid in patients where that is contraindicated!

    • RhoGam -- we’re essentially inflicting trauma on the uterus. Check a type-and-screen beforehand. If delivery won’t be performed in the next 72 hours, a dose should be given.

      • Re-review our episode on preventing alloimmunization too! 

• Step 5: procedure time!

  • The procedure can be accomplished with one or two people.

  • Use LOTS of gel on the maternal abdomen to prevent trauma to the skin and facilitate easy ultrasound access for fetal heart rate checks. 

  • Classically, the procedure involves lifting the breech out of the pelvis with one hand, and then using pressure on the fetal head to facilitate a forward or backward roll. 

    • The procedure is successful when cephalic presentation is accomplished.

    • The procedure should be abandoned if there is prolonged bradycardia, extreme maternal discomfort, or if a few attempts have been unsuccessful. There’s no “right or wrong” number but having attempted many of these, you get a sense of whether they’ll roll or not. 

    • A great video of technique can be seen at https://www.youtube.com/watch?v=aWTmxPV15DI

  • Usually, institutions will have a monitoring protocol post-ECV attempt -- ACOG recommends at least 30 minutes of continuous monitoring, regardless of success.