Plan for cervical incompetence risk

•  Discuss the options of transvaginal cerclage (TVC) or transabdominal cerclage (TAC)
•  Surveillance for cervical change
•  Dynamic testing (fundal pressure)
•  Aggressive suppression of uterine activity to reduce pressure on cervix
  

Plan for chorion sharing

•  First trimester evaluation of fetal number and chorions/amnions
•  Frequent ultrasounds between 16 and 28 weeks
•  Monitor relative amniotic fluid volumes
•  Monitor size discordancy
•  Focused evaluation if oligo/poly or discordance
•  Amnioreduction if oligo/poly (Chorionic vessel interruption)

Surveillance for/treatment of preterm labor

•  Surveillance for evolution of uterine activity
•  Serial cervical evaluation by TV ultrasound
•  Modulate intervention according to effects on cervix
•  Bedrest
•  Calcium channel blocker
•  Subcutaneous terbutaline infusion
•  Intravenous magnesium sulfate
•  Indomethacin
  

Surveillance for growth deficiency

•  Serial ultrasound assessment of growth
•  Interfetal less important than intrafetal comparison
•  IGR will happen if carry long enough
•  IGR probably important by itself, but probably not curable by delivery
•  Biophysical surveillance for risk of fetal death
•  Delivery of one means delivery of all
  

Surveillance for/amelioration of preeclampsia

•  Minidose aspirin
•  Early detection of hypertension
•  Bedrest/antihypertensives
•  Assessment of proteinuria/LFT/Platelets
•  Fetal biophysical surveillance
•  Deliver for fetal status or ominous signs
•  Management of fluid shifts postpartum
  

Monitoring for risk of demise

•  NST’s must provide simultaneous recording
•  Biophysical profile probably most applicable
•  UA flow dynamics probably adjunctive, rather than centrally diagnostic
•  Subjective fetal movement assessment
  

Planning for delivery

•  Statistically, 35 weeks is point of lowest risk
•  Individualization is critical
•  Amniocentesis in face of IGR and 34 weeks
•  Biophysical deterioration at > 27 weeks
• Difficult decision before 28 weeks

Management of delivery

•  Blood available, depending on uterine size and clinical situation
•  Cesarean if 3rd trimester
•  Potent uterotonics available
•  Plan for hypogastric or uterine artery ligation if large uterus/late gestation
•  B-Lynch is a consideration
• Possibility of hysterectomy