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Monday, 28 September 2015

External Cephalic Version (ECV)

In a normal pregnancy, the baby settles in a cephalic (head down) position by the last few weeks of pregnancy, ready for delivery ^[1]. But sometimes, the baby may remain in a feet-down position (breech baby) ^[2] even as your labor starts, often requiring a c-section. In such cases, the External cephalic version or ECV may come useful, letting you consider a natural delivery ^[3].

What is and external cephalic version (ECV)

An external cephalic version or ECV is a medical procedure for turning your baby into a proper head-down position from a breech or transverse presentation by applying pressure on a certain point in your belly ^[4].

ECV procedure: Turning a breech baby

The main purpose of attempting an ECV is to give the mother a chance to have a natural vaginal birth. Before an ECV, you may be given some tocolytic medication (labor repressants) to relax the uterine muscles and prevent contractions during the procedure ^[4]. The doctor then places his hands on your abdomen, one above the place where the baby’s head is and another below his buttocks and pushes the baby to make him rotate ^[5]. In some cases, it may need more than one attempt to successfully turn the baby. You may be offered a local anesthesia, especially if ECV is attempted multiple times.

External Cephalic Version

Your baby’s position, as well as his heart rate is closely monitored at all time ^[6] so the process can be stopped the moment there is the smallest sign of fetal distress (such as his heart rate dropping suddenly) ^[5]. Due to this reason, an ECV is always performed at a hospital where the doctor may monitor the baby easily using methods and equipments like ultrasound, and an emergency c-section may be arranged in case of a possible threat to the mother or the baby ^[7]. The amniotic fluid level is also measured prior to the procedure while Rh-negative women are given an Rh immune globulin injection to avoid complications ^[8].

When is an ECV attempted

No specific gestational age has been set as ideal for attempting an ECV. Although, studies have shown it to reduce the chances of a breech presentation at birth when performed before term (weeks 33-36), it is usually performed in or after week 37 ^{[7, 9]} as your baby may still have time to turn on his own before that ^[10]. It is associated with a considerable success rate when performed in up to 42 weeks ^[11].

Women with their first pregnancy are usually offered an ECV at or after the 36th week while those with a second or subsequent pregnancy may have the procedure after week 37 ^[11].

Does an external cephalic version hurt

Most women describe the process as uncomfortable to moderately painful, but bearable due to its short duration ^[18]. About 5% of women undergoing ECV have reported severe pain during the attempt ^[11]. Analgesic medication may be necessary to carry on the process in some cases. The version may be stopped if the mother experiences excessive pain as it might indicate some complications ^[14]. It has been found that a successful ECV causes less pain than an unsuccessful one ^[19].

When is external cephalic version avoided

Your doctor may check your medical history and examine your baby to see if a cephalic version should be contraindicated. Common factors to avoid it include:

Having a suspected placental complication, such as a previa or an abruption, in this pregnancy or history of one in a previous pregnancy

Severe high blood pressure or preeclampsia ^[12]

Having experienced any vaginal bleeding within the past week ^[13]

Having an abnormally shaped uterus (e.g. a bicornuate uterus) ^[14]

Low levels of amniotic fluid or any other complication associated with the fluid or sac, such as ruptured membranes

Tocolytic medications contraindicated for the mother due to some heart disorder or some other health condition ^[5]

History of a cesarean section or needing a c-section in current pregnancy due to some other complications ^[15]

Carrying twins

Ultrasound or some other test detecting any sign of fetal distress (e.g. irregular heart rate) ^[16]

Suspecting some fetal growth restriction or anomaly ^[18]

Are there any risks of an external cephalic version (ECV)

Studies show ECV to be possibly safe, being associated with a small chance of some serious complications.

Maternal complications

It rarely leads to any complications, but in any case, the following complications should be considered before opting for the procedure:

Placental abruption ^[20]

Your waters breaking early (premature rupture of membranes) ^[21]

Uterine rupture (rare) ^[22]

Beginning of labor (in about 1% of the cases) ^[15]

Women who opt for an ECV have a higher chance of requiring a cesarean delivery than those with a spontaneously occurring cephalic presentation (study). Due to this reason, it is usually preferable to wait for as long as possible to give the baby a chance to turn into position on his own before attempting a version ^[23].

Fetal complications

Multiple studies have shown no increase in the risk of intrauterine fetal death within 24 hours of successfully turning a breech baby. The fetal heart rate is monitored immediately after the procedure to check for any abnormalities. There are usually no complications, but EVC may sometimes lead to:

Changes in the fetal heartbeat detected on the monitor ^[24]

The umbilical cord getting squeezed, reducing the oxygen and blood flow to the fetus ^[5] (increasing the risk of birth defects and problems such as brain damage)

Nuchal cord ^[29]

Fetomaternal hemorrhage (fetal blood cells getting into the mother’s blood-stream) ^[25]

An emergency c-section is necessary in around 0.50% of all ECV attempts, commonly because of signs of fetal distress or placental bleeding ^{[8, 13]}.

External cephalic version success rate

It is successful in over 50% of cases ^[26] in reducing the chances of a vaginal breech delivery as well as a c-section (study review), with the exact success rates depending on the medical history of the mother as well as the health of the baby ^[13]. About 90% of transverse babies have been turned successfully using this method ^[8].

C-section is one of the principle causative factors for various maternal complications after childbirth. So, ECV also contributes to reducing the risk of such problems ^[4]. However, even after a successful attempt, your baby may turn back into a breech position (in less than 5% cases ^[27]), requiring a cesarean birth ^[6]. Your doctor may also schedule a second attempt if possible.

Factors contributing to a better chance of success

Having had a baby before ^[26]

The baby being situated high up in the uterus and not engaged in the pelvis ^[6]

Having proper amniotic fluid levels around the baby

Having a posterior placenta (located at the posterior side of the uterus) ^[16]

The mother having proper BMI and body weight

A complete breech presentation of the baby

Routine use of tocolytics has also been shown by studies to increase the success rate of ECV when performed at term. Epidural anesthesia has been shown to contribute to a better chance of success as well (study).

When to call the doctor

Talk to your doctor to understand the care and restrictions necessary following the procedure. Watch out for the following warning signs after an ECV:

Any vaginal bleeding ^[21]

Increased fluid leakage

Reduced fetal movement ^[6]

Abdominal pain or contractions

Oral temperature being over 102°F ^[14]

External cephalic version ICD-9 code

The ICD-9-CM code used for referring to ECV is 73.91 ^[28].

References +

http://www.nct.org.uk/birth/baby-positions-birth

http://www.babycentre.co.uk/a158/breech-birth

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/breech-birth.aspx#close

http://emedicine.medscape.com/article/1848353-overview

http://www.webmd.com/baby/external-cephalic-version-version-for-breech-position

http://www.babycentre.co.uk/x2063/can-my-breech-baby-be-turned-safely

http://apps.who.int/rhl/pregnancy_childbirth/childbirth/breech/cd000083_leder_com/en/

http://www.babycenter.com/0_breech-birth_158.bc?showAll=true

http://www.babycenter.com.my/x2063/are-there-any-safe-and-proven-methods-to-turn-a-breech-baby

http://www.whattoexpect.com/pregnancy/breech-baby/

https://www.rcog.org.uk/globalassets/documents/guidelines/gt20aexternalcephalicversion.pdf

http://www.kemh.health.wa.gov.au/development/manuals/OG_guidelines/sectionb/2/b2.10.2.pdf

https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/turning-a-breech-baby-in-the-womb-external-cephalic-version.pdf

http://www.sw.org/HealthLibrary?page=External%20Cephalic%20Version

http://www.newcastle-hospitals.org.uk/services/maternity-unit_treatment-and-medication_external-cephalic-version.aspx

http://evidencebasedbirth.com/what-is-the-evidence-for-using-an-external-cephalic-version-to-turn-a-breech-baby/

http://www.aafp.org/afp/1998/0901/p731.html

http://www.uhcw.nhs.uk/clientfiles/File/ECV_163_Mar_2013.pdf

http://www.ncbi.nlm.nih.gov/pubmed/16026399

http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/placental_abruption

https://www.ottawahospital.on.ca/wps/wcm/connect/612592804f7cbd779d4cdf62660efeb4/P325+English+Jan+2011.pdf?MOD=AJPERES

http://addisonob-gyn.org/ECV.pdf

http://www.nct.org.uk/birth/breech-birth

http://www.acog.org/Patients/FAQs/If-Your-Baby-Is-Breech

http://www.ncbi.nlm.nih.gov/pubmed/18591311

http://www.uptodate.com/contents/external-cephalic-version

http://patient.info/doctor/breech-presentations

http://icd9cm.chrisendres.com/index.php?srchtype=procssrchtext=73.91Submit=Searchaction=search

http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?AccessionNumber=12006008180

External Cephalic Version (ECV)

Amniocentesis

What is amniocentesis?

Amniocentesis (also referred to as amnio, amniotic fluid test or AFT) is a prenatal testing procedure with significant accuracy. It involves collecting an amniotic fluid sample from the uterus and testing it in the laboratory for certain fetal abnormalities and genetic conditions. ^[1]

Who should have amniocentesis?

Women over 35 years old (babies born to older women are more at risk of developing genetic conditions like Down syndrome) ^[2]

Women with a history of a neural tube defect (a condition affecting the brain and spinal cord) or any chromosomal condition in a previous pregnancy ^[13]

Women with positive results from prenatal screening tests such as a blood test or noninvasive prenatal testing ^[3]

Women who have a family history of any genetic condition like cystic fibrosis, sickle cell disease and Down syndrome ^[4]

Why is amniocentesis performed?

For detecting hereditary conditions like spina bifida ^[5], Down syndrome and fragile X syndrome

For assessing the lung maturity of the baby if an early delivery is required due to some pregnancy complication

For detecting intrauterine infections

For finding out whether the baby has any life threatening conditions like Edward’s syndrome (Trisomy 18), Patau syndrome (Trisomy 13) and Tay-Sachs disease

For assessing the health of the baby in case the mother has a blood sensitization, like Rh sensitization (a serious condition that occurs when the mother has a different blood type than the baby). But at present, obstetricians often use a Doppler ultrasound instead of AFT for detecting such conditions.

For determining the gender of the baby ^[6]

For decreasing the amniotic fluid volume within the uterus (rarely in cases of polyhydramnios)

When is amniocentesis performed?

AFT is usually performed during the second trimester, particularly between the 15th and 20th weeks of pregnancy ^[7]. It may also be performed during the later stages of pregnancy (third trimester), especially before a pre-term delivery or a c-section birth.

Guidelines to prepare for amniocentesis

Drinking lots of water may be recommended prior to the ultrasound as a full bladder helps to produce better results

One may be advised not use Aspirin pills for five days before the amnio procedure ^[8]

One may be asked to avoid heparin and Lovanox for 24 hours before the procedure

What is the procedure of amniocentesis?

The step by step procedure includes performing an ultrasound to ascertain the positions of the baby, the placenta and the amniotic fluid pockets, then disinfecting the mother’s belly area with an antibacterial solution to prevent infecting the fluid while collecting the sample ^[7]. Next, the diagnostician collects around one ounce of amniotic fluid using a thin needle while monitoring the path of the needle on ultrasound. The ultrasound also helps to make sure that the baby’s heartbeat is normal after collecting the fluid sample. It is then sent to a clinical laboratory for karyotyping ^[18] – a process used for examining the chromosomes in the cells within the sample.

Amniocentesis Tests

Does amniocentesis hurt?

It is not a painful process as most women feel only a sharp pinch, along with a lot pressure, when the needle goes through the uterus. Some women can barely feel it when the needle is run through the abdominal skin, but may feel a sharp pain when the needle goes through the uterus (it does not last for more than a few seconds).

Does amniocentesis need any aftercare?

Doctors recommend 24-hour bed rest following the test

Following a healthy diet containing fresh fruits, vegetables and dairy products

Drinking ample amounts of fluid

Practicing relaxations techniques as the stress and anxiety associated with the test may be harmful for the baby ^[9]

How long does it take to get the amniocentesis results?

Depending on the purpose of the test, the results are available:

Within 10 days (when checking fetal abnormalities like neural tube defects and protein levels in the fluid)

Up to 2 weeks (when checking for any genetic conditions in the baby)

Having a FISH (fluorescent in situ hybridization) test along with an amnio helps to get the results within a couple of days instead of weeks. It has a significant accuracy rate in predicting chromosomal abnormalities in the baby. ^[14]

Are there any side effects of amniocentesis in the mother?

It is a fairly safe screening procedure that often does not cause any side effects; however, some women may experience:

Mild to moderate cramping that continues for a few hours after the fluid sample is collected

Soreness and irritation around the spot where the needle was inserted (usually lasts for a couple of days) ^[10]

Continuous vaginal wetness due to leakage of amniotic fluid

Moderate to severe headache (rare)

What are the risks of amniocentesis for the baby?

Amniotic Fluid Leakage: Occurs after the test, often stopping on its own without causing any serious complications. However, in some cases, chronic fluid leakage may lead to orthopedic complications for the baby. ^[11]

Needle Injury: The baby may get injured by the needle if it moves a leg or an arm into its path. However, serious injuries of this kind are rare.

Rh sensitization: In some rare instances, the test leads the blood cells of the baby to enter the bloodstream of the mother ^[11]. This may cause various complications if the mother has Rh negative blood (in such cases, the mother is given Rh immunoglobulin following the test to prevent her body from generating antibodies against the baby’s blood cells).

Uterine Infection (rare)

Infection transmission: If the mother is affected by an infectious disease, like toxoplasmosis, hepatitis C or HIV, the infection may be transferred to the baby during the examination.

Scarring: Sometimes, the baby may be born with a small depressed scar resulting from an amnio test performed during mid-trimester. ^[12]

What are the odds of a miscarriage following an amniocentesis?

The risk of miscarriage associated with the test ranges from 1 in 300 to 1 in 500 ^[11]. According to researchers, having amniocentesis before the 15th week of pregnancy increases the danger of a miscarriage. The chances of miscarriage are somewhat higher in women carrying twins or triplets.

What are the limitations of amniocentesis?

An AFT can rule out only certain chromosomal and genetic disorders in the baby. It cannot detect conditions like autism, non-specific mental retardation, cleft lip and various heart defects ^[6]. So, having a negative test result does not guarantee that one will have a normal baby.

Although amnio produces accurate results, it is sometimes difficult to interpret them. Such cases may call for additional chromosome testing. ^[17]

Amniocentesis Vs Chorionic Villus Sampling

Chorionic villus sampling (CVS) is another prenatal screening test that helps with the diagnosis of chromosomal abnormalities in the fetus. Although, the basic purpose of both amnio and chronic villus sampling is to detect chromosomal or genetic abnormalities in the baby, their procedures are completely different. CVS involves collecting cell sample from the tiny finger-like projections called chorionic villi, located on the placenta ^[15]. The sample is then sent to a lab for genetic analysis.

One of the main advantages of amnio over CVS is that the former can detect neural tube defects (spina bifida) as well as chromosomal defects in the baby ^[15] while the latter cannot. On the other hand, CVS has the advantage over amnio as it can be performed during the first trimester (typically between the 11th and 12th week), which enables parents to know whether their baby has any serious birth defects at an earlier stage.

Are there any alternatives to amniocentesis?

There is a new non-invasive fetal DNA test that can be used instead of amnio ^[16]. This cell-free blood test produces accurate results while there is no risk of miscarriage. In this test, a blood sample is collected from the mother to examine the DNA of the baby for any abnormalities.