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Re: Nuchal CordFrom: art fougner, md (evsono@pipeline.com)Tue Feb 24 06:42:09 2004
Frank Manning weighed in on this issue in an editorial in the November 1999 issue of the White Journal - "...it is our opinion that the presence of nuchal cord(s) should be sought for and become an integral part of third-trimester ultrasonographic assessment of the fetus and its environment. When this diagnosis is suspected yet not confirmed with application of gray-scale real-time ultrasound, if available, color Doppler imaging and/or Doppler flow velocimetry should be utilized. Following prenatal ultrasonographic identification of nuchal cord(s)we believe that modification of clinical management of this condition is in order. Despite the lack of objective data, we believe that it is intuitive and of major importance that, in addressing clinical management following the prenatal ultrasonographic diagnosis of nuchal cord(s), a number of pertinent questions be addressed. These include the number of loops of cord involved, the amniotic fluid volume status, fetal growth, gestational age and current status of fetal wellbeing. It appears that, when further complicating issues are confronted, such as significantly decreased amniotic fluid volume, postdates, fetal growth restriction, and especially decreased fetal movements, that immediate and repeated fetal testing measures be sought. With less than optimal fetal testing, delivery should be considered. Such fetal testing should consist of fetal biophysical profile, nonstress testing and Doppler velocimetry of the umbilical artery (other fetal vessels might also be interrogated – the middle cerebral artery, ductus venosus). Possibly further evoked tests, such as vibratory acoustic stimulation, or oxytocin challenge testing to assess the presence of variable decelerations of the fetal heart rate, may assist in dictating management. We anticipate that application of the aboveoutlined suggested management may decrease the occurrence of third-trimester in utero fetal demise associated with nuchal cord(s). While, clearly, physicians will be required mostly to reassure patients and relieve significant associated anxiety, we strongly believe that notation of this not uncommon prenatal condition should be forwarded to the patient and her physician, recorded in the medical records, and managed with close fetal surveillance of fetal movement counts, interval fetal testing and, in selected cases, delivery." Ultrasound in Obstetrics and Gynecology, Volume 14, Issue 1 (p 1-8) There is one caveat here - data concerning either the predictive value of the ultrasound diagnosis of nuchal cord is sorely lacking. Additionally, the history of modern obstetrics suggests that the introduction of technology often leads to multiple interventions with negligible benefit. A large prospective trial should be done. art
At Mon, 23 Feb 2004, Dave Berck wrote:
>
-- art fougner, md ich bin ein New Yorker
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