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Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
Prediction of early pregnancy outcomes.
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Prediction of early pregnancy outcomes.

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prediction of viability

prediction of viability

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  • 1. prediction of early pregnancy outcomes Narendra Malhotra Jaideep Malhotra Neharika Malhotra Bora Rishabh Bora Keshav Malhotra www.malhotrahospitals.com
  • 2. Outline of this Presentation Ultrasound diagnosis of early pregnancy failure Definition/Terminologies Sonographic criteria Guidelines for diagnosis Issues Current Recommendations Safe cut off level Follow up
  • 3. Definite signs of Early Pregnancy Failure • Absence of cardiac activity in an embryo -Embryonic demise • Absence of yolk sac/embryo in a large GS -Blighted ovum FAILED PREGNANCY
  • 4. Definite signs of Early Pregnancy Failure What is the descriminatory size for safe diagnosis? Mean Sac diameter CRL
  • 5. Definite signs of Early Pregnancy Failure What is the descriminatory size for safe diagnosis? TAS TVS Gestational sac (MSD) > 20mm with out YS > 8mm without YS > 25mm without cardiac activity >16mm without embryo cardiac activity Nyberg, 1986 Threatened Abortion: Sonographic distinction of normal and abnormal pregnancy
  • 6. Definite signs of Early Pregnancy Failure What is the descriminatory size for safe diagnosis? TAS TVS Embryo (CRL) > 8mm1 > 4mm 2 > 5mm 1,3 1 Pennell, 1991 Prospective comparison of vaginal and abdominal sonography in normal early pregnancy 2 Levi, 1990 TVS: Demonstration of cardiac activity in embryos of less than 5mm in CRL 3 Brown, 1990 Diagnosis of early embryonic demise by TVS
  • 7. GUIDELINES FOR DIAGNOSIS OF EARLY PREGNANCY FAILURE Royal College of Obstetricians and Gynaecologists (RCOG) 2006 • CRL ≥ 6mm with no visible cardiac activity • MSD ≥ 20mm without a visible embryo or yolk sac Society of Obstetricians and Gynaecologists of Canada (SOGC) 2005 • CRL > 5mm with no visible cardiac activity, >9mm(TAS) • MSD > 8mm without a visible yolk sac, 20mm (TAS) • MSD > 16mm without a visible embryo, (25mm (TAS) LEVEL 11-2 a AIUM, 2007 • CRL > 5mm (TVS) with no visible cardiac activity American College of Radiologists (ACR) 2000 • CRL > 5mm with no visible cardiac activity • MSD > 16mm without a visible embryo or yolk sac
  • 8. GUIDELINES FOR DIAGNOSIS OF EARLY PREGNANCY FAILURE Practice in the Philippines • CRL > 5mm with no visible cardiac activity • MSD > 18mm without a visible embryo or yolk sac Australian Society for Ulltrasound in Medicine (ASUM) • CRL > 6mm with no visible cardiac activity • MSD > 20mm without a visible embryo or yolk sac Hongkong College of Obstetricians and Gynaecologists (HKCOG) 2004 • CRL > 5mm (TVS), >9mm (TAS) with no visible cardiac activity • MSD ≥ 20mm without a visible embryo or yolk sac OB-GYN USG for practicing Clinician 2nd Ed FOGSI GUIDELINES A FEW YEARS BACK MSD >20without YS/E :CRL >6mm without cardiac activity IFUMB/ICMU and ICOG
  • 9. Author Type of Study Study Pop (n) Exam Sonographic criteria used Nyberg (1986) Cohort, Retrospective 168 TAS No embryo, MSD >25mm, No yolk sac, MSD > 20mm Nyberg (1987) Cohort Prospective 83 TAS No embryo, MSD >25mm, No yolk sac, MSD > 20mm Scott (1987) Cohort Prospective 102 TAS Empty GS > 26mm Levi (1988) Cohort Prospective 55 TVS No YS and MSD > 8mm No embryo, cardiac > 16mm Levi (1990) Cohort retrospective 71 TVS No cardiac activity, CRL < 5mm
  • 10. Best criteria have 95% CI range of 0.96 to 1.00
  • 11. Best criteria: An empty gestational sac > 25mm Missing yolk sac with gestational sac > 20mm: Specificity 1, 95% CI range of 0.96 to 1.00 ***Up to 4 in every 100 diagnosis may be false positive
  • 12. Inclusion criteria: - Intrauterine pregnancy of uncertain viability (IPUV) at sonography IPUV defined as an MSD < 20mm with no obvious yolk sac/embryo or CRL < 6mm with no fetal heart activity 2D-transvaginal scans (6–12 MHz) at 0 and 7–14 days later
  • 13. MSD 16mm: FPR (viable pregnancy): 4.4% MSD 20mm: FPR is 0.5% MSD 21mm: vFPR is 0
  • 14. CRL 4mm and 5mm: FPR= 8.3% CRL 5.3mm: FPR=0
  • 15. ** There are still a number of cases at or around the critical decision boundaries(descriminatory level) used to define miscarriage. ** There is a need to increase the cut off level to a safer level.
  • 16. Pexsters A et al., UOG 2011 Prospective cross-sectional study 54 women at 6–9 weeks • Observers blinded • CRL measured from the outer ends • Gestational sac measured in three planes • CRL and MSD measured twice by each observer
  • 17. Pexsters A et al., UOG 2011 Results • Based on 95% CI, for a given CRL of 6mm as measured by one observer, the second observer’s measurement may range from 5.4 to 6.7mm • Similarly, given an MSD of 20mm as measured by one observer, the measurement for the second observer may range from 16.8 to 24.5mm
  • 18. • Data from these studies show that current definitions used to diagnose miscarriage are potentially unsafe • Significant interobserver variability may be associated with a misdiagnosis of miscarriage • Current national guidelines should be reviewed to avoid inadvertent termination of wanted pregnancy • Large prospective studies with agreed reference standards are urgently required
  • 19. RECOMMENDATIONS Empty GS = an MSD of 25 mm with out yolk sac or embryo Embryonic demise= A CRL of 7mm with no cardiac activity Wait for 7-10 days before a repeat scan if results are below the descriminatory level.
  • 20. SUMMARY The current criteria used to diagnose miscarriage at ultrasound show variation. Current guidelines are based on weak or moderate level of evidence (small studies or opinion). Diagnosis of Early Pregnancy Failure The descriminatory size of 5mm for CRL and 20mm for GS may be unsafe cut off levels and may result to inadvertent termination of pregnancy.
  • 21. SUMMARY A new cut off level of MSD of 25mm empty sac and CRL of 7mm without cardiac activity to make a diagnosis of pregnancy level is being considered Diagnosis of Early Pregnancy Failure National guidelines should be reviewed, a diagnosis of pregnancy failure should have no chance of error (100% specificity).

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