Moderator- Dr.Sameer Dikshit
Dr.Sameer Dikshit MD, DGO,FCPS,FICOG Fetal Medicine Consultant <ul><li>FMF certified sonologist </li></ul><ul><li>Trained ...
Dr.Poonam Loomba
Dr.Ratna Kaul
Dr.Chander Lulla
Dr.Sabuj Sengupta
Dr.Madhuri Sengupta
<ul><li>Mrs. A, 32 year Primigravida first seen at 12 weeks gestational age </li></ul><ul><li>She was corresponding to the...
<ul><li>Targeted Scan done at 20 weeks- NAD </li></ul><ul><li>She was seen at 28 weeks when Fundal Height was correspondin...
How will you proceed?
USG done showed:-
28 weeks GA Measurement Weeks BPD 64 mm 26 weeks HC 234 mm 25 week 4 days AC 201 mm 24 weeks 5 days FL 44 mm 24 weeks 3 days
Is this information sufficient?
28 weeks GA Measurement Weeks Centile BPD 64 mm 26 weeks <2 nd HC 234 mm 25 week 4 days <2 nd AC 201 mm 24 weeks 5 days <2...
Would you call this IUGR?
28 weeks GA Measurement Weeks Centile BPD 64 mm 26 weeks <2 nd HC 234 mm 25 week 4 days <2 nd AC 201 mm 24 weeks 5 days <2...
Now, would you call this IUGR? What is more significant? AC or EFW?
 
Umbilical Vein (LUV) Intra hepatic portion of UV Portal  Sinus Right Portal vein Ductus Venosus IVC Left Portal vein Left ...
Evolution of IUGR <ul><li>Adverse placental conditions results in deficient delivery of nutrients to the Fetus </li></ul><...
<ul><li>This results in delivery of more nutrients to RA at the cost of PORTAL CIRCULATION </li></ul><ul><li>PRECLINICAL ...
<ul><li>First to get affected is AC </li></ul><ul><li>Fetal vascular adjustments with “Brain Sparing” effect </li></ul><ul...
Let us assume that both AC and EFW are less
28 weeks GA Measurement Weeks Centile BPD 64 mm 26 weeks <2 nd HC 234 mm 25 week 4 days <2 nd AC 201 mm 24 weeks 5 days <2...
Any other sonography finding you would like to know?
28 weeks GA Measurement Weeks Centile BPD 64 mm 26 weeks <2 nd HC 234 mm 25 week 4 days <2 nd AC 201 mm 24 weeks 5 days <2...
What investigations would you like to do?
Could this be due to Perinatal Infection? <ul><li>TORCH???? </li></ul>
Ventriculomegaly <ul><li>Markers for Perinatal Infection </li></ul>
Intra Cranial Calcifications <ul><li>Markers for Perinatal Infection </li></ul>
Hepatic Calcifications <ul><li>Markers for Perinatal Infection </li></ul>
Thick Placenta <ul><li>Markers for Perinatal Infection </li></ul>
Fetal Hydrops <ul><li>Markers for Perinatal Infection </li></ul>
Echogenic Bowel <ul><li>Markers for Perinatal Infection </li></ul>
Could this be a genetic syndrome?
<ul><li>Early onset IUGR </li></ul><ul><li>Hydrocephalus/ Microcephaly/Abnormal shape of skull </li></ul><ul><li>Macrosomi...
<ul><li>Micro-opthalmos, cataract </li></ul><ul><li>“ Abnormal Facies” </li></ul><ul><li>Cystic Hygroma </li></ul><ul><li>...
<ul><li>Extra digits/ Clenched fists/ club feet </li></ul><ul><li>Absent/ short radius </li></ul><ul><li>Posterior fossa a...
<ul><li>Hyper/ Hypo telorism </li></ul><ul><li>Cranio synostosis </li></ul><ul><li>Proboscis </li></ul>
What about Doppler Studies?
What vessels will you study?
<ul><li>Umbilical Artery </li></ul><ul><li>Middle Cerebral Artery </li></ul>
What are cut-off values?
http://www.perinatology.com/calculators/umbilicalartery.htm
http://www.perinatology.com/calculators/exbiometry.htm
At 30 weeks.. 5 th  centile 95 th  centile Umb Artery PI 1.1 0.88 1.39 MCA  PI 2.1 1.51 3.0 CPR 1.9
What is the interpretation? When will you repeat the test?
At 32 weeks.. 5 th  centile 95 th  centile Umb Artery PI 1.4 0.7 1.23 MCA  PI 1.8 1.5 2.8 CPR 1.28
What is the interpretation? How often will you monitor the pregnancy now?
At 33 weeks.. 5 th  centile 95 th  centile Umb Artery PI 1.7 0.6 1.21 MCA  PI 1.2 1.4 2.7 CPR 0.7
Ductus Venosus doppler shows “A wave reversal. What will you do now?
Is there some test before DV abnormalities?
Reversal of flow in Aortic Isthmus
<ul><li>Increasing placental resistance and decreasing cerebral resistance </li></ul><ul><li>Reversal of diastolic flow in...
<ul><li>Umbilical Artery/ MCA </li></ul><ul><li>MCA/Umbilical Artery </li></ul><ul><li>Abnormal CPR </li></ul><ul><li>DV <...
 
Doppler Parameter Days to delivery/ demise Abn Umb A PI 3 weeks Abn CPR 2 weeks Absent Umb A EDV 10 days Abn MCA PI 7 days...
Mild Disease <ul><li>Usually doppler abnormality detected at 32 weeks </li></ul><ul><li>Usually only Umb Art abnormality <...
<ul><li>No perinatal mortality </li></ul><ul><li>Pregnancy can be taken to 36 weeks </li></ul>
Progressive Disease <ul><li>Initial Doppler abn at 28-30 weeks </li></ul><ul><li>Either 1 vessel abn which progressed to 2...
<ul><li>Full fledged Doppler abn by 21 days </li></ul><ul><li>Pregnancy can be extended max by 5 weeks from date of first ...
Severe Early Onset <ul><li>First Doppler abn before 28 weeks </li></ul><ul><li>Median progression interval 7-9 days </li><...
<ul><li>Delivery by 32-33 weeks </li></ul><ul><li>Significant perinatal mortality </li></ul>
 
Role of NST….?
If NST is non reactive at 37 weeks, which Doppler study would you recommend?
Doppler changes in IUGR <ul><li>Normoxemic centralisation </li></ul><ul><li>2) Hypoxemic centralisation </li></ul><ul><li>...
<ul><li>Doppler progression occurs in this stage </li></ul>Stage of Normoxemic Centralisation
Stage of Hypoxemic Centralisation  <ul><li>NST is non reactive </li></ul><ul><li>Beat to beat variability is affected </li...
Stage of Decompensation <ul><li>Venous abnormalities </li></ul><ul><li>DV “A” wave reversal </li></ul><ul><li>Umbilical Ve...
<ul><li>Further hypoxia </li></ul><ul><li>Build up of tissue lactic acid </li></ul><ul><li>Rapid shifting of O 2  dissocia...
<ul><li>Use of computerised NST </li></ul><ul><li>Baseline FHR, short term/ long term variability </li></ul><ul><li>Accele...
<ul><li>Can be used judiciously if one knows that NST changes appear late in the chain of events </li></ul>
Is there any role of Fetal Biophysical Profile?
Uterine Artery Doppler showed bilateral diastolic notches. What is the significance?
How will you manage the pregnancy during labour?
Role of Fetal ST wave analysis?
STAN S-31
 
<ul><li>ST waveform represents balance between energy yielding and energy consuming processes </li></ul><ul><li>With Fetal...
<ul><li>Scalp Electrode is required </li></ul><ul><li>Initial 20 minutes recording to get baseline pattern </li></ul><ul><...
<ul><li>Terminally sick fetuses may not be able to show ST wave changes </li></ul><ul><li>In these fetuses the ST wave cha...
What about Fetal Pulse Oximeters?
<ul><li>Only indirect estimate of Fetal PO2 </li></ul><ul><li>Measures PO2 at systole in scalp skin microcirculation </li>...
<ul><li>Single reading is not sufficient </li></ul><ul><li>ACOG has raised concerns about potential increase in costs with...
Where does continuous electronic Fetal Monitoring stack??
<ul><li>Commercially available in 1960s </li></ul><ul><li>Widely used in 1980s  </li></ul><ul><li>However, Cochrane review...
<ul><li>Suggested that failure to interpret the FHR chart was the common cause of mistakes </li></ul><ul><li>Failure to un...
<ul><li>False positive rate of EFM for predicting cerebral palsy exceeds 90% </li></ul><ul><li>Interpretation of FHR is su...
<ul><li>Intermittent Auscultation in labour for low risk cases </li></ul><ul><li>Electronic Fetal Heart Monitoring is reco...
<ul><li>G3 P2 L1 with previous history of preterm delivery at 24 weeks comes for ANC registration at 12 weeks.  </li></ul>...
Which is the better route for cervical length assessment? PA or PV??
<ul><li>In PA route, cervix may not be seen in 50% of cases </li></ul><ul><li>But when the bladder is full, the cervical l...
What is the technique for measuring cervical length?
<ul><li>Empty the bladder, in dorsal lithotomy position </li></ul><ul><li>Probe is placed in the anterior fornix </li></ul...
<ul><li>TVUSS of cervical length is highly accurate and reproducible </li></ul>
What is the significance of cervical length?
<ul><li>Median cervical length is 36 mm </li></ul><ul><li>In 1.6% of the cases it is < 15 mm </li></ul><ul><li>Cut off of ...
 
What is the significance of past h/o Preterm Delivery in the obstetric outcome
<ul><li>Cervical length at 23 weeks only predicts risk of preterm delivery <32 weeks or within next 10 weeks </li></ul><ul...
Is there a role for routine screening for bacterial vaginosis?
<ul><li>No association between bacterial vaginosis and short cervical length </li></ul><ul><li>Mere colonisation of lower ...
<ul><li>Cervical mucus plug provides an effective barrier for infection </li></ul><ul><li>Loss of the cervical mucus due t...
Would you offer the patient elective cerclage?
<ul><li>Elective cervical cerclage in the absence of cervical changes is reserved for those patients with 3 or more second...
This patient had a cervical length of 2.8 at 14 weeks. At 23 weeks, the cervical length is 1.4 cm. What would you do? <ul>...
<ul><li>In women with cervical length less than 1.5 cm at 23 weeks, insertion of Shirodkar cerclage results in 10 fold red...
<ul><li>All the patients who underwent cerclage had a take home baby rate of 100% </li></ul><ul><li>95% of those with cerv...
Before cerclage
Immediately after cerclage
4 weeks post cerclage
<ul><li>No consensus if supra cerclage shortening of cervix had any prognostic relevance </li></ul>
<ul><li>In women with increased risk of preterm delivery based on history, a policy of sonographic surveillance followed b...
What is the role of “early” cervical assessment @ 11-13 weeks? <ul><li>Some studies have stated that it is of no consequen...
<ul><li>23 weeks’ cervical assessment may be too late for prevention </li></ul><ul><li>False negatives occur because inadv...
 
<ul><li>Identify endocervical canal (translucent or echodense) </li></ul><ul><li>No pressure on cervix </li></ul><ul><li>W...
 
<ul><li>Cervical length <25 mm was significant </li></ul>
What is the role of Fetal Fibronectin?
<ul><li>It is a protein produced by Trophoblast </li></ul><ul><li>It is considered as glue between placental membranes and...
<ul><li>Maternal salivary Estriol >2.1 ng/mL </li></ul><ul><li>Uterine activity monitor </li></ul><ul><li>Multiple Marker ...
Amniotic Fluid Sludge
Amniotic Fluid Sludge <ul><li>AF sludge is defined as presence of dense aggregates of particulate matter in proximity to t...
<ul><li>Prevalence of AF sludge was high in asymptomatic patients at risk for PT labour </li></ul><ul><li>AF sludge was an...
Images of Cervix
Dilatation of cervix
Funneling of cervix
Herniation of membranes
What is the significance of funneling?
<ul><li>Funneling is defined as dilatation of internal os > 5mm persisting throughout 3 min duration of the procedure </li...
<ul><li>When cervical length is taken into account, “Funneling” did not provide any extra information </li></ul><ul><li>Wo...
 
<ul><li>36 year old G2 P1 came to the ANC clinic with a sonography report saying “Twin Pregnancy of 8 weeks and 2 days” </...
Is this report adequate?
<ul><li>Chorionicity </li></ul><ul><li>CRL discrepancy, if any </li></ul><ul><li>Mapping </li></ul>
It is monochorionic Twin Pregnancy How will you monitor the pregnancy?
She comes for First Trimester Screening   What is more significant? NT or Biochemistry or Both?
What is the false positive of NT measurement in Monochorionic Twins Pregnancy?
Can one predict development of TTS?
<ul><li>Inter-twin discrepancy in CRL </li></ul><ul><li>Increased NT </li></ul><ul><li>“ A” wave reversal of DV </li></ul>
No development of TTTS
TTTS developed later
<ul><li>Difference in CRL > 10 mm (8% sensitivity) </li></ul><ul><li>Difference in NT > 0.6 mm (50% sensitivity) </li></ul...
<ul><li>NT difference > 0.6 mm AND abnormal DV in at least 1 fetus, the relative risk was 21 </li></ul>
How frequently should one monitor the pregnancy? And what should one monitor?
<ul><li>Monitored by USG every 15 days  </li></ul>
<ul><li>EFW </li></ul><ul><li>Folding of inter-twin membrane </li></ul><ul><li>Deepest Vertical Pocket </li></ul><ul><li>B...
What are the signs of TTTS?
<ul><li>Oligohydramnios and absent bladder in donor </li></ul><ul><li>Polyhydramnios and dilated bladder in recipient </li...
The pregnancy progresses to 26 weeks, there is no TTS, how will you monitor the pregnancy?
Role of cervical screening
<ul><li>In twin pregnancies, the rate of preterm birth is 5-10% </li></ul><ul><li>Median cervical length was 35 mm </li></...
<ul><li>In addition to cervical length, patient characteristics like parity, Obs history, weight , race also influence the...
<ul><li>G3 P2 first came for ANC registration at 12 weeks </li></ul><ul><li>All investigations were normal </li></ul><ul><...
What counseling will you offer?
What other tests will you do?
What is the role of TORCH test?
Toxo IgG negative, IgM negative   ?
Toxo IgG positive, Toxo IgM positive 
Toxo IgG negative, Toxo IgM positive 
 
What are the sonological markers of TORCH infection?
 
When do these markers appear??
What is Toxo Avidity Test? How do you interpret it?
<ul><li>High Avidity antibodies develop  12-16 weeks  after infection </li></ul><ul><li>So high avidity suggests that the ...
What test will you perform next?
<ul><li>Positive 6 weeks after fetal infection </li></ul><ul><li>It is indicated in:- </li></ul><ul><ul><li>When serologic...
GA @ sero -conversion Risk of congenital infection Development of severe clinical signs Avidity Test Amniotic fluid PCR 1 ...
 
How will you treat the patient?
<ul><li>G3 P2 weighing 70 kg came for ANC check up </li></ul><ul><li>She was 28 weeks and glucose challenge test showed gl...
How will you monitor the fetus?
What things will you look for in Ultrasound examination?
<ul><li>Look for congenital abnormalities </li></ul><ul><ul><li>Cardiac </li></ul></ul><ul><ul><li>CNS </li></ul></ul><ul>...
What are sonological signs of poor glycemic control?
<ul><li>Fetal Macrosomia </li></ul><ul><li>Increased Fetal Fat (> 5 mm at anterior abd wall) </li></ul><ul><li>Increased t...
How will you monitor the fetal well being?
What is the role of Doppler?
<ul><ul><li>MCA PI and UA PI are less than optimal in predicting adverse outcome </li></ul></ul><ul><ul><li>Give a false s...
<ul><ul><li>There is risk of placental dysfunction </li></ul></ul><ul><ul><li>Hyper viscosity of the fetal blood due to po...
<ul><li>DV PI is considered to be more significant in predicting adverse outcome </li></ul><ul><li>Fetal IVS > 6mm is used...
Can you predict shoulder dystocia?
<ul><li>DM  </li></ul><ul><li>Fetal Macrosomia </li></ul><ul><li>Short occipito frontal diameter   rounder head   slips ...
<ul><li>A model with  </li></ul><ul><ul><li>Expected Fetal Weight </li></ul></ul><ul><ul><li>Maternal Weight </li></ul></u...
<ul><li>G1 P0 with 4 days postdated came for routine ANC examination </li></ul>Case#6
When would you carry out investigations?
What investigations would you carry out?
Role of NST?
Role of Fetal BPP?
Role of Doppler?
<ul><li>36 year old G2 P1 with previous history of Down’s baby  </li></ul><ul><li>Came at 9 weeks </li></ul>Case #7 First ...
What advise will you give”
Is the risk higher? By what percent?
Will you go for straight invasive testing?
<ul><li>Her NT is 2.8 </li></ul><ul><li>The combined risk is 1:60 </li></ul>
CVS or Amnio?
FISH of full Karyotype?
What about cell free DNA?
Karyotype is Normal….what next?
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Fetal monitoring panel discussion

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My Panel Discussion on Fetal Monitoring

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  • IUGR
  • TORCH? Perinatal Infection? Genetic Syndrome?
  • PT
  • Twins
  • Fetal Infection
  • Diabetes
  • Postdated
  • Fetal monitoring panel discussion

    1. 1. Moderator- Dr.Sameer Dikshit
    2. 2. Dr.Sameer Dikshit MD, DGO,FCPS,FICOG Fetal Medicine Consultant <ul><li>FMF certified sonologist </li></ul><ul><li>Trained at King’s College </li></ul><ul><li>Professional attachments </li></ul><ul><ul><li>Nowrosjee Wadia Maternity Hospital </li></ul></ul><ul><ul><li>S L Raheja Fortis Hospital </li></ul></ul><ul><ul><li>BSES MG Hospital </li></ul></ul><ul><ul><li>Irla Nursing Home </li></ul></ul>
    3. 3. Dr.Poonam Loomba
    4. 4. Dr.Ratna Kaul
    5. 5. Dr.Chander Lulla
    6. 6. Dr.Sabuj Sengupta
    7. 7. Dr.Madhuri Sengupta
    8. 8. <ul><li>Mrs. A, 32 year Primigravida first seen at 12 weeks gestational age </li></ul><ul><li>She was corresponding to the weeks of gestation </li></ul><ul><li>BP-110/60, Hb-8.8 gm </li></ul>Case #1
    9. 9. <ul><li>Targeted Scan done at 20 weeks- NAD </li></ul><ul><li>She was seen at 28 weeks when Fundal Height was corresponding to 24 weeks </li></ul>
    10. 10. How will you proceed?
    11. 11. USG done showed:-
    12. 12. 28 weeks GA Measurement Weeks BPD 64 mm 26 weeks HC 234 mm 25 week 4 days AC 201 mm 24 weeks 5 days FL 44 mm 24 weeks 3 days
    13. 13. Is this information sufficient?
    14. 14. 28 weeks GA Measurement Weeks Centile BPD 64 mm 26 weeks <2 nd HC 234 mm 25 week 4 days <2 nd AC 201 mm 24 weeks 5 days <2 nd FL 44 mm 24 weeks 3 days <2 nd
    15. 15. Would you call this IUGR?
    16. 16. 28 weeks GA Measurement Weeks Centile BPD 64 mm 26 weeks <2 nd HC 234 mm 25 week 4 days <2 nd AC 201 mm 24 weeks 5 days <2 nd FL 44 mm 24 weeks 3 days <2 nd Weight 735 gms 10 th
    17. 17. Now, would you call this IUGR? What is more significant? AC or EFW?
    18. 19. Umbilical Vein (LUV) Intra hepatic portion of UV Portal Sinus Right Portal vein Ductus Venosus IVC Left Portal vein Left Hepatic vein Right Hepatic vein Superior mesenteric vein & splenic vein Left Liver Lobe Right Liver Lobe
    19. 20. Evolution of IUGR <ul><li>Adverse placental conditions results in deficient delivery of nutrients to the Fetus </li></ul><ul><li>Fetus makes adjustments by shunting the blood AWAY from portal circulation into the DV </li></ul>
    20. 21. <ul><li>This results in delivery of more nutrients to RA at the cost of PORTAL CIRCULATION </li></ul><ul><li>PRECLINICAL  before any parameter is abnormal </li></ul>Pre Clinical Phase
    21. 22. <ul><li>First to get affected is AC </li></ul><ul><li>Fetal vascular adjustments with “Brain Sparing” effect </li></ul><ul><li>Large head </li></ul><ul><li>Now HC starts getting affected </li></ul><ul><li>EFW < 5 th centile </li></ul>Clinical Phase
    22. 23. Let us assume that both AC and EFW are less
    23. 24. 28 weeks GA Measurement Weeks Centile BPD 64 mm 26 weeks <2 nd HC 234 mm 25 week 4 days <2 nd AC 201 mm 24 weeks 5 days <2 nd FL 44 mm 24 weeks 3 days <2 nd Weight 535 gms <2 nd
    24. 25. Any other sonography finding you would like to know?
    25. 26. 28 weeks GA Measurement Weeks Centile BPD 64 mm 26 weeks <2 nd HC 234 mm 25 week 4 days <2 nd AC 201 mm 24 weeks 5 days <2 nd FL 44 mm 24 weeks 3 days <2 nd Weight 735 gms 10 th AFI 15 cm
    26. 27. What investigations would you like to do?
    27. 28. Could this be due to Perinatal Infection? <ul><li>TORCH???? </li></ul>
    28. 29. Ventriculomegaly <ul><li>Markers for Perinatal Infection </li></ul>
    29. 30. Intra Cranial Calcifications <ul><li>Markers for Perinatal Infection </li></ul>
    30. 31. Hepatic Calcifications <ul><li>Markers for Perinatal Infection </li></ul>
    31. 32. Thick Placenta <ul><li>Markers for Perinatal Infection </li></ul>
    32. 33. Fetal Hydrops <ul><li>Markers for Perinatal Infection </li></ul>
    33. 34. Echogenic Bowel <ul><li>Markers for Perinatal Infection </li></ul>
    34. 35. Could this be a genetic syndrome?
    35. 36. <ul><li>Early onset IUGR </li></ul><ul><li>Hydrocephalus/ Microcephaly/Abnormal shape of skull </li></ul><ul><li>Macrosomia </li></ul>
    36. 37. <ul><li>Micro-opthalmos, cataract </li></ul><ul><li>“ Abnormal Facies” </li></ul><ul><li>Cystic Hygroma </li></ul><ul><li>Cardiac/ Renal/ Genital defects </li></ul>
    37. 38. <ul><li>Extra digits/ Clenched fists/ club feet </li></ul><ul><li>Absent/ short radius </li></ul><ul><li>Posterior fossa abnormalities </li></ul>
    38. 39. <ul><li>Hyper/ Hypo telorism </li></ul><ul><li>Cranio synostosis </li></ul><ul><li>Proboscis </li></ul>
    39. 40. What about Doppler Studies?
    40. 41. What vessels will you study?
    41. 42. <ul><li>Umbilical Artery </li></ul><ul><li>Middle Cerebral Artery </li></ul>
    42. 43. What are cut-off values?
    43. 44. http://www.perinatology.com/calculators/umbilicalartery.htm
    44. 45. http://www.perinatology.com/calculators/exbiometry.htm
    45. 46. At 30 weeks.. 5 th centile 95 th centile Umb Artery PI 1.1 0.88 1.39 MCA PI 2.1 1.51 3.0 CPR 1.9
    46. 47. What is the interpretation? When will you repeat the test?
    47. 48. At 32 weeks.. 5 th centile 95 th centile Umb Artery PI 1.4 0.7 1.23 MCA PI 1.8 1.5 2.8 CPR 1.28
    48. 49. What is the interpretation? How often will you monitor the pregnancy now?
    49. 50. At 33 weeks.. 5 th centile 95 th centile Umb Artery PI 1.7 0.6 1.21 MCA PI 1.2 1.4 2.7 CPR 0.7
    50. 51. Ductus Venosus doppler shows “A wave reversal. What will you do now?
    51. 52. Is there some test before DV abnormalities?
    52. 53. Reversal of flow in Aortic Isthmus
    53. 54. <ul><li>Increasing placental resistance and decreasing cerebral resistance </li></ul><ul><li>Reversal of diastolic flow in isthmus </li></ul><ul><li>Deoxygenated blood from RV reaches brain </li></ul>
    54. 55. <ul><li>Umbilical Artery/ MCA </li></ul><ul><li>MCA/Umbilical Artery </li></ul><ul><li>Abnormal CPR </li></ul><ul><li>DV </li></ul>
    55. 57. Doppler Parameter Days to delivery/ demise Abn Umb A PI 3 weeks Abn CPR 2 weeks Absent Umb A EDV 10 days Abn MCA PI 7 days Reversed Umb A EDV 5 days Elevated DV PI 3 days Umb V Pulsation 2 days Reversed DV a Wave 1 day
    56. 58. Mild Disease <ul><li>Usually doppler abnormality detected at 32 weeks </li></ul><ul><li>Usually only Umb Art abnormality </li></ul><ul><li>Max abn CPR </li></ul><ul><li>Median time for next vessel abn is 4-5 weeks </li></ul>
    57. 59. <ul><li>No perinatal mortality </li></ul><ul><li>Pregnancy can be taken to 36 weeks </li></ul>
    58. 60. Progressive Disease <ul><li>Initial Doppler abn at 28-30 weeks </li></ul><ul><li>Either 1 vessel abn which progressed to 2 vessel abn </li></ul><ul><li>Or 2 vessel abn to begin with </li></ul><ul><li>Median time for next vessel 7 days </li></ul>
    59. 61. <ul><li>Full fledged Doppler abn by 21 days </li></ul><ul><li>Pregnancy can be extended max by 5 weeks from date of first doppler abn </li></ul><ul><li>Small risk of perinatal abnormality </li></ul>
    60. 62. Severe Early Onset <ul><li>First Doppler abn before 28 weeks </li></ul><ul><li>Median progression interval 7-9 days </li></ul><ul><li>Progression to full blown abn took 19 days </li></ul>
    61. 63. <ul><li>Delivery by 32-33 weeks </li></ul><ul><li>Significant perinatal mortality </li></ul>
    62. 65. Role of NST….?
    63. 66. If NST is non reactive at 37 weeks, which Doppler study would you recommend?
    64. 67. Doppler changes in IUGR <ul><li>Normoxemic centralisation </li></ul><ul><li>2) Hypoxemic centralisation </li></ul><ul><li>3) Decompensation </li></ul>
    65. 68. <ul><li>Doppler progression occurs in this stage </li></ul>Stage of Normoxemic Centralisation
    66. 69. Stage of Hypoxemic Centralisation <ul><li>NST is non reactive </li></ul><ul><li>Beat to beat variability is affected </li></ul><ul><li>Liquor is reduced </li></ul><ul><li>Fetal movements reduced </li></ul><ul><li>Fetal breathing pattern reduced </li></ul>
    67. 70. Stage of Decompensation <ul><li>Venous abnormalities </li></ul><ul><li>DV “A” wave reversal </li></ul><ul><li>Umbilical Venous pulsations </li></ul>
    68. 71. <ul><li>Further hypoxia </li></ul><ul><li>Build up of tissue lactic acid </li></ul><ul><li>Rapid shifting of O 2 dissociation curve to right </li></ul><ul><li>Acidosis </li></ul>
    69. 72. <ul><li>Use of computerised NST </li></ul><ul><li>Baseline FHR, short term/ long term variability </li></ul><ul><li>Accelerations, deccelerations </li></ul><ul><li>Well documented progression from 25 – 42 weeks </li></ul>
    70. 73. <ul><li>Can be used judiciously if one knows that NST changes appear late in the chain of events </li></ul>
    71. 74. Is there any role of Fetal Biophysical Profile?
    72. 75. Uterine Artery Doppler showed bilateral diastolic notches. What is the significance?
    73. 76. How will you manage the pregnancy during labour?
    74. 77. Role of Fetal ST wave analysis?
    75. 78. STAN S-31
    76. 80. <ul><li>ST waveform represents balance between energy yielding and energy consuming processes </li></ul><ul><li>With Fetal Hypoxia the ST wave either becomes biphasic or shows downward slope </li></ul>STAN- ST waveform Analysis
    77. 81. <ul><li>Scalp Electrode is required </li></ul><ul><li>Initial 20 minutes recording to get baseline pattern </li></ul><ul><li>Avoid signal attenuation </li></ul>Limitations
    78. 82. <ul><li>Terminally sick fetuses may not be able to show ST wave changes </li></ul><ul><li>In these fetuses the ST wave changes had happened in past and now the ST wave has returned to horizontal position </li></ul><ul><li>False Negative </li></ul>False Negatives
    79. 83. What about Fetal Pulse Oximeters?
    80. 84. <ul><li>Only indirect estimate of Fetal PO2 </li></ul><ul><li>Measures PO2 at systole in scalp skin microcirculation </li></ul><ul><li>This is pre ductal circulation (before Ductus Arteriosus) </li></ul><ul><li>Saturation is between UA and UV saturation </li></ul>Fetal Pulse Oximeter
    81. 85. <ul><li>Single reading is not sufficient </li></ul><ul><li>ACOG has raised concerns about potential increase in costs without potential benefits </li></ul><ul><li>The signal weakens during pushing by the mother </li></ul><ul><li>Negative predictive value is more important than positive predictive value </li></ul>
    82. 86. Where does continuous electronic Fetal Monitoring stack??
    83. 87. <ul><li>Commercially available in 1960s </li></ul><ul><li>Widely used in 1980s </li></ul><ul><li>However, Cochrane review in mid 1990 suggested that continuous electronic monitoring had no effect on perinatal mortality </li></ul><ul><li>They also said that it increased LSCS rate </li></ul>
    84. 88. <ul><li>Suggested that failure to interpret the FHR chart was the common cause of mistakes </li></ul><ul><li>Failure to understand that changes in FHR may not actually represent changes in Acid Base balance </li></ul><ul><li>Fear that non recurring changes in FHR may be retrospectively held against doctor in case something goes wrong </li></ul>Confidential Inquiries into Stillbirth
    85. 89. <ul><li>False positive rate of EFM for predicting cerebral palsy exceeds 90% </li></ul><ul><li>Interpretation of FHR is subject to high intra observer and inter observer variability </li></ul><ul><li>Re-interpretation of FHR tracing once neonatal outcome is known is not of benefit </li></ul><ul><li>FHR pattern should be classified as reassuring/ equivocal/ ominous </li></ul>ACOG Recommendations
    86. 90. <ul><li>Intermittent Auscultation in labour for low risk cases </li></ul><ul><li>Electronic Fetal Heart Monitoring is recommended for high risk cases </li></ul><ul><li>In first stage of labour, if the pattern is reassuring then the EFM may be interrupted for 30 min </li></ul>
    87. 91. <ul><li>G3 P2 L1 with previous history of preterm delivery at 24 weeks comes for ANC registration at 12 weeks. </li></ul><ul><li>What will you do? </li></ul>Case#2
    88. 92. Which is the better route for cervical length assessment? PA or PV??
    89. 93. <ul><li>In PA route, cervix may not be seen in 50% of cases </li></ul><ul><li>But when the bladder is full, the cervical length is increased artificially </li></ul><ul><li>Transperineal examination is unreliable </li></ul>
    90. 94. What is the technique for measuring cervical length?
    91. 95. <ul><li>Empty the bladder, in dorsal lithotomy position </li></ul><ul><li>Probe is placed in the anterior fornix </li></ul><ul><li>A sagittal view of the cervix is obtained </li></ul><ul><li>Calipers are used to measure the distance between echodensity at the external os and V shaped notch at internal os </li></ul>
    92. 96. <ul><li>TVUSS of cervical length is highly accurate and reproducible </li></ul>
    93. 97. What is the significance of cervical length?
    94. 98. <ul><li>Median cervical length is 36 mm </li></ul><ul><li>In 1.6% of the cases it is < 15 mm </li></ul><ul><li>Cut off of 15 mm predicts risk of delivery before 33 weeks </li></ul>
    95. 100. What is the significance of past h/o Preterm Delivery in the obstetric outcome
    96. 101. <ul><li>Cervical length at 23 weeks only predicts risk of preterm delivery <32 weeks or within next 10 weeks </li></ul><ul><li>For prediction of delivery <36 weeks, cervical length is only 20% sensitive in predictions </li></ul><ul><li>Past obstetric history is a significant independent contributor </li></ul>
    97. 102. Is there a role for routine screening for bacterial vaginosis?
    98. 103. <ul><li>No association between bacterial vaginosis and short cervical length </li></ul><ul><li>Mere colonisation of lower genital tract does not mean ascending infection </li></ul>
    99. 104. <ul><li>Cervical mucus plug provides an effective barrier for infection </li></ul><ul><li>Loss of the cervical mucus due to shortening of cervix effectively exposes the membranes to infection </li></ul><ul><li>Cervix is an effective barrier to infection until 1/3 of its length is lost </li></ul>
    100. 105. Would you offer the patient elective cerclage?
    101. 106. <ul><li>Elective cervical cerclage in the absence of cervical changes is reserved for those patients with 3 or more second trimester losses or preterm deliveries </li></ul>ACOG Practice Guidelines
    102. 107. This patient had a cervical length of 2.8 at 14 weeks. At 23 weeks, the cervical length is 1.4 cm. What would you do? <ul><li>Would you have been better off doing prophylactic cerclage? </li></ul><ul><li>Have you decreased the chances of the woman to go past 32 weeks by delaying the cerclage? </li></ul>
    103. 108. <ul><li>In women with cervical length less than 1.5 cm at 23 weeks, insertion of Shirodkar cerclage results in 10 fold reduction in risk of Preterm Delivery < 32 weeks </li></ul>
    104. 109. <ul><li>All the patients who underwent cerclage had a take home baby rate of 100% </li></ul><ul><li>95% of those with cervix < 1.5 cm at 23 weeks and who underwent cerclage had pregnancy lasting > 32 weeks </li></ul>
    105. 110. Before cerclage
    106. 111. Immediately after cerclage
    107. 112. 4 weeks post cerclage
    108. 113. <ul><li>No consensus if supra cerclage shortening of cervix had any prognostic relevance </li></ul>
    109. 114. <ul><li>In women with increased risk of preterm delivery based on history, a policy of sonographic surveillance followed by cervical cerclage, if required, reduces the need for surgical intervention without increasing perinatal mortality </li></ul><ul><li>Cervix was assessed at 13 weeks, 17 weeks and 21 weeks </li></ul>
    110. 115. What is the role of “early” cervical assessment @ 11-13 weeks? <ul><li>Some studies have stated that it is of no consequence </li></ul>
    111. 116. <ul><li>23 weeks’ cervical assessment may be too late for prevention </li></ul><ul><li>False negatives occur because inadvertent inclusion of uterine isthmus in the measurements </li></ul>
    112. 118. <ul><li>Identify endocervical canal (translucent or echodense) </li></ul><ul><li>No pressure on cervix </li></ul><ul><li>Whole of cervix occupies the screen </li></ul><ul><li>Linear distance between the two ends of the glandular area represents cervical length </li></ul>Correct technique
    113. 120. <ul><li>Cervical length <25 mm was significant </li></ul>
    114. 121. What is the role of Fetal Fibronectin?
    115. 122. <ul><li>It is a protein produced by Trophoblast </li></ul><ul><li>It is considered as glue between placental membranes and decidua </li></ul><ul><li>Levels > 50 ng/mL between 22-30 weeks are suggestive of risk of PT del </li></ul>Fetal Fibronectin
    116. 123. <ul><li>Maternal salivary Estriol >2.1 ng/mL </li></ul><ul><li>Uterine activity monitor </li></ul><ul><li>Multiple Marker screening ( History, Fetal Fibronectin, testing for bacterial vaginosis) </li></ul>Other tests
    117. 124. Amniotic Fluid Sludge
    118. 125. Amniotic Fluid Sludge <ul><li>AF sludge is defined as presence of dense aggregates of particulate matter in proximity to the internal os </li></ul>
    119. 126. <ul><li>Prevalence of AF sludge was high in asymptomatic patients at risk for PT labour </li></ul><ul><li>AF sludge was an independent risk factor for PROM </li></ul>
    120. 127. Images of Cervix
    121. 128. Dilatation of cervix
    122. 129. Funneling of cervix
    123. 130. Herniation of membranes
    124. 131. What is the significance of funneling?
    125. 132. <ul><li>Funneling is defined as dilatation of internal os > 5mm persisting throughout 3 min duration of the procedure </li></ul><ul><li>It is present in 4% of pregnancies </li></ul><ul><li>Incidence of funneling increases as the cervical length shortens( 98% if Cx < 15 mm to <1% if Cx >30 mm) </li></ul>
    126. 133. <ul><li>When cervical length is taken into account, “Funneling” did not provide any extra information </li></ul><ul><li>Women with long cervix and funneling are NOT at increased risk of preterm delivery </li></ul>
    127. 135. <ul><li>36 year old G2 P1 came to the ANC clinic with a sonography report saying “Twin Pregnancy of 8 weeks and 2 days” </li></ul>Case #3
    128. 136. Is this report adequate?
    129. 137. <ul><li>Chorionicity </li></ul><ul><li>CRL discrepancy, if any </li></ul><ul><li>Mapping </li></ul>
    130. 138. It is monochorionic Twin Pregnancy How will you monitor the pregnancy?
    131. 139. She comes for First Trimester Screening  What is more significant? NT or Biochemistry or Both?
    132. 140. What is the false positive of NT measurement in Monochorionic Twins Pregnancy?
    133. 141. Can one predict development of TTS?
    134. 142. <ul><li>Inter-twin discrepancy in CRL </li></ul><ul><li>Increased NT </li></ul><ul><li>“ A” wave reversal of DV </li></ul>
    135. 143. No development of TTTS
    136. 144. TTTS developed later
    137. 145. <ul><li>Difference in CRL > 10 mm (8% sensitivity) </li></ul><ul><li>Difference in NT > 0.6 mm (50% sensitivity) </li></ul><ul><li>At least one twin showed absent or reversed DV “A” wave  relative risk for TTTS was 15.5 </li></ul>
    138. 146. <ul><li>NT difference > 0.6 mm AND abnormal DV in at least 1 fetus, the relative risk was 21 </li></ul>
    139. 147. How frequently should one monitor the pregnancy? And what should one monitor?
    140. 148. <ul><li>Monitored by USG every 15 days </li></ul>
    141. 149. <ul><li>EFW </li></ul><ul><li>Folding of inter-twin membrane </li></ul><ul><li>Deepest Vertical Pocket </li></ul><ul><li>Bladder Filling </li></ul><ul><li>UA end diastolic flow </li></ul><ul><li>A wave of Ductus Venosus </li></ul>
    142. 150. What are the signs of TTTS?
    143. 151. <ul><li>Oligohydramnios and absent bladder in donor </li></ul><ul><li>Polyhydramnios and dilated bladder in recipient </li></ul><ul><li>Varying degrees of Doppler abnormalities </li></ul>
    144. 152. The pregnancy progresses to 26 weeks, there is no TTS, how will you monitor the pregnancy?
    145. 153. Role of cervical screening
    146. 154. <ul><li>In twin pregnancies, the rate of preterm birth is 5-10% </li></ul><ul><li>Median cervical length was 35 mm </li></ul><ul><li>Cervical length < 25 mm, detection rate of PT labour before 32 weeks was 67% </li></ul>
    147. 155. <ul><li>In addition to cervical length, patient characteristics like parity, Obs history, weight , race also influence the risk </li></ul>
    148. 156. <ul><li>G3 P2 first came for ANC registration at 12 weeks </li></ul><ul><li>All investigations were normal </li></ul><ul><li>At 18 weeks Targeted Scan showed cerebral Ventriculomegaly 12 mm </li></ul><ul><li>No other abnormality was detected </li></ul>Case #4
    149. 157. What counseling will you offer?
    150. 158. What other tests will you do?
    151. 159. What is the role of TORCH test?
    152. 160. Toxo IgG negative, IgM negative  ?
    153. 161. Toxo IgG positive, Toxo IgM positive 
    154. 162. Toxo IgG negative, Toxo IgM positive 
    155. 164. What are the sonological markers of TORCH infection?
    156. 166. When do these markers appear??
    157. 167. What is Toxo Avidity Test? How do you interpret it?
    158. 168. <ul><li>High Avidity antibodies develop 12-16 weeks after infection </li></ul><ul><li>So high avidity suggests that the infection was acquired before pregnancy and hence the fetus is NOT at risk </li></ul><ul><li>Low Avidity test report should be used with caution </li></ul>Toxo Avidity Test
    159. 169. What test will you perform next?
    160. 170. <ul><li>Positive 6 weeks after fetal infection </li></ul><ul><li>It is indicated in:- </li></ul><ul><ul><li>When serological tests suggest infection acquired in early pregnancy </li></ul></ul><ul><ul><li>Evidence of damage on Ultrasound </li></ul></ul><ul><ul><li>Immunosuppressed patients </li></ul></ul>Amniotic fluid PCR
    161. 171. GA @ sero -conversion Risk of congenital infection Development of severe clinical signs Avidity Test Amniotic fluid PCR 1 st Trimester 6% 61% High If negative, then fetal infection is ruled out 2 nd Trimester 40% 25% 3 rd Trimester 72% 9%
    162. 173. How will you treat the patient?
    163. 174. <ul><li>G3 P2 weighing 70 kg came for ANC check up </li></ul><ul><li>She was 28 weeks and glucose challenge test showed glucose intolerance </li></ul><ul><li>Gestational Diabetes was confirmed by GTT </li></ul>Case#5
    164. 175. How will you monitor the fetus?
    165. 176. What things will you look for in Ultrasound examination?
    166. 177. <ul><li>Look for congenital abnormalities </li></ul><ul><ul><li>Cardiac </li></ul></ul><ul><ul><li>CNS </li></ul></ul><ul><ul><li>Spinal </li></ul></ul><ul><ul><li>Caudal regression syndrome </li></ul></ul><ul><li>Look for Biometry to chart the fetal growth </li></ul>
    167. 178. What are sonological signs of poor glycemic control?
    168. 179. <ul><li>Fetal Macrosomia </li></ul><ul><li>Increased Fetal Fat (> 5 mm at anterior abd wall) </li></ul><ul><li>Increased thickness of IVS </li></ul><ul><li>Polyhydramnios </li></ul>
    169. 180. How will you monitor the fetal well being?
    170. 181. What is the role of Doppler?
    171. 182. <ul><ul><li>MCA PI and UA PI are less than optimal in predicting adverse outcome </li></ul></ul><ul><ul><li>Give a false sense of security </li></ul></ul><ul><ul><li>Fetal circulation is different in Diabetic mothers with Right Ventricular dominance </li></ul></ul>Role of Doppler-
    172. 183. <ul><ul><li>There is risk of placental dysfunction </li></ul></ul><ul><ul><li>Hyper viscosity of the fetal blood due to polycythemia </li></ul></ul><ul><ul><li>Fetal venous thrombosis </li></ul></ul><ul><ul><li>Abnormal Thromboxane and Prostacyclin action </li></ul></ul><ul><ul><li>There is fetal cardiac dysfunction </li></ul></ul><ul><ul><li>Fetal acidosis </li></ul></ul><ul><li>All this is responsible for predictive capacity of the Doppler </li></ul>
    173. 184. <ul><li>DV PI is considered to be more significant in predicting adverse outcome </li></ul><ul><li>Fetal IVS > 6mm is used to predict risk of LV dynamic outflow tract obstruction </li></ul>
    174. 185. Can you predict shoulder dystocia?
    175. 186. <ul><li>DM </li></ul><ul><li>Fetal Macrosomia </li></ul><ul><li>Short occipito frontal diameter  rounder head  slips through easily before shoulder rotation  shoulder dystocia </li></ul>
    176. 187. <ul><li>A model with </li></ul><ul><ul><li>Expected Fetal Weight </li></ul></ul><ul><ul><li>Maternal Weight </li></ul></ul><ul><ul><li>Glucose levels </li></ul></ul><ul><ul><li>OFD </li></ul></ul><ul><li>Positive likelihood ratio of 18 and negative likelihood ration of 0.15 </li></ul>
    177. 188. <ul><li>G1 P0 with 4 days postdated came for routine ANC examination </li></ul>Case#6
    178. 189. When would you carry out investigations?
    179. 190. What investigations would you carry out?
    180. 191. Role of NST?
    181. 192. Role of Fetal BPP?
    182. 193. Role of Doppler?
    183. 194. <ul><li>36 year old G2 P1 with previous history of Down’s baby </li></ul><ul><li>Came at 9 weeks </li></ul>Case #7 First Trimester Screening
    184. 195. What advise will you give”
    185. 196. Is the risk higher? By what percent?
    186. 197. Will you go for straight invasive testing?
    187. 198. <ul><li>Her NT is 2.8 </li></ul><ul><li>The combined risk is 1:60 </li></ul>
    188. 199. CVS or Amnio?
    189. 200. FISH of full Karyotype?
    190. 201. What about cell free DNA?
    191. 202. Karyotype is Normal….what next?

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