Emergency ultrasonography in 2nd 3rd timester


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Emergency ultrasonography in 2nd 3rd timester

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Emergency ultrasonography in 2nd 3rd timester

  1. 1. Prof. Aboubakr Elnashar Benha University Hospital, Egypt Aboubakr Elnashar
  2. 2. 1.2nd trimester miscarriage 2.Ante partum hemorrhage 3.PTL 4.PROM 5.Decreased or absent fetal movements 6.Trauma Aboubakr Elnashar
  3. 3. Causes: 1.Cervical incompetence 2.Fibroid 3.Uterine malformation Aboubakr Elnashar
  4. 4. Cervical incompetence •TVS: only technique used reliably to measure the cervical length [TAS: full bladder to visualize the cervix elongates the cervix TVS: an empty bladder and no distortion] Aboubakr Elnashar
  5. 5. 1. Cervix length < 25 mm 2. Funneling of int os: -T, Y, V, U (correlation between the length of the cervix and the changes in the internal os). (Trust Your Vaginal Ultrasound) -in response to pressure on the uterine fundus -Serial evaluation/2 w 4. Protrusion of the membranes. 5. Fetal parts in the cervix or vagina Aboubakr Elnashar
  6. 6. Aboubakr Elnashar
  7. 7. History-indicated cerclage (RCOG, 2011) Indications Three or more previous PTL and/or 2nd T miscarriage. Not an indication: two or fewer PTL and/or 2nd T miscarriage. Aboubakr Elnashar
  8. 8. Ultrasound-indicated cerclage (RCOG, 2011) Indication:  History of one or more spontaneous 2nd T miscarriage or PTL TVS: cervix is 25 mm or less  Not indicated No history of spontaneous 2nd T miscarriage or PTL Funnelling of the cervix Aboubakr Elnashar
  9. 9. Cervical cerclage is not recommended (RCOG, 2011) 1. Multiple pregnancies {±detrimental increase in 2nd T miscarriage or PTL}. 2. Uterine anomalies 3. Cervical surgery cone biopsy LLETZ destructive procedures (laser ablation or diathermy) multiple dilatation and evacuation. Aboubakr Elnashar
  10. 10. Define: Bleeding from genital tract after fetal viability Causes: 1.Placenta praevia: 2.Abruptio placentae 3.Vasa praevia 4.Local causes Aboubakr Elnashar
  11. 11. IV. Complete Centralis III. Complete partial II. Marginalis I. Lateralis Major Minor TVS: Distance between lower edge of the placenta & internal os <2 cm in the third trimester: CS especially if the placenta is thick (RCOG, 2011) Placenta praevia Grading: Now obsolete in clinical practice Aboubakr Elnashar
  12. 12. US: diagnose placenta praevia (RCOG,2011) TVS safe in the presence of PP more accurate than TAS in locating the placenta (RCOG , 2005 ). Aboubakr Elnashar
  13. 13. Placental abruption Retroplacental Marginal Subamniotic, intraplacental Aboubakr Elnashar
  14. 14. US: (RCOG, 2011) does not exclude abruption. {Placental abruption is a clinical diagnosis sensitivity is poor} Sensitivity: 24%: fail to detect three-quarters of cases Specificity: 96%: When suggests an abruption, the likelihood that there is an abruption is high. Fetal heart pulsation if fetal viability cannot be detected using external auscultation. Aboubakr Elnashar
  15. 15.  Regular contractions with cervical change before 37w (ACOG, 2003) 1. Prediction 2. Management Aboubakr Elnashar
  16. 16. I. Prediction: TVS is more accurate than digital examination [Provides reliable length, dilation, funneling] High NPV: 89% if > 2.5 cm Risk PTD  with cervix length  Accepted safe length is 3 cm Cx length > 3cm: No risk of PTL Cx length <2cm: 70% will deliver PT Recommended high risk/symptomatic patients Not for routine screening Aboubakr Elnashar
  17. 17. Length of the endocervix can be measured using TVS Aboubakr Elnashar
  18. 18. Antenatal corticosteroids (RCOG, 2010) Single course of to women between 24+0 and 34+6W who are at risk of PTL. should be given to all women for whom an elective CS is planned prior to 38+6 w. Elective CS should be performed at or after 39+0 w to reduce respiratory morbidity. Aboubakr Elnashar
  19. 19. II. Management: 1. Presentation 2. Fetal weight Shepard: BPD & AC Accurate within 10-15 % Hadlock: FL & AC 3. Fetal wellbeing in high risk pregnancies, Aboubakr Elnashar
  20. 20. Tocolytic drugs: RCOG, 2011 Nifedipine and atosiban oxytocin receptor agonist have comparable effectiveness in delaying birth for up to seven days. Compared with beta-agonists, nifedipine is associated with improvement in neonatal outcome. Nifedipine: initial oral dose of 20 mg followed by 10– 20 mg three to four times daily, adjusted according to uterine activity for up to 48 h. Aboubakr Elnashar
  21. 21. Define: Leakage of AF in absence of uterine activity Latency: The interval between ROM & onset of contractions Types: PretermPROM TermPROM Aboubakr Elnashar
  22. 22. Management: useful: history PROM but negative speculum exam.  Cervix length, gestational age •AFV correlate with: latency in PPROM neonatal morbidity & mortality in 2nd PROM •FBP: reduced in chorioamnionitis. sensitivity: 25% Aboubakr Elnashar
  23. 23. PPROMP (RCOG,2010) Observe for signs of clinical chorioamnionitis. Not necessary: Weekly high vaginal swab weekly CBC or CRP {sensitivity is low}. CTG is useful: fetal tachycardia: cl chorioamnionitis. FBP and Doppler: limited value in predicting fetal infection. Antenatal corticosteroids should be administered Delivery should be considered at 34 w Aboubakr Elnashar
  24. 24. I. Living II. Fetal wellbeing 1. Foetal growth assessment 2. FBP 3. Doppler Aboubakr Elnashar
  25. 25. 1. Fetal growth assessment US/2w: HC and AC. AC most sensitive predictor of fetal growth. increases 2cm/2w after 24 w in the average fetus. measurements are plotted on centile charts. fall in the growth velocity of AC indicates IUGR. AC used to assess fetal growth Aboubakr Elnashar
  26. 26. Aboubakr Elnashar
  27. 27. Score 2 Score 0 CTG >2 accelrations/40 min < F. movements >3/30 min < F.breathing. movements (FBM) 30 sec sustained FBM/30 min < F.tone closed fist or flexion to extension movement Neither Am Fluid Volume >1 cm pocket < 2. BPP Aboubakr Elnashar
  28. 28. 3. Doppler more useful test of fetal wellbeing than CTG or FBP. Umbilical arterial blood flow Middle cerebral artery Aboubakr Elnashar
  29. 29. a. Umbilical artery Doppler Idea: Umbilical Arterial Flow is normally low resistance. In hypoxic states: relative placental hypoxia: reactive VC of umbilical artery tributaries: higher resistance: relative decrease in diastolic flow Aboubakr Elnashar
  30. 30. Doppler indices Aboubakr Elnashar
  31. 31. •Resistance index: Best ability to predict abnormal outcomes (RCOG,2002 Evidence level II)  Normal pregnancy: {progressive increase in end-diastolic velocity {growth& dilatation of the umbilical circulation}: Resistance index falls. Fetal growth restriction and/or PET: > 0.72 is outside the normal limits from 26 w. Aboubakr Elnashar
  32. 32. •S/D should be <3. small increases in S/D= 3-5: chronic intrauterine disease manifest by IUGR. Not strictly useful: {1. low sensitivity. 2. Gestation age dependent}. •Diastolic flow is absent {AED}or reversed (RED} Fetal distress is almost certain: Immediate BPP or NST or Delivery may be indicated. Aboubakr Elnashar
  33. 33. Normal Absent Reversed Aboubakr Elnashar
  34. 34. b. Middle cerebral artery peak systolic velocity (MCA- PSV) The most significant breakthrough in the surveillance of the potentially anemic fetus Based on: In fetal anemia: Enhanced fetal cardiac output and Decrease in blood viscosity: Increased blood flow velocity preferentially shunt blood to brain faster most pronounced MCA PSV Aboubakr Elnashar
  35. 35. Frequency •Initiated: 18 w •Repeated: every 1–2 w as the clinical situation MCA waveforms in an anemic fetus requiring serial transfusions for severe Rh (D) disease. The peak systolic velocities of 62, 50, and 61 cm per second (top to bottom) corresponded to fetal hematocrits of 19%, 44%, and 32%, before, at the time of, and a week after the first intravascular transfusion, respectively. Aboubakr Elnashar
  36. 36. Aboubakr Elnashar
  37. 37. Advantage More sensitive for predicting f anemia than the ΔOD450 (Recent studies) Alternative to serial amniocenteses Excellent noninvasive tool for the monitoring of f anemia. Aboubakr Elnashar
  38. 38. Reduced Foetal movements (RCOG, 20011) 1. History Risk factors for stillbirth and FGR. Sudden change in fetal activity 2. Auscultate the fetal heart Doppler device to exclude fetal death. 3. CTG {exclude fetal compromise} Aboubakr Elnashar
  39. 39. 4. US RFM persists despite a normal CTG risk factors for FGR/stillbirth.  AC EFW {detect the SGA} AFV Doppler Fetal morphology Aboubakr Elnashar
  40. 40. 5. ± BPP: ± a role in high risk pregnancies: Systematic review of RCT: does not support its use as a test of fetal wellbeing Uncontrolled observational studies: BBP has good NPV Fetal death is rare with normal BPP. Aboubakr Elnashar
  41. 41. Mother: •Noninvasive •Does not require transport of the mother out of the ED. •Detects free intraperitoneal fluid or hemorrhage •FAST: The focused assessment with sonography for trauma routine in many trauma centers high sensitivity and accuracy Aboubakr Elnashar
  42. 42. Fetus: •Safe •Assess viability. multiple gestations. size, gestational age, and position of the fetus. Aboubakr Elnashar
  43. 43. Indications of cerclage: 1. Three or more PTL and/or 2nd T miscarriage. 2. History of one or more spontaneous 2nd T miscarriage or PTL and TVS: cervix is 25 mm or less Cervical cerclage is not recommended: multiple pregnancies, uterine anomalies, cervical surgery CS if placenta <2 cm from internal os in the 3rd T Antenatal corticosteroids if elective CS is planned prior to 38+6 w. Aboubakr Elnashar
  44. 44.  Umbilical a Doppler: • RI >0.72 is outside the normal limits from 26 w. • S/D >3. • Diastolic flow is absent or reversed: Fetal distress is almost certain: Immediate BPP or NST or delivery  Middle cerebral artery peak systolic velocity: most significant breakthrough in the surveillance of the potentially anemic fetus Aboubakr Elnashar
  45. 45. Thanks elnashar53@hotmail.com Aboubakr Elnashar