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Tra ecoinicial master

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  • 1. Gestación incipiente Corionicidad EmbriorreducciónCribaje aneuploidias y anomalias
  • 2. Eco TV Gest loc Gest incipiente desconocida(PUL)INTRAUTERO ECTOPIC0 VIABILIDAD INCIERTA Algoritmo PUL CONTROL EN 7D
  • 3. Current evidence on surgery, systemic methotrexate and expectant management in thetreatment of tubal ectopic pregnancy: a systematic review and meta-analysis. Mol et al Laparoscopy vs cirugia abierta 0,90 Salpingostomia vs salpingost + MTX post 0,89 MTX multidose vc laparos salpingostomia 1,15 MTX dosis unica vs laparos salpingostomia 0,82 Human Reproduction Update 2008 14(4):309-319;
  • 4. Laparoscopy vs cirugia abiertaMTX multidose vc laparos salpingostomiaMTX dosis unica vs laparos salpingostomiaMTX 0,25 VS 50 mg/m2 dosis unica Human Reproduction Update 2008 14(4):309-319;
  • 5. Zona discriminacion: bhcg >1500 BHCG<66 % O PLATEAU > 66%ABORTO GEU GEST EVOLUTIVA INTRAUTERINA EXTRAUTERINA
  • 6. Haemodynamically Haemodynamically Haemodynamically stable Pain free stable +Pain unstable +PainExpectant management Serum hCG Serum hCG*Serum hCG levels at 0 Consider Consider and 48 hours laparoscopy laparotomy < 66% increase or < > 15% decrease in > 66% increase in 15% decrease in serum serum hCG 0-48 serum hCG 0-48 hCG 0–48 hours hours hours ? Ectopic pregnancy ? Failing PUL ? Intra-uterine pregnancy Repeat serum hCG in one week to confirm failing Rescan one week to confirm pregnancy location Consider weekly hCG monitoring until < 15 IU/L
  • 7. Rescan one week to confirm pregnancy location Early Intra-uterine Ectopic pregnancy PULPregnancy visualised visualisedRescan in two weeks Management as Repeat hCG now to confirm viability clinically and 48 hours later indicated* Consider rescan at 24 If no pregnancy seen on repeat scanhours if PUL and initial and suboptimal rise in hCG considerserum hCG >1000 IU/L methotrexate
  • 8. Schieve LA, et al. (2003). Spontaneous abortion among pregnanciesconceived using assisted reproductive technology in the UnitedStates. Obstetrics and Gynecology, 101(5, Part 1): 959–967.
  • 9. Hoesli IM et al: Spontaneous fetal loss rates in a non-selected population. Am J Med Genet 100: 106, 2001)
  • 10. Birth weight (g) 3279,0 2379,0Low and very low birthweight 8,2 48,4Gestation (weeks) 38,4 35,0Caesarean section 42,4 71,1Perinatal mortality (per1000 births) 10,9 29,3
  • 11.  SAB = most COMMON complication of early pregnancy 8-20% of clinically recognized pregnancies under 20 wks undergo SAB, 80% of these will be <12 wks Low risk of loss after 15 wks (0.6%) if fetus chromosomally normal Loss of unrecognized/subclinical pregnancies occurs in 13-26% of all pregs ◦ Unlikely to be recognized without daily UPTs
  • 12.  With daily hCG assays, total rate of pregnancy loss after implantation was 31% (70% of these prior to detection of pregnancy) Daily hCG assays on 518 nulliparous women ages 20-34 trying to conceive w/o hx of infertility: ◦ 26% loss of preclinical pregnancy ◦ 8% loss of clinically recognized pregnancy ◦ 64% live birth ◦ 2% EAB, ectopic, molar, stillbirth
  • 13.  Definitive diagnosis of SAB when: ◦ Absence of FCA with CRL >5mm ◦ Absence of fetal pole when mean sac diameter >25 mm (TAUS) or >18 mm (TVUS) ◦ Absence of yolk sac 32 days post IVF Promising findings for lack of SAB ◦ Yolk sac b/w 22-32 days from IVF associated with +FCA in 94% pregs ◦ Positive FCA…. But age matters! Women <36 +FCA associated with SAB in only 4.5% pregs. 36- 39 y/o SAB rate 10%, women >40 y/o SAB rate 29%.
  • 14.  YS abnormal (irregular, LGA, free floating) Slow fetal heart rate (ie HR <85 bmp at 6-8 wks associated with 0% survival) Small sac (MSS-CRL <5 mm) Subchorionic hematoma (ie double SAB rate with women with large -- >25% of gest sac volume -- subchorionic hematomas in study of first trimester bleeders) Management? Repeat US in one week
  • 15.  hCG rises in curvilinear fashion until 41 days gestation, then rises more slowly to 10 wks and declines until plateaus in 2nd-3rd trimesters Mean doubling time: 1.4-2.1 days Should rise by 66% every 48 hours (will do so in 85% viable pregs) Trivia: slowed recorded 48-hr rise with viable IUP was 53% Ectopics: only 21% follow minimal doubling time
  • 16.  DZ = serum hCG above which gest sac should be seen by TVUS if +IUP 1500-2000 with TVUS (6500 TAUS) Above DZ – no gest sac – ectopic/nonviable IUP Below DZ – no gest sac – early viable IUP, nonviable IUP, ectopic. Anywhere from 8- 40% ultimately diagnosed as ectopic pregs DZ dependent on ultrasonographer, US equipment, physical factors (fibroids, multiple gestation)
  • 17.  What is the incidence of ectopic pregnancy? The reported incidence of ectopic pregnancy aborto after IVF treatment varies between 2-11% of all pregnancies. This is much higher than is reported after natural conception, which is about 1 in 100 to 300 pregnancies. After one ectopic geu pregnancy, the risk of recurrence is between 10- 20%. In addition there is heterotopic pregnancy (a combined normal pregnancy and ectopic pregnancy). The incidence of heterotopic multiples pregnancy after IVF is about 1% of all pregnancies compared with 2 in 30,000 after natural conception
  • 18. Hum Reprod. 2004 Feb;19(2):272-7. Incidence of spontaneous abortion among aborto pregnancies produced by assisted reproductive technology geu • x4 multiples
  • 19. TRA Concepcion Nat ComentariosAborto 18 % 14-30% 15-20% +/-Ectopico 1,5 % 1-11% 0.2-1.4% ++Multiples 27 %Gemelos 24-31% 1.2-4.5% Increase due toTriples 0.5-5.2% 0.012% higher number of embryosCuadruple 0.5% 0.0001% transferred. Registro SEF 2007
  • 20. >95% ectopicpregs in fallopiantubes70% ampulla12% isthmic11.1% fimbrial3.2% ovarian2.4% interstitial1.3% abdominal
  • 21. Tubal Ectopic Pregnancy
  • 22. Fertil Steril. 2009 Aug;92(2):515-9. Epub 2008 Oct 1.Effect of methotrexate exposure on subsequent fertilityin women undergoing controlled ovarian stimulation.McLaren JF, Burney RO, Milki AA, Westphal LM, DahanMH, Lathi RB.Fertil Steril. 2008 Nov;90(5):1579-82. Epub 2007 Dec11.Systemic methotrexate to treat ectopic pregnancy doesnot affect ovarian reserve.Oriol B, Barrio A, Pacheco A, Serna J, ZuzuarreguiJL, Garcia-Velasco JA.
  • 23. ART Outcomes by Age SART,CDC, 2004
  • 24. Pregnancy Loss by Age: CDC 2002
  • 25. Tv/TC vs TA Outcome Studies Tv-TC Transabd RR, 95%CI Pregnancy Berkowitz 1/3 3/8 1.12, 0.79-1.59 loss 1988 Shalev 1989 1/10 4/10 Boulot 1993 2/16 3/49 Evans 1994 32/238 96/846 Birth < 32 Berkowitz 0/4 4/16 1.00, 0.71-1.40 weeks 1988 Shalev 1989 1/9 2/6 Boulot 1993 2/14 7/46 Evans 1994 33/206 113/750Birthweight < Berkowitz 0/4 3/14 0.33, 0.04-2.55 1500 g 1988 Shalev 1989 0/18 1/12 Birth < 37 Berkowitz 0/4 9/14 0.70, 0.59-0.83 weeks 1988 Shalev 1989 1/9 1/6 Boulot 1993 2/14 27/46 Evans 1994 52/206 298/750
  • 26. Uterine Arteries NB, TC, DV Hormones Placenta Anatomia MultiplesNuchal Screening The First Trimester Scan (11-13 weeks 6 days)
  • 27. Fertil Steril. 2009 Feb;91(2):305-15.
  • 28. ER ExpectanteRisks of miscarriage and early preterm birth in trichorionic triplet pregnancies with embryo reductionversus expectant management: new data and systematic review. .A Papageorghiou, Hum Rep 2006
  • 29. ER.Triples aborto ER 4% 8 % Risks of miscarriage and early preterm birth in trichorionic triplet pregnancies with embryo reduction versus expectant management: new data and systematic review. .A Papageorghiou, Hum Rep 2006
  • 30. preterm 27.5% 10.5%Risks of miscarriage and early preterm birth in trichorionic triplet pregnancies with embryo reductionversus expectant management: new data and systematic review. .A Papageorghiou, Hum Rep 2006
  • 31. 9080706050 único40 Doble30 Triple20100 2000 2001 2002 2003 2004 2005 2006 2007
  • 32. Assisted reproductive technologies and the risk of birth defects—a systematic reviewThe results of meta-analyses of all 25 studies suggest astatistically significant 30–40% increased risk ofbirth defects associated with ART Human Reproduction Vol.20, No.2 pp. 328–338, 2005
  • 33. EditorialCongenital malformations after assisted reproduction: risks andimplications for prenatal diagnosis and fetal medicineUltrasound Obstet Gynecol 2010; 35: 255–259
  • 34. EditorialCongenital malformations after assisted reproduction: risks andimplications for prenatal diagnosis and fetal medicineUltrasound Obstet Gynecol 2010; 35: 255–259 Approximate OR of increased risk with ART vs. Type of malformation spontaneous conception Comments All malformations 1.3-1.5 ICSI and IVF rates similar* Cardiovascular defects 2-4 Especially cardiac septal defects Neural tube defects 5 Facial clefts 2 Urogenital defects 2-5 Especially hypospadias with ICSI* Imprinting defects 3-9 Especially Beckwith- Wiedemann syndrome Table 1. Congenital malformations which occur with increased frequency in assisted reproductive technology (ART) conceptions compared with spontaneous conceptions
  • 35. PRE-TERM < 37 WTRA Natur RR613/5361 (11.4) 428/7038 (6.1) 2.04 (1.80 to 2.32)Frans M Helmerhorst BMJ. 2004 January 31; 328(7434): 261.
  • 36. No (‰) assisted No (‰) natural Relative risk (95% CI)SINGLETON 57/4582 (12.4) 45/5641 (8.0) 1.68 (1.11 to 2.55) TWIN 30/1440 (20.8) 60/2118 (28.3) 0.84 (0.53 to 1.32) Frans M Helmerhorst BMJ. 2004 January 31; 328(7434): 261. Dichorionic pregnancies fare better than monochorionic pregnancies and the latter account for 5-7% of assisted compared with 30% of natural twin pregnancies. J Ultrasound Med 2001;20: 757-60
  • 37.  Gravidanze multiple  Dizigoti  Monozigoti (↑2-volte)  Basso peso alla nascita(↑2-volte)  Parto prematuro  Riduzione della crescita fetale corretto per la gemellarità  Complicanze e mortalità perinatale  Emorragia cerebrale intraventricolare(↑4-volte)  Paralisi cerebrale infantile(↑4-volte)  5600PMA/11000ContrObstet Gynecol 2004;103:1154–63.The American Collegeof Obstetricians and Gynecologists
  • 38.  Anomalie congenite  9% nei nati da PMA vs 4% controlli  Registri australiano e svedese Corretto per la gemellarità Tecnica ICSI  Aumento alterazioni cromosomiche de novo, microdelezioni dell’Y e mutazioni causanti la fibrosi cistica• Cancro nell’infanzia - Retinoblastoma (↑7 volte) - Neuroblastoma ?? Obstet Gynecol 2004;103:1154–63
  • 39. aMalformazioni dopo Fertilizzazione in VitroAutori N Maggiori minoriWennerholm, 2000 1139 4.1%Lancaster, 2000 2762 2.5%Bonduelle, 2002 2840 3.4% 6.3%Hansen, 2002 1138 8.8%
  • 40. Studio Australiano di Hansen - NEJM March 2002 anomalie maggiori a un anno di vitaICSI 26/301 8.6 % (5.7-12.4%)IVF 75/837 9.0 % (7.1-11.1%)PopulazioneGenerale 168/4000 4.2 % (3.6-4.9%)(N Engl J Med 2002;346:725-30.)
  • 41.  Bambini concepiti con IntraCytoplasmic Sperm Injection o Fertilizzatione In Vitro Raddoppia rischio malformazioni maggiori rispetto ai controlli (N Engl J Med 2002;346:725- 30.)
  • 42. Prenatal Diagnosis and Multiple PregnancyJane Cleary-Goldman, Semin Perinatol 29:312-320 2005
  • 43.  CVS is considered a safe alternative to amniocentesis in multiples. if discordant results are obtained and the patient desires selective termination,that procedure can be performed relatively early in pregnancy, when it is associated with a lower risk of adverse outcomes. Miscarriage occurred in 4.18% of pregnancies undergoing second trimester amniocentesis and in 4.54% of those following CVS.

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