Gestación incipiente         Corionicidad       EmbriorreducciónCribaje aneuploidias y anomalias
Eco TV                                                      Gest loc                Gest incipiente                       ...
Current evidence on surgery, systemic methotrexate and expectant management in thetreatment of tubal ectopic pregnancy: a ...
Laparoscopy vs cirugia abiertaMTX multidose vc laparos salpingostomiaMTX dosis unica vs laparos salpingostomiaMTX 0,25 VS ...
Zona discriminacion: bhcg >1500            BHCG<66 % O PLATEAU           > 66%ABORTO    GEU      GEST EVOLUTIVA           ...
Haemodynamically           Haemodynamically            Haemodynamically   stable Pain free            stable +Pain        ...
Rescan one week to confirm                    pregnancy location Early Intra-uterine       Ectopic pregnancy              ...
Schieve LA, et al. (2003). Spontaneous abortion among pregnanciesconceived using assisted reproductive technology in the U...
Hoesli IM et al: Spontaneous fetal loss rates in a non-selected population. Am J Med Genet 100: 106, 2001)
Birth weight (g)           3279,0   2379,0Low and very low birthweight                        8,2     48,4Gestation (weeks...
   SAB = most COMMON complication of early    pregnancy   8-20% of clinically recognized pregnancies    under 20 wks und...
   With daily hCG assays, total rate of    pregnancy loss after implantation was 31%    (70% of these prior to detection ...
   Definitive diagnosis of SAB when:    ◦ Absence of FCA with CRL >5mm    ◦ Absence of fetal pole when mean sac diameter ...
   YS abnormal (irregular, LGA, free floating)   Slow fetal heart rate (ie HR <85 bmp at 6-8    wks associated with 0% s...
   hCG rises in curvilinear fashion    until 41 days gestation, then    rises more slowly to 10 wks and    declines until...
   DZ = serum hCG above which gest sac    should be seen by TVUS if +IUP   1500-2000 with TVUS (6500 TAUS)   Above DZ –...
   What is the incidence of ectopic pregnancy?   The reported incidence of ectopic pregnancy                           a...
Hum Reprod. 2004 Feb;19(2):272-7.   Incidence of spontaneous abortion among                       aborto    pregnancies p...
TRA      Concepcion Nat                                                ComentariosAborto      18 %    14-30%        15-20%...
>95% ectopicpregs in fallopiantubes70% ampulla12% isthmic11.1% fimbrial3.2% ovarian2.4% interstitial1.3% abdominal
Tubal Ectopic Pregnancy
Fertil Steril. 2009 Aug;92(2):515-9. Epub 2008 Oct 1.Effect of methotrexate exposure on subsequent fertilityin women under...
ART Outcomes by Age   SART,CDC, 2004
Pregnancy Loss by Age: CDC 2002
Tv/TC vs TA  Outcome         Studies     Tv-TC    Transabd      RR, 95%CI Pregnancy       Berkowitz     1/3       3/8     ...
Uterine Arteries                   NB, TC, DV                                Hormones Placenta                            ...
Fertil Steril. 2009 Feb;91(2):305-15.
ER                                     ExpectanteRisks of miscarriage and early preterm birth in trichorionic triplet preg...
ER.Triples                                                                        aborto                                  ...
preterm                                   27.5%                                          10.5%Risks of miscarriage and ear...
9080706050                                             único40                                             Doble30        ...
Assisted                                            reproductive                                            technologies  ...
EditorialCongenital malformations after assisted reproduction: risks andimplications for prenatal diagnosis and fetal medi...
EditorialCongenital malformations after assisted reproduction: risks andimplications for prenatal diagnosis and fetal medi...
PRE-TERM < 37 WTRA                Natur               RR613/5361 (11.4)   428/7038 (6.1)       2.04 (1.80 to 2.32)Frans M ...
No (‰) assisted   No (‰) natural     Relative risk (95% CI)SINGLETON   57/4582 (12.4)      45/5641 (8.0)       1.68 (1.11 ...
   Gravidanze multiple            Dizigoti            Monozigoti (↑2-volte)    Basso peso alla nascita(↑2-volte)      ...
   Anomalie congenite        9% nei nati da PMA vs 4% controlli        Registri australiano e svedese                  ...
aMalformazioni dopo Fertilizzazione in VitroAutori             N         Maggiori   minoriWennerholm, 2000   1139       4....
Studio Australiano di Hansen - NEJM March                   2002             anomalie maggiori a un anno di vitaICSI      ...
   Bambini concepiti con    IntraCytoplasmic    Sperm Injection o    Fertilizzatione In Vitro   Raddoppia rischio    mal...
Prenatal Diagnosis and Multiple PregnancyJane Cleary-Goldman, Semin Perinatol 29:312-320 2005
   CVS is considered a safe alternative to amniocentesis in    multiples.   if discordant results are obtained and the p...
Tra ecoinicial master
Tra ecoinicial master
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Tra ecoinicial master

  1. 1. Gestación incipiente Corionicidad EmbriorreducciónCribaje aneuploidias y anomalias
  2. 2. Eco TV Gest loc Gest incipiente desconocida(PUL)INTRAUTERO ECTOPIC0 VIABILIDAD INCIERTA Algoritmo PUL CONTROL EN 7D
  3. 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. 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. 5. Zona discriminacion: bhcg >1500 BHCG<66 % O PLATEAU > 66%ABORTO GEU GEST EVOLUTIVA INTRAUTERINA EXTRAUTERINA
  6. 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. 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. 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. 9. Hoesli IM et al: Spontaneous fetal loss rates in a non-selected population. Am J Med Genet 100: 106, 2001)
  10. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 20. >95% ectopicpregs in fallopiantubes70% ampulla12% isthmic11.1% fimbrial3.2% ovarian2.4% interstitial1.3% abdominal
  21. 21. Tubal Ectopic Pregnancy
  22. 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. 23. ART Outcomes by Age SART,CDC, 2004
  24. 24. Pregnancy Loss by Age: CDC 2002
  25. 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. 26. Uterine Arteries NB, TC, DV Hormones Placenta Anatomia MultiplesNuchal Screening The First Trimester Scan (11-13 weeks 6 days)
  27. 27. Fertil Steril. 2009 Feb;91(2):305-15.
  28. 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. 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. 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. 31. 9080706050 único40 Doble30 Triple20100 2000 2001 2002 2003 2004 2005 2006 2007
  32. 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. 33. EditorialCongenital malformations after assisted reproduction: risks andimplications for prenatal diagnosis and fetal medicineUltrasound Obstet Gynecol 2010; 35: 255–259
  34. 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. 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. 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. 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. 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. 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. 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. 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. 42. Prenatal Diagnosis and Multiple PregnancyJane Cleary-Goldman, Semin Perinatol 29:312-320 2005
  43. 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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