Gestación incipiente Corionicidad EmbriorreducciónCribaje aneuploidias y anomalias
Eco TV Gest loc Gest incipiente desconocida(PUL)INTRAUTERO ECTOPIC0 VIABILIDAD INCIERTA Algoritmo PUL CONTROL EN 7D
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;
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;
Zona discriminacion: bhcg >1500 BHCG<66 % O PLATEAU > 66%ABORTO GEU GEST EVOLUTIVA INTRAUTERINA EXTRAUTERINA
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
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
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.
Hoesli IM et al: Spontaneous fetal loss rates in a non-selected population. Am J Med Genet 100: 106, 2001)
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
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
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%.
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
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
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)
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
Hum Reprod. 2004 Feb;19(2):272-7. Incidence of spontaneous abortion among aborto pregnancies produced by assisted reproductive technology geu • x4 multiples
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
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
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
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
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
EditorialCongenital malformations after assisted reproduction: risks andimplications for prenatal diagnosis and fetal medicineUltrasound Obstet Gynecol 2010; 35: 255–259
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
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.
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
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
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
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%
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.)
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.)
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.