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sabato 29 giugno 13
sabato 29 giugno 13
sabato 29 giugno 13
T
Sagittal T1-3D VIBE sequences following gadoterate meglumine administration in a normal placenta.
∼ 2 min
The signal enhancement of the intervillous space was intense and homogeneous, with rapid kinetics throughout the entire
parenchyma, as anticipated in such a low resistance, low pressure and high flow district where the exchange processes need to be
optimized.
sabato 29 giugno 13
T
Sagittal T1-3D VIBE sequences following gadoterate meglumine administration in a IUGR placenta
∼ 4 min.
The placenta of patients with fetal IUGR showed many patchy unperfused areas ; therefore, occluded maternal spiral arteries behave
like terminal arteries, with no shared circulation between different sectors of the intervillous space.
sabato 29 giugno 13
Brain sparing
Hind sparing
Liver sparing
Meccanismi reologici di adattamento alla ipossia
sabato 29 giugno 13
Aumento del precarico: massiccia
vasodilatazione del dotto venoso con
inversione del flusso nel sistema portale
Aumento del postcarico: vasocostrizione del
dotto arterioso con aumento dello shunt
intracardiaco.
Implicazioni funzionali per il miocardio (1)
sabato 29 giugno 13
Deterioramento della condizione inotropa.
Implicazioni funzionali per il miocardio (2)
sabato 29 giugno 13
Protons directly compete for Ca" binding at the
regulatory sites of TnC, but this competition is
influenced by pH-dependent alterations in the
interactions of TnC with neighboring proteins,
especially TnI. Expression of the ssTnI isoform in
developing myocardium has been proposed to
provide a significant protective effect on force in
fetal/neonatal hearts during ischemia. Indeed, TnI
acts as an important pH sensor in an isoform-
specific manner.
Protezione della condizione inotropa del miocardio fetale
sabato 29 giugno 13
Early/atrial ratio (atrioventricular flow)
Myocardial performance index
Tissue Doppler Imaging
Functional assessment of the fetal heart
Venous flow assessment
sabato 29 giugno 13
Myocardial tissue Doppler (MTD) ultrasonography is a technique that allows measurement
of myocardial velocimetry in systole and diastole without the limitations of transvalvar
mitral and tricuspid flow analysis by conventional Doppler, which is influenced by a high
cardiac rate and by preload and afterload conditions.
sabato 29 giugno 13
Alterazioni del flusso nel dotto venoso
sabato 29 giugno 13
Proprietà batmotrope; ruolo dell’asfissiaPerdita del controllo autonomico: ritmo idiocardiaco
X
sabato 29 giugno 13
Testo
Alterazioni inotrope e batmotrope; timing del parto nell’asfissia
sabato 29 giugno 13
...while we strongly believe that flow measurement in the DV is an important indicator
of fetal condition, in some cases DV pathology is not representative of the fetal
condition. Caution is warranted when using single Doppler measurements to trigger
delivery... a combination of various parameters constitutes the best approach...
...Clinica...
Alterazioni isolate nel flusso del dotto venoso; ruolo nelle condizioni non asfittiche
sabato 29 giugno 13
(1) how many fetuses with anti- SSA/
Ro have prolonged PR intervals?
(2) is first degree block predictive of
more advanced forms of AVB?
(3) which is the outcome of first
degree block?
98 fetuses
definition of first-degree AVB; ≥ 150 msec.
Occurrence of first-degree AVB; 3 cases.
Occurrence of third degree block; 3 cases; NO ONE with previous
abnormal P-R interval.
First-degree AVB outcome; 1 case reversed to normal sinus rhythm
spontaneously and 2 cases with DEXA.
24 fetuses
definition of first-degree AVB; ≥ 95 percentile.
Occurrence of first-degree AVB; 8 cases.
First-degree AVB outcome; 6 cases spontaneously reversed to
sinus rhythm, 1 progressed to complete block and 1 showed
recovery from second-degree block after DEXA.
AVB grado 1
sabato 29 giugno 13
BAV congenito da autoanticorpi; grado 1vs. 2/3
sabato 29 giugno 13
Which is the response of advanced
heart block to DEXA treatment ?
6 cases of second-degree heart block; 3 progressed to grade 3, 2
stabilized at grade 2 and 1 reverted to normal sinus rhythm.
22 cases of complete heart block; no reversal observed.
sabato 29 giugno 13
Less intensive surveillance. It remains unproven
whether a prolonged PR interval represents a
putative “biomarker” of early disease. Fetal
conduction disease can progress exceedingly
rapidly. First- degree AV block may not be a
necessary precursor to third-degree AV.
Perhaps the “PR-fect solution” can be identified
by a multicenter randomized trial comparing
observation alone with treatment following an
“abnormal PR.
Second-degree AV block should be treated with
fluorinated steroids, and acute third-degree AV
block may benefit given the possibility of rare,
albeit transient, reversibility. Dexa can also
benefit cases with complete heart block
associated with fetal hydrops.
[
sabato 29 giugno 13
Algoritmo procedurale per colestasi gravidica
38 wk 37 wk
sabato 29 giugno 13
Il trasferimento netto di acidi biliari al feto
non è funzione della concentrazione
assoluta ma della permeabilità placentare, in
base ad una risposta individuale ad insulti
ossidativo/infiammatori
Colestasi gravidica; patogenesi
sabato 29 giugno 13
Pitfalls of the proposed algorhytm.
In utero fetal death from
intrahepatic cholestasis of
pregnancy is cardiogenic, can be
abrupt in nature and cannot be
predicted reliably from reactive
nonstress tests.
sabato 29 giugno 13
sabato 29 giugno 13
a low number of participants
Ursodeoxycholic acid or antihistamines
might be responsible for the increased fetal
PR interval that was seen in ICP in this
study.
Despite the limitations of this study, we
demonstrated a potential difference in the
conduction system in fetuses of
pregnancies that were complicated by ICP.
Further studies of the fetal PR interval are
needed to evaluate whether this or other
measurements may be of any clinical
benefit as an instrument to predict adverse
fetal outcome in ICP.
sabato 29 giugno 13
Monocorialità: TTTS e sequenza TRAP
sabato 29 giugno 13
Progressiva contrazione dello spazio intravascolare
sabato 29 giugno 13
Ventricular hypertrophy is present (1 point) if the free walls of
the ventricle or ventricular septum appear thickened or if the
right ventricle free wall or ventricular septum thickness exceeds
2 SD from the expected mean for gestational age (1 point)
Cardiac dilation/enlargement is graded as a normal heart size (0
points) when the cardiothoracic ratio is ≤1/3, as mild (1 point)
when the cardiothoracic ratio is >1/3 but <50%, or more than
mild (2 points) when cardiothoracic ratio is ≥50%.
Systolic function is evaluated by calculation of the percentage of
shortening fraction = [ventricular end-diastolic dimension -
systolic dimension]/end-diastolic dimension. No dysfunction (0
points) is the percentage of systolic function at ≥30%; mild
dysfunction (1 point) is the percentage of systolic function at SF
<30% but >20%; more than mild dysfunction (2 points) is the
percentage of systolic function at <20%.
Tricuspid and mitral valve regurgitation are graded as none (0
points), mild (1 point) when the regurgitant jet area is ≤25% of
the atrial area, or more than mild (2 points) when the regurgitant
jet area is >25% of the atrial area.
Tricuspid and mitral valve Doppler in- flow interrogation; 2-peak
signal (0 points) or single peak signal (1 point).
Decreased right ventricular compliance; blood flow in the ductus
venosus (1 point) or absent/reversed blood flow with atrial
contraction (2 points) umbilical venous blood flow pulsations (1
point).
The pulmonary artery may be equal to the aorta (1 point) or
smaller than the aorta (2 points); for frank right ventricular
outflow tract obstruction (3 points).
In the donor. diminished (1 point) or absent or reversed diastolic
blood flow (2 points) of the umbilical artery.
1 0-5
2 6-10
3 11-15
4 16-20
sabato 29 giugno 13
Preterm delivery was strongly associated
with the development of hydramnios and
congestive heart failure in the pump twin.
If the twin-weight ratio was above 70%,
the incidence of preterm delivery was
90% and pump-twin congestive heart
failure, 30% compared with 75% and
10%, respectively, when the ratio was
less.
Predizione del “fetal demise” nella TRAP sequence (1)
Rapporto peso gemello acardico Sviluppo di idrope Evidenza di focolai ischemici
sabato 29 giugno 13
Predizione del “fetal demise” nella TRAP sequence (2)
sabato 29 giugno 13
L'intelletto è sempre ingannato dal cuore.
François de La Rochefoucauld
sabato 29 giugno 13

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Fetal cardiac assessment using tissue Doppler imaging

  • 4. T Sagittal T1-3D VIBE sequences following gadoterate meglumine administration in a normal placenta. ∼ 2 min The signal enhancement of the intervillous space was intense and homogeneous, with rapid kinetics throughout the entire parenchyma, as anticipated in such a low resistance, low pressure and high flow district where the exchange processes need to be optimized. sabato 29 giugno 13
  • 5. T Sagittal T1-3D VIBE sequences following gadoterate meglumine administration in a IUGR placenta ∼ 4 min. The placenta of patients with fetal IUGR showed many patchy unperfused areas ; therefore, occluded maternal spiral arteries behave like terminal arteries, with no shared circulation between different sectors of the intervillous space. sabato 29 giugno 13
  • 6. Brain sparing Hind sparing Liver sparing Meccanismi reologici di adattamento alla ipossia sabato 29 giugno 13
  • 7. Aumento del precarico: massiccia vasodilatazione del dotto venoso con inversione del flusso nel sistema portale Aumento del postcarico: vasocostrizione del dotto arterioso con aumento dello shunt intracardiaco. Implicazioni funzionali per il miocardio (1) sabato 29 giugno 13
  • 8. Deterioramento della condizione inotropa. Implicazioni funzionali per il miocardio (2) sabato 29 giugno 13
  • 9. Protons directly compete for Ca" binding at the regulatory sites of TnC, but this competition is influenced by pH-dependent alterations in the interactions of TnC with neighboring proteins, especially TnI. Expression of the ssTnI isoform in developing myocardium has been proposed to provide a significant protective effect on force in fetal/neonatal hearts during ischemia. Indeed, TnI acts as an important pH sensor in an isoform- specific manner. Protezione della condizione inotropa del miocardio fetale sabato 29 giugno 13
  • 10. Early/atrial ratio (atrioventricular flow) Myocardial performance index Tissue Doppler Imaging Functional assessment of the fetal heart Venous flow assessment sabato 29 giugno 13
  • 11. Myocardial tissue Doppler (MTD) ultrasonography is a technique that allows measurement of myocardial velocimetry in systole and diastole without the limitations of transvalvar mitral and tricuspid flow analysis by conventional Doppler, which is influenced by a high cardiac rate and by preload and afterload conditions. sabato 29 giugno 13
  • 12. Alterazioni del flusso nel dotto venoso sabato 29 giugno 13
  • 13. Proprietà batmotrope; ruolo dell’asfissiaPerdita del controllo autonomico: ritmo idiocardiaco X sabato 29 giugno 13
  • 14. Testo Alterazioni inotrope e batmotrope; timing del parto nell’asfissia sabato 29 giugno 13
  • 15. ...while we strongly believe that flow measurement in the DV is an important indicator of fetal condition, in some cases DV pathology is not representative of the fetal condition. Caution is warranted when using single Doppler measurements to trigger delivery... a combination of various parameters constitutes the best approach... ...Clinica... Alterazioni isolate nel flusso del dotto venoso; ruolo nelle condizioni non asfittiche sabato 29 giugno 13
  • 16. (1) how many fetuses with anti- SSA/ Ro have prolonged PR intervals? (2) is first degree block predictive of more advanced forms of AVB? (3) which is the outcome of first degree block? 98 fetuses definition of first-degree AVB; ≥ 150 msec. Occurrence of first-degree AVB; 3 cases. Occurrence of third degree block; 3 cases; NO ONE with previous abnormal P-R interval. First-degree AVB outcome; 1 case reversed to normal sinus rhythm spontaneously and 2 cases with DEXA. 24 fetuses definition of first-degree AVB; ≥ 95 percentile. Occurrence of first-degree AVB; 8 cases. First-degree AVB outcome; 6 cases spontaneously reversed to sinus rhythm, 1 progressed to complete block and 1 showed recovery from second-degree block after DEXA. AVB grado 1 sabato 29 giugno 13
  • 17. BAV congenito da autoanticorpi; grado 1vs. 2/3 sabato 29 giugno 13
  • 18. Which is the response of advanced heart block to DEXA treatment ? 6 cases of second-degree heart block; 3 progressed to grade 3, 2 stabilized at grade 2 and 1 reverted to normal sinus rhythm. 22 cases of complete heart block; no reversal observed. sabato 29 giugno 13
  • 19. Less intensive surveillance. It remains unproven whether a prolonged PR interval represents a putative “biomarker” of early disease. Fetal conduction disease can progress exceedingly rapidly. First- degree AV block may not be a necessary precursor to third-degree AV. Perhaps the “PR-fect solution” can be identified by a multicenter randomized trial comparing observation alone with treatment following an “abnormal PR. Second-degree AV block should be treated with fluorinated steroids, and acute third-degree AV block may benefit given the possibility of rare, albeit transient, reversibility. Dexa can also benefit cases with complete heart block associated with fetal hydrops. [ sabato 29 giugno 13
  • 20. Algoritmo procedurale per colestasi gravidica 38 wk 37 wk sabato 29 giugno 13
  • 21. Il trasferimento netto di acidi biliari al feto non è funzione della concentrazione assoluta ma della permeabilità placentare, in base ad una risposta individuale ad insulti ossidativo/infiammatori Colestasi gravidica; patogenesi sabato 29 giugno 13
  • 22. Pitfalls of the proposed algorhytm. In utero fetal death from intrahepatic cholestasis of pregnancy is cardiogenic, can be abrupt in nature and cannot be predicted reliably from reactive nonstress tests. sabato 29 giugno 13
  • 24. a low number of participants Ursodeoxycholic acid or antihistamines might be responsible for the increased fetal PR interval that was seen in ICP in this study. Despite the limitations of this study, we demonstrated a potential difference in the conduction system in fetuses of pregnancies that were complicated by ICP. Further studies of the fetal PR interval are needed to evaluate whether this or other measurements may be of any clinical benefit as an instrument to predict adverse fetal outcome in ICP. sabato 29 giugno 13
  • 25. Monocorialità: TTTS e sequenza TRAP sabato 29 giugno 13
  • 26. Progressiva contrazione dello spazio intravascolare sabato 29 giugno 13
  • 27. Ventricular hypertrophy is present (1 point) if the free walls of the ventricle or ventricular septum appear thickened or if the right ventricle free wall or ventricular septum thickness exceeds 2 SD from the expected mean for gestational age (1 point) Cardiac dilation/enlargement is graded as a normal heart size (0 points) when the cardiothoracic ratio is ≤1/3, as mild (1 point) when the cardiothoracic ratio is >1/3 but <50%, or more than mild (2 points) when cardiothoracic ratio is ≥50%. Systolic function is evaluated by calculation of the percentage of shortening fraction = [ventricular end-diastolic dimension - systolic dimension]/end-diastolic dimension. No dysfunction (0 points) is the percentage of systolic function at ≥30%; mild dysfunction (1 point) is the percentage of systolic function at SF <30% but >20%; more than mild dysfunction (2 points) is the percentage of systolic function at <20%. Tricuspid and mitral valve regurgitation are graded as none (0 points), mild (1 point) when the regurgitant jet area is ≤25% of the atrial area, or more than mild (2 points) when the regurgitant jet area is >25% of the atrial area. Tricuspid and mitral valve Doppler in- flow interrogation; 2-peak signal (0 points) or single peak signal (1 point). Decreased right ventricular compliance; blood flow in the ductus venosus (1 point) or absent/reversed blood flow with atrial contraction (2 points) umbilical venous blood flow pulsations (1 point). The pulmonary artery may be equal to the aorta (1 point) or smaller than the aorta (2 points); for frank right ventricular outflow tract obstruction (3 points). In the donor. diminished (1 point) or absent or reversed diastolic blood flow (2 points) of the umbilical artery. 1 0-5 2 6-10 3 11-15 4 16-20 sabato 29 giugno 13
  • 28. Preterm delivery was strongly associated with the development of hydramnios and congestive heart failure in the pump twin. If the twin-weight ratio was above 70%, the incidence of preterm delivery was 90% and pump-twin congestive heart failure, 30% compared with 75% and 10%, respectively, when the ratio was less. Predizione del “fetal demise” nella TRAP sequence (1) Rapporto peso gemello acardico Sviluppo di idrope Evidenza di focolai ischemici sabato 29 giugno 13
  • 29. Predizione del “fetal demise” nella TRAP sequence (2) sabato 29 giugno 13
  • 30. L'intelletto è sempre ingannato dal cuore. François de La Rochefoucauld sabato 29 giugno 13