This document discusses focused antenatal care and first trimester screening. It describes the essential elements of antenatal care including targeted assessments based on individual risk factors. First trimester screening aims to detect conditions like aneuploidy through measuring the nuchal translucency, analyzing maternal serum markers, and assessing fetal heart rate between 11-13 weeks of gestation. Screening tests are evaluated based on their sensitivity, specificity, and rates of false positives and negatives.
Embryo implantation in the region of a previous caesarean section scar is a rare but potentially catastrophic complication of a previous cesarean birth.
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
Ovarian Hyperstimulation Syndrome(OHSS), is a Rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy where a patient's ovaries become swollen and fluid builds up around her abdomen
Embryo implantation in the region of a previous caesarean section scar is a rare but potentially catastrophic complication of a previous cesarean birth.
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
Ovarian Hyperstimulation Syndrome(OHSS), is a Rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy where a patient's ovaries become swollen and fluid builds up around her abdomen
The role of uterine artery embolization in gynecology practiceApollo Hospitals
Uterine artery embolization (UAE) is a minimally invasive interventional radiological procedure to occlude the arterial
supply to the uterus. UAE has been very useful for controlling hemorrhage following delivery/abortion, in ectopic or cervical pregnancy, gestational trophoblastic disease or carcinoma cervix. Currently it is being mostly used for treating uterine fibroids. It requires a shorter Hospital stay with early resumption to normal activity. This review briefly summarizes the role of this relatively new technique in gynecologic practice.
Fetal growth restriction (FGR), formerly called intrauterine growth restriction (IUGR), refers to a condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb.
Mild FGR usually doesn't cause long-term problems. In fact, most babies who have it catch up in height and weight by age 2. But severe FGR can seriously harm a baby before and after birth. The extent of the problems depends on the cause and how severe the growth restriction is. It also depends on what point in the pregnancy it starts.
Hello everyone
This presentation will give a insight into the recent advances in fetal therapy. Hope it might help you
Thanking you
Dr Ankit gupta
MD Pediatrics
Kims karad
Recurrent pregnancy loss (RPL), also referred to as recurrent miscarriage or habitual abortion, is historically defined as 3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period.
This Presentation is made by Dr.Laxmi Shrikhande
The role of uterine artery embolization in gynecology practiceApollo Hospitals
Uterine artery embolization (UAE) is a minimally invasive interventional radiological procedure to occlude the arterial
supply to the uterus. UAE has been very useful for controlling hemorrhage following delivery/abortion, in ectopic or cervical pregnancy, gestational trophoblastic disease or carcinoma cervix. Currently it is being mostly used for treating uterine fibroids. It requires a shorter Hospital stay with early resumption to normal activity. This review briefly summarizes the role of this relatively new technique in gynecologic practice.
Fetal growth restriction (FGR), formerly called intrauterine growth restriction (IUGR), refers to a condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb.
Mild FGR usually doesn't cause long-term problems. In fact, most babies who have it catch up in height and weight by age 2. But severe FGR can seriously harm a baby before and after birth. The extent of the problems depends on the cause and how severe the growth restriction is. It also depends on what point in the pregnancy it starts.
Hello everyone
This presentation will give a insight into the recent advances in fetal therapy. Hope it might help you
Thanking you
Dr Ankit gupta
MD Pediatrics
Kims karad
Recurrent pregnancy loss (RPL), also referred to as recurrent miscarriage or habitual abortion, is historically defined as 3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period.
This Presentation is made by Dr.Laxmi Shrikhande
In this presentation we will focus on aetiological factors that cause infirtility. Our focus is on US depiction of these aetiological factors to help physician in the management of infirtility.
We have nothing to do with direct radiological intervention in the management of infirtility in this presentation.
In this presentation we will discuss
First trimester US especially TVS is an integral part for confirmation of intrauterine pregnancy and to rule out ectopic pregnancy.
First trimester US helps us in suggesting conceptus viability.
First trimester US especially TVS is very efficient in approaching and evaluating the cause of vaginal bleeding.
E. Atypical HUS (aHUS)
1. Epidemiology. aHUS is much less common than STEC-HUS.
2. Etiology
a. Drugs (e.g., oral contraceptives, cyclosporine, tacrolimus) or pregnancy may cause
aHUS.
b. Inherited aHUS occurs with both autosomal dominant and autosomal recessive
inheritance patterns, although not all patients have identifiable mutations. These
genetic mutations cause chronic, excessive activation of complement, which also
leads to platelet activation, endothelial cell damage, and systemic thrombotic
microangiopathy.
3. Clinical features. Clinical findings are similar to those of STEC-HUS. Diarrhea may also
be present, and severe proteinuria and hypertension are more consistently found. The
clinical course is generally more severe with multiorgan damage.
4. Management. Treatment is supportive. Inciting medications, if any, must be stopped
immediately.
5. Prognosis. Some patients have a chronic relapsing course (recurrent HUS). All patients
with aHUS have a higher risk of progression to ESRD than patients with STEC-HUS.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
Focused approach to antenatal care - First trimester screening
1. FOCUSED APPROACH TO ANTENATAL CARE
FIRST TRIMESTER SCREENING
DR BHARTI GAHTORI
12WKS FETOMATERNAL WELLBEING CLINIC
2. WHAT DEFINES A GOOD ANTENATAL CARE
1) It should be focused and individualised - Each patient has its
own risk factors and history, which need to be divulged with
utmost patience and precision.
2) It should aim at screening for conditions which are treatable,
conditions which need constant vigilance &surveillance and conditions
which needs urgent management.
3) We as obstetricians should be educated as well as updated with
the new advances in detection, counselling and management of
conditions complicating maternal as well as fetal outcome.
4) We should be aware of our expertise and limits and very prompt in
counselling and referring patients without delay when in a fix .
5) We should not be hesitant but interactive and close knit to share
and discuss our professional queries for the benefit of our patients.
3. THE ESSENTIAL ELEMENTS OF A FOCUSED
APPROACH TO ANTENATAL CARE IN OUR SETUPS
Targeted assessment based on woman’s individual health situations to
ensure normal progress of the pregnancy which includes antepartum-
intrapartum-postpartum and postnatal period
To facilitate the early detection of and special care of complications ,
chronic conditions and other potential problems that can affect the
mother.
By incorporating new investigations, screening methods – routine &
special , diagnostic modalities and management options for early
detection, counselling and treatment of the affected mother and the fetus
Identification and surveillance of fetal conditions like aneuploidy,
malformations, infections , metabolic and haematological conditions
etc as early as possible by utilizing all the available modalities and plan
its management according to its severity and treatability
4. DEFINE SCREENING
Screening is a process of identifying apparently healthy people who
may be at increased risk of a disease or condition. Screening allows
high-risk individuals to be selected out of a population at low risk for
a given complication.
They can then be offered information, further diagnostic tests and
appropriate treatment to reduce their risk and/or any complications
arising from the disease or condition.
SENSITIVITY : ABILITY TO DETECT
INDIVIDUALS WITH THE PRESENCE
OF TARGET CONDITION.
SPECIFICITY : ABILITY TO DETECT
INDIVIDUALS WHO ARE
COMPLETELY DISEASE FREE.
FALSE POSITIVE :INDIVIDUALS NOT
WITH THE DISEASE BUT DETECTED
WITH IT. LEAST THE FP MORE THE
TEST SENSITIVE
FALSE NEGATIVE : INDIVIDUALS
WHO HAVE THE DISEASE BUT
DETECTED FREE OF IT. LEAST THE
FALSE NEGATIVE MORE THE TEST
SPECIFIC
9. TYPES OF SCREENING IN FIRST TRIMESTER
1) AGE : < 18 > 35
2)ETHNICITY : *Sickle cell anemia- African, African American, or Mediterranean
heritage
*Tay-Sachs disease, Ashkenazi (eastern and central European) Jewish
or French Canadian ancestry
* Cystic fibrosis : Caucasians
* Pregestational/ gestational diabetes : Asian , Hispanics
* Hemoglobinopathies : South east Asians
*Alpha & beta Thalassemia : Indian subcontinent
*Small nasal bone : Africans
3)OCCUPATION ( COUPLE) : For viral diseases like HIV , HBsAg , and CMV & other STD
PTO
RISK FACTOR SCREENING
BIODATA :
10. HISTORY OF PRESENT ILLNESS
H/o Fever with rash + LAP / other Infections(UTI, STI etc)
H/o Excessive Nausea /vomiting
H/o Pain lower abdomen ± Bleeding P/V
H/o Exposure to X-Ray/CT scan/Intake of medical abortifacient
H/o Intake of folic acid /Current medications /Pre-pregnancy
medication / vaccination
MENSTRUAL AND GYNECOLOGICAL HISTORY
H/o regular / irregular cycles
H/o spontaneous conception/ ART
H/o Gynecological surgeries e.g myomectomy , septal resection ,
repeated D&C
H/o vaginal infection, warts etc
LMP by ( DATES/ UPT/ ART/ USG )
11. OBSTETRICAL HISTORY
G P A L
Pregnancy history -antepartum , intrapartum and postpartum
(associated illness and any complications)
H/o abortion , ectopic, IUD , stillbirth , neonatal death, HYDROPS
Mode of delivery( no. of LSCS & its complications )
PERSONAL AND FAMILY HISTORY
FAMILY H/O:
T.B/ D.M/ H.T/ Multiple Pregnancy/ Familial cancer/ Birth defects/
genetic disorders / hemoglobinopathies & others .
PERSONAL H/O :
Addictions / Pica /worms in stools /Depression /anxiety /Drug Allergy
PAST MEDICAL , MEDICATION & SURGICAL HISTORY
12. ANEUPLOIDY /GENETIC SCREENING
Age > 35 at EDB
H/oKnown teratogen exposure e.g Teratogenic drugs,( antiepileptics, isotretinion ,
ACE inhibitors, radiations including Xrays/CTscan/ radiotherapy
H/o High grade fever with rash , nonimmune to Rubella
H/o intake of abortifacient
H/o Exposure to medical conditions including maternal diabetes , Epilepsy, severe
thyroid ds , autoimmune ds.
H/o consanguinity
H/o termination of pregnancy for fetal abnormality
H/o previous child born with major congenital defect
H/o baby is mentally challenged /hearing disability/ delayed
H/o bleeding disorder in the baby
H/o any genetic disease in the family
13. RISK FACTORS FOR PET/IUGR/GDM/ THYROID DIS
/PRETERM DELIVERY
Previous pregnancies:
H/o recurrent spontaneous miscarriages(< >12wks) without a known
cause .
H/o unexplained IUD/ still birth/neonatal death.
H/o PIH/Thyroid dis/GDM/other illness in previous pregnancy.
H/o Any complication of pregnancy related disease /chronic disease .
H/o Previous baby with SGA/IUGR/LGA(>3.5kg)
IF Rh negative :
* H/o anti D for all pregnancies .
* H/o early/severe jaundice in baby, s/s of isoimmunisation irrespective
of Anti-D in the past , hydrops or IUD fetus .
14. EXAMINATION :
Weight - BMI (BMI is your weight (in kilograms) over your
height squared (in meters) 18 < > 30
Blood pressure : correct method
Mean arterial pressure : Pulse rate :
Chest /CVS
Pallor , icterus , cyanosis , pedal edema , etc
15. MATERNAL SCREENING
ROUTINE : At booking
*Blood group , Rh typing ( If Positive then HBG )
*Hb , Hct , CBC, platelets ( repeat at 28 weeks)
*Infection : VDRL , HIV , HBsAg , Rubella titre
*Urine routine and culture sensitivity
*Random Blood sugar
ADDITIONAL : depends on prevalence
*TSH * Gonorrhae/ chlamydia
*HCV * Pap smear
*Hb Electrophoresis ( thalassemia )
*GTT ( 75 gm glucose load with Fasting, Ist hr , 2nd hr)
*BMI >30 Kg/m2
*Previous baby ≥4.5 Kg
*Previous h/o gestational diabetes
*Family history of diabetes
*Black, South Asian, M Eastern
FPG ≥ 92 mg% but < 126 mg% at first visit; 2 hr
post-glucose load level ≥ 140 mg% < 200mg%
If one of the following is abnormal at 24-28
weeks:
Fasting ≥ 92 mg%
1 hour ≥ 180 mg%
2 hours ≥ 153 mg%
16. • Cardiac disease
• Hypertension
• Renal disease
• Endocrine disorder or diabetes requiring insulin
• Psychiatric disorder (on medication)
• Haematological disorder, including thromboembolic disease
• Autoimmune diseases such as antiphospholipid syndrome
• Epilepsy requiring anticonvulsant drugs
• Severe asthma
• Drug use such as heroin, cocaine (including crack
cocaine) and ecstasy
• HIV or hepatitis B virus infection /cholestasis
• Obesity (BMI of 30 or more at first contact) or underweight (BMI
less than 18 at first contact)
Conditions in pregnant women increasing their risks, with
obstetric and/or medical care indicated:
17. • Recurrent miscarriage (three or more consecutive
pregnancy losses) or a mid - trimester loss
• Severe pre - eclampsia, HELLP syndrome or eclampsia
• Rhesus isoimmunization or other signifi cant blood group
antibodies
• Uterine surgery including caesarean section, myomectomy
• Antenatal or postpartum haemorrhage on two occasions
• Retained placenta on two occasions
• Puerperal psychosis
• Grand multiparity (more than six pregnancies)
• A stillbirth or neonatal death
• A small for gestational age infant ( <5th centile)
• A large for gestational age infant ( >95th centile)
• A baby weighing < 2500 g or > 4500 g
• A baby with a congenital anomaly (structural or chromosomal)
Women who have experienced any of the following in
previous pregnancies
18. PRENATAL SCREENING: Is testing for diseases or
conditions in a fetus or embryo before it is born.
MATERNAL SERUM MARKERS + 2D/3D ULTRASOUND + DOPPLER
1) Beta HCG / FREE Beta HCG
2) PAPP-A
VIABILITY SCAN ( 6.5 WKS – 10 WKS)
a. Confirmation of the presence of an intrauterine live pregnancy
b. Evaluation of a suspected ectopic pregnancy/H mole / abortion
c. Defining and evaluating the cause of vaginal bleeding & pelvic pain
d. Estimation of gestational (menstrual) age
e) Diagnosis or evaluation of multiple gestations
f) Evaluation of maternal pelvic masses and/or uterine abnormalities
NUCHAL SCAN ( 11- 13.6 WKS)
21. FIRST TRIMESTER SCREENING : TURNING THE SPECIALIST CARE
PYRAMID UPSIDE DOWN
• FETAL MEDICINE ESTABLISED AS A NEW FIELD SPECIFICALLY WORKING IN
CREATING PROTOCOLS ,NEWER METHODOLOGIES AND GENERATE
SPECIALIST TRAINERS TO ASSESS NUCHAL TRANSLUCENCY & OTHER USG
MARKERS FOR ANEUPLOIDY .
• FURTHER HELP BEING PROVIDED BY THE CONSTANT ADVANCEMENTS IN
THE RESOLUTION & QUALITY OF ULTRASOUND MACHINES AND ADDITION
OF NEW FINER SERUM MARKERS WITH BETTER SENSITIVITY AND SPECIFICITY
• AVAILABILITY OF SPECIALISED LABORATORIES WHICH PROVIDE
ASSISTANCE EVEN IN SMALL CITIES WITH SPECIAL SOFTWARES GENERATED
TO CALCULATE COMBINED RISK INCLUDING THE PRIORI RISK ALL WITH
OTHER HIGH RISK, SERUM AND ULTRASOUND MARKER RISK AND THEREBY
IMPROVE DETECTION RATE
22. COMPONENTS OF FIRST TRIMESTER SCREENING
1 ) SCREENING FOR ANEUPLOIDY /CHROMOSOMAL DEFECTS
2) SCREENING FOR FETAL STRUCTURAL ANOMALY
3) SCREENING FOR RISK OF EARLY PRECLAMPSIA & FGR
4) MULTIFETAL GESTATION SCREENING FOR CHRIONICITY &
PREDICTION OF RELATED COMPLICATIONS
7) SCREENING FOR PRETERM LABOUR
COMBINING : ULTRASOUND 2D+ 3D UT. A DOPPLER PAPP-A βHCG
5) DETECTION AND SCREENING FOR GENETIC DISORDERS
6) DETECTION OF PREXISTING DM ,GDM AND THYROID DISORDERS
23. FETAL ANEUPLOIDY
Fetal aneuploidy refers to the abnormal number of chromosomes,
other than usual diploid complement of 46 chromosomes .
TRISOMY : Presence of single additional chromosome, known as trisomy, is
an important cause of congenital malformations. The most common
autosomal trisomies are Down syndrome ( Trisomy 21) , Edward’s
syndrome ( trisomy 18) and Patau syndrome ( Trisomy 13).
Trisomy 21 is the most common of them and one of the most important
cause of congenital mental retardation, affecting approx. 1:800 to 1 :900
live births .
Trisomy 18 & 13 are considered lethal malformation with 95% trisomy 18
infants dying with in 1 yr of age and trisomy 13 infants dying within 3 mths
of age.
Incidence of trisomy 18 ~ 1:3000 live births
Incidence of trisomy 13 ~ 1:5000 live births
Antenatal sonographic based screening is
able to detect over 90% of cases of trisomy
21, trisomy 18 and trisomy 13.
24. SCREENING FOR CHROMOSOMAL DEFECTS
Every time a test is carried out the a priori risk is multiplied by the
likelihood ratio of the test to calculate a new risk, which then becomes
the a priori risk for the next test.
Every woman has a risk that her fetus/baby has a chromosomal defect
.The background or A PRIORI RISK depends on maternal age and gestation
The individual patient-specific risk is calculated by multiplying the a
priori risk with a series of likelihood ratios, which depend on the results of
a series of ultrasound and serum markers used as screening tests in first
trimester.
The likelihood ratio for a given sonographic or biochemical measurement
is calculated by dividing the percentage of chromosomally abnormal
fetuses by the percentage of normal fetuses with that measurement.
25. ANEUPLOIDY SCREENING- MAIN COMPONENTS
• MATERNAL AGE
• NUCHAL TRANSLUCENCY
• FETAL HEART RATE
• SERUM BIOCHEMISTRY
• NEW ULTRASOUND MARKERS
26. MATERNAL AGE
The risk for trisomy 21:
Increases with maternal age
Decreases with gestational age
because about 30% of affected
fetuses die between the 12th and 40th
week of pregnancy
• The risk for trisomy 21 increases with
maternal age but because there are
a lot more women in the younger
age group the majority of fetuses
with trisomy 21 are in the women
aged under 35 years
27. OTHER DEFECTS
The risk for trisomies 18 and 13
increases with maternal age and
decreases with gestation. The rate
of fetal death between the 12th
and 40th week is about 80%
Turner syndrome is unrelated to
maternal age. The rate of fetal
death between the 12th and 40th
week is about 80%. The
prevalence is about 1 in 1500 at 12
weeks and 1 in 4000 at 40 weeks
Triploidy is unrelated to maternal
age. The prevalence at 12 weeks
is about 1 in 2000 but it is highly
lethal and is very rarely observed
in live births
28. NUCHAL TRANSLUCENCY
Definition :Nuchal translucency (NT) is the
sonographic appearance of a collection of fluid
under the skin behind the fetal neck in the first
trimester of pregnancy
The term translucency is used, irrespective of
whether it is septated or not and whether it is
confined to the neck or envelopes the whole
fetus
The incidence of chromosomal and other
abnormalities is related to the size, rather than
the appearance of NT
During the second trimester, the translucency
usually resolves and, in a few cases, it evolves
into either nuchal edema or cystic hygromas
with or without generalized hydrops
29. WHY ONLY BETWEEN 11WKS- 13.6 WKS
The reasons for selecting 11 weeks as the earliest gestation are:
The physiological extra-abdominal herniation of bowel persists and
cranial vault is not ossified till 11 weeks gestation.
Screening necessitates the availability of a diagnostic test and chorionic
villous sampling before this gestation is associated with transverse limb
reduction defects.
Finally, aside from NT measurement, the effectiveness of first trimester
markers prior to 11 week’s gestation is likely reduced
• The reasons for selecting 13 weeks and 6 days as the upper limit are:
To provide women with affected fetuses the option of 1st rather than
2nd trimester termination
• The incidence of abnormal accumulation of nuchal fluid in
chromosomally abnormal fetuses decreases after 13 weeks.
• The success rate for taking a measurement decreases after 13 weeks
because the fetus becomes vertical making it more difficult to obtain
the appropriate image
The optimal gestational age for measurement of fetal NT is 11+0-13+6 weeks. The
minimum fetal crown–rump length (CRL) should be 45 mm and the maximum 84 mm.
30. NUCHAL TRANSLUCENCY
Nuchal thickness increases with CRL in euploid
The median NT for euploid =2.0 mm
For trisomy 21 =3.4 mm
For trisomy 18= 5.5 mm
For trisomy 13 =4.0 mm
For turners Syn = 9.2 mm resp.
The thicker the NT the worse foetal prognosis
is. Pathological values of NT usually range
between 1.8 - 2 MoM or a measure greater
than 3 mm (regardless of the MoM) increases
30% risk of aneuploidy
The 99th centile is about 3.5 mm
and does not change with CRL
In 75-80% of trisomy 21 fetuses the NT
thickness is above the 95th centile of the
normal range .
31. IF RAISED NT BUT NORMAL CHROMOSOMES ON
DIAGNOSTIC TEST
Good chance of a healthy baby
90% if NT < 4.5 mm
80% if NT between 4.5 and 6.4 mm
45% if NT > 6.5 mm
ADVICE : QUADRUPLE MARKER , TARGET SCANNING WITH GENETIC
SONOGRAM IN 2ND TRIMESTER PLUS FETAL ECHO
-20-30% have adverse pregnancy outcome eg IUFD, PRETERM ,
LBW
-Increased chances of other genetic syndrome not detectable
by genetic testing , skeletal dysplasias , congenital heart disease
and non immune hydrops .
32. FETAL HEART RATE
Measurement of fetal heart rate (FHR):
*A transverse or longitudinal section of the heart is
obtained. Pulsed wave Doppler is used to obtain 6-10
cardiac cycles during fetal quiescence
*The FHR is calculated by the ultrasound machine
software
In normal pregnancy,
The FHR increases from about
110 bpm at 5 weeks of gestation to
170 bpm at 10 weeks and then gradually decreases to
150 bpm by 14 weeks
In trisomy 21 the FHR is mildly increased and is above
the 95th centile in about 15% of cases
In trisomy 18 the FHR is mildly decreased and is below
the 5th centile in about 15% of cases
In trisomy 13 the FHR is substantially increased and is
above the 95th centile in 85% of cases
Inclusion of FHR brings a major improvement in the detection of trisomy 13
It is important in distinguishing between trisomy 18 and 13, which are otherwise similar in
presenting with increased fetal NT and decreased maternal serum free β-hCG and PAPP-A
33. MATERNAL SERUM MARKERS IN FIRST TRIMESTER
*Dimeric glycoprotein hormone (α & ß subunits) secreted by the
fertilised ovum and later by placental tissue.
*Primary function is to maintain the corpus luteum, later
produces Progesterone & Oestrogen to maintain early
pregnancy
*Maternal serum hCG maximal during first trimester, then
declines during second trimester
Serum human chorionic gonadotrophin (hCG)
Overall, in Trisomy 21 ßhCG values are higher, those higher than
2.5 MoM indicating a possible pathology. In Trisomies 13 and
18, these values are generally low, with suspicious values being
those below 0.4 MoM.
34. *It is a glycoprotein synthesized in chorionic villi of the placenta . This
protein is a key regulator of insulin-like growth factor bioavailability
essential for normal fetal development. It continues to increase during
the pregnancy period and declines after delivery.
Pregnancy Associated Plasma Protein A (PAPP A)
*ALSO, pathological low level of PAPP-A if <0.5 MOM (normal = 1MOM)
has been associated with other adverse fetal outcomes and
thrombophilia and patients can be empirically started on LDA & LMW
Heparin.
*It has become an important serum marker individually and in
combination for detecting aneuploidies including all trisomies and
other chromosomal defect. When PAPP-A is low ( < 0.4 MoM )the risk
for Down syndrome is increased and when it is elevated, the risk is
reduced.
<0.45 MoM (5th percentile)
- 1 to 4% risk of pregnancy loss before 20 weeks
- increased risk of intrauterine growth restriction,
positive predictive value 14%
- increased risk of preterm delivery before 34
weeks
<0.29 MoM (1st percentile)
- significantly increased risk of intrauterine growth
restriction, with positive predictive values of
24%
35. FREE ß-hCG & PAPP-A VALUES IN DOWN SYNDROME
In trisomy 21 pregnancies maternal serum
free ß-Hcg ( ~2.5 MoM) is about twice as
high and PAPP-A( ~ 0.4MoM) is reduced to
about half compared to chromosomally
normal pregnancies
90% detection of Tri 18 4.5% FPR
If both PAPP-A and B-hCG are very low
MoM = Increased risk for tri 18, triploidy,
fetal anomalies or perinatal complications
Performance of screening for trisomy 21 by
maternal age and serum free ß-hCG and
PAPP-A:
Detection rate 65%
False positive rate 5%
36. MATERNAL SERUM MARKERS
We know now that Trisomic pregnancies are
associated with altered maternal serum
concentrations of various feto-placental
products
Screening in the first trimester by a
combination of maternal age, fetal NT, FHR
and serum free ß-hCG and PAPP-A identifies
about 90% of trisomy 21 pregnancies for a
false positive rate of 3%
38. FACTORS AFFECTING THE SERUM MARKER VALUES
The measured concentration of free
ß-hCG and PAPP-A is influenced by-
* the machine and reagents used,
* gestational age calculation
* maternal weight
* ethnicity
* smoking status
* method of conception
In the calculation of accurate patient-specific risks it is necessary to make
adjustments in the measured free ß-hCG and PAPP-A. Each measured level is
first converted to a multiple of the expected normal median (MoM) specific to
a pregnancy of the same gestation, maternal weight, smoking status, ethnicity
and method of conception
39. HOW TO GET BEST RESULTS FROM COMBINED
SCREENING
A good way of achieving a high performance
of screening for trisomy 21 and diagnosing
major fetal defects by ultrasound is to carry
out the blood test at 10 or 11 weeks and the
ultrasound scan at 12 weeks
40. DIFFERENCES IN MAIN ANEUPLOIDIES
At 11-13 weeks the relative prevalence of
trisomies 18 and 13 to trisomy 21 are about 1 to
2.5 and 1 to 7, respectively
All three trisomies are associated with increased
maternal age, increased fetal NT and decreased
maternal serum PAPP-A
A beneficial consequence of first-trimester
combined screening for trisomy 21 is the early
diagnosis of trisomies 18 and 13.
At a false positive rate of 3% the detection rate of
trisomy 21 is 90% and of trisomies 18 and 13 is
about 75%
41. DIFFERENCES BETWEEN ALL TRISOMIES
There are differences between
the three trisomies:
Fetal NT is higher in trisomies 18
and 13 than in trisomy 21
Serum PAPP-A is lower in
trisomies 18 and 13 than in
trisomy 21
Serum free ß-hCG in trisomy 21 is
high whereas in trisomies 18 and
13 this is low
Fetal heart rate in trisomy 13,
unlike trisomies 21 and 18, is high
43. INTERPRETATION OF MOM VALUES AND RISK OF
ANEUPLOIDY
MoM (multiple of median) - result reported strictly as multiple of median
MoM’s vary with gestational age ,with assay method , with population tested
May need adjustment for:
– weight – ethnic group – other conditions e.g. diabetes – twin pregnancies - ART
- In screening using maternal serum biochemical markers, the measured concentration of
the markers is converted into a multiple of the median (MOM) of unaffected pregnancies at
the same gestation.
- The Gaussian distributions of log10 (MoM) in trisomy 21 and unaffected pregnancies are
then derived, and the ratio of the heights of the distributions at a particular MoM, which is
the likelihood ratio for trisomy 21.
-It is used to modify the a priori maternal age-related risk to derive the patient-specific risk.
44. RISK ASSESSMENT - EXAMPLE
MoMs that typically yield a high risk of Down’s are those where, in
combination, the Free β HCG MoM is > 2.5 and the PAPP-A is < 0.4
HIGH RISK-
Woman > 35 years of age, with a
NT of > 2.0 mm, and
Free β HCG -MoM >2.5 and
PAPP-A -MoM < 0.4
LOW RISK –
Women < 35 years of age, with a
NT of < 2.0 mm, combined with a
Free β HCG and PAPP-A MoM of 1.0.
Further tests required at an overall risk of 1:150
45. Reference Values
DOWN SYNDROME
Calculated screen risks <1/230 are reported as screen negative.
Risks > or =1/230 are reported as screen positive.
TRISOMY 18
Calculated screen risks <1/100 are reported as screen negative.
Risks > or =1/100 are reported as screen positive. A numeric risk for trisomy 18 risk is provided
with positive results on non-diabetic, non-twin pregnancies.
An interpretive report will be provided.
Interpretation
Screen-Negative:
A screen-negative result indicates that the calculated screen risk is below the established cutoff
of 1/230 for Down syndrome and 1/100 for trisomy 18. A negative screen does not guarantee the
absence of trisomy 18 or Down syndrome. Screen-negative results typically do not warrant
further evaluation.
Screen-Positive:
When a Down syndrome risk cutoff of 1/230 is used for follow-up, the combination of maternal
age, pregnancy-associated plasma protein A, human chorionic gonadotropin, and nuchal
translucency has an overall detection rate of approximately 85% with a false-positive rate of 5%
to 10%.
47. ? WHEN TO OPT FOR NEW USG MARKERS
There are two strategies for
assessment of the new markers in
screening for trisomy 21 with similar
detection and false positive rates:
• One, some, or all markers are
examined in all cases
• The markers are examined only in
the subgroup of pregnancies with
an intermediate-risk (between 1 in
51 and 1 in 1000) after combined
fetal NT, FHR, free ß-hCG and
PAPP-A screening, which
constitutes only one sixth (15%) of
the total population
48. NASAL BONE AND FACIAL ANGLE
Done at the same plane as of CRL and NT
• At 11-13 weeks the nasal bone is considered to be absent in about:
Euploid fetuses 1-3%
Fetuses with trisomy 21 60%
Fetuses with trisomy 18 50%
Fetuses with trisomy 13 40%
Baby of Black woman might have small or absent nasal bone
• Assessment of the nasal bone & facial angle improves the performance
of combined screening increasing the detection rate from 90% to 94%
and decreasing the false positive rate from 3% to 2.5%
NEEDS EXPERTISE AND SPECIAL TRAINING TO MASTER IT
49. DUCTUS VENOSUS FLOW
Blood flow in the ductus has a
characteristic waveform with:
High velocity during ventricular
systole (S-wave) and diastole (D-
wave)
Forward flow during atrial
contraction (a-wave)
Qualitative assessment of the ductus
venosus blood flow is based on the
appearance of the a-wave:
Positive or absent (normal)
Reversed (abnormal)
50. REVERSED A-WAVE FORM
At 11-13 weeks reversed a-wave is found in about 4%
of fetuses
Reversed a-wave is more common if:
The gestation is 11 than 13 weeks
The fetal nuchal translucency is high
The maternal serum PAPP-A is low
The mother is Black
Reversed a-wave is associated with increased risk for:
*Chromosomal abnormalities *Сardiac defects
*Fetal death
However, in about 80% of cases with reversed a-wave the
pregnancy outcome is normal
High pulsatility index for veins and absent or reversed a-
wave are observed in fetuses with aneuploidies, cardiac
defects, growth restriction and either the recipient or
donor fetus in twin-to-twin transfusion syndrome
Assessment of ductus venosus
a-wave improves the
performance of first-trimester
combined screening:
Detection rate 95%
False positive rate 2.5%
51. TRICUSPID FLOW
Normal profile with no regurgitation
during systole
*Regurgitation during
approximately half of systole and
with a velocity more than 60 cm/s
Do not mistake for tricuspid
regurgitation:
*The jet produced by aortic or
pulmonary arterial blood flow,
which at this gestation can
produce a maximum velocity of 50
cm/s
*The short reverse ‘spike’ generated
by closure of the valve cusp
52. TRICUSPID REGURGITATION
At 11-13 weeks tricuspid
regurgitation is found in about:
Euploid fetuses 1%
Fetuses with trisomy 21 55%
Fetuses with trisomy 18 30%
Fetuses with trisomy 13 30%
Tricuspid regurgitation is more
common if:
The gestation is 11 than 13 weeks
The fetal nuchal translucency is
high
Assessment of the tricuspid flow improves
the performance of combined screening
increasing the detection rate from 90% to
95% and decreasing the false positive rate
from 3% to 2.5%
53. DETECTING FETAL CARDIAC DEFECTS
The prevalence of major cardiac defects in euploid
fetuses is about 4 in 1,000
The risk for major cardiac defects is increased if the
fetal NT is high.
-Increased if the ductus a-wave is reversed
-Decreased if the ductus a-wave is normal
-Increased if there is tricuspid regurgitation
-Decreased if tricuspid flow is normal
-If there is tricuspid regurgitation examine the fetal
heart for major defects
54. FETAL DEATH
The risk of miscarriage or fetal death between
11 weeks and delivery is about 2%
The prevalence of reversed a-wave at 11-13
weeks is more than 10% in pregnancies
resulting in fetal death and less than 4% in
those resulting in live birth
The risk of fetal death is increased if:
The ductus venosus a-wave is reversed
*The maternal serum PAPP-A is low
*The mother is Black
*The mother is obese
If the ductus venosus a-wave is reversed
*Monitor fetal growth (scan at 20 and 28 wks)
*Monitor uterine artery PI
63. MULTIFETAL GESTATION
CHORIONICITY : The accurate determination of chorionicity is
fundamental for successful management of twin pregnancies
A distinct thickening of the dividing membrane (“lambda”or“twin peak” sign)
represent dichorionic (DC)
Thin, “T-shaped” insertion of the membrane into the placental surface is
indicative of monochorionic placentation.
In monochorionic/diamniotic gestations, the risk of developing twin-to-twin
transfusion syndrome (TTTS) later in pregnancy may be estimated by
1) measuring the NT’s (the likelihood of TTTS increases with increasing
difference in the NT measurements between the two fetuses)
2)evaluating the ductus venosus with Doppler (presence of reversed a-
wave increases the riskof TTTS)
3) Assessing the vascular connection in placenta via doppler
First trimester ultrasound screening is the only best option to detect
aneuploidy in multifetal gestation because serum markers are not valid.
66. PRETERM BIRTH SCREENING
Universal cervical length
screening and vaginal
progesterone prevents early
preterm births, reduces
neonatal morbidity and is
cost saving: Doing nothing
is no longer an option
68. CERVICAL LENGTH MEASUREMENT
Newer studies that proposed
measuring the endocervical
length avoiding the lower uterine
segment (isthmic part) show more
promising results for the prediction
of preterm delivery.
Fig. 1a &1b: Transvaginal
ultrasound pictures illustrating
(1a) the cervico-isthmic complex
and (1b) the measurement of the
length of the endocervix (A to B)
and the isthmus (C to D).
69. Inclusion of both low risk and high risk women:
1) H/o spontaneous preterm birth in the past
2) H/o recurrent mid-trimester pregnancy loss
3) Multifetal gestation
4) H/o cervical trauma
*The risk of spontaneous preterm birth is inversely related to the cervical
length measured by transvaginal sonography 11-14 weeks gestation .
In women with a short cervix (< 1.5 cm), sent to specialist care where
repeat cervical length assessment done .
* If again same finding then if the length was <1.5 cm, the women were
treated by cervical cerclage or vaginal progesterone( Gel with 90mg
progesterone / 200mg pessary) administration. It was found progesterone
reduces the risk of spontaneous early preterm delivery by about 45% .
*However, progesterone and cerclage is not as effective in women
with cervical length of 10 mm or those with a length of 10–20 mm and
funnelling seen.
WORK IS GOING ON
REGARDING USE OF
CERVICAL PESSARIES
DURING PREGNANCY
70. SCREENING FOR RISK OF EARLY PRECLAMPSIA & FGR
INCLUDES : DETAILED HISTORY + PRESENCE OF HIGH RISK FACTORS IF ANY
WITH -MEAN ARTERIAL PRESSURE + PAPP-A + UTERINE ART DOPPLER PI
• Retrospective analysis of 1,658 singleton pregnancies at CRL of 45 to
84mm with outcomes
• Uterine artery – mean PI and lowest PI were plotted and the 95th centile
for each were calculated
• Mean PI : 95th centile: 2.51
Lowest PI : 95th centile: 2.29
(ACFM data)
71. MEASURING MEAN ARTERIAL PRESSURE
METHODOLOGY :The BP was taken by automated devices (3BTO-A2,
Microlife),which were calibrated before and at regular intervals during the
study. The recordings were made by doctors who had received
appropriate training on the use of these machines. The women were
in the seated position, their arms were supported at the level of the heart,
and a small (22-cm), normal (22- to 32-cm), or large (33- to 42-cm) adult
cuff was used depending on the midarm circumference.26 After rest for 5
minutes, BP was measured in both arms simultaneously, and a series of
recordings were made at 1-minute intervals until variations between
consecutive readings fell within 10 mm Hg in systolic and 6 mm Hg in
diastolic BP in both arms.When this point of stability was reached, we
calculated the MAP of each arm as the average of the last 2 stable
measurements, and, as recommended, we took the arm with the highest
final MAP for the subsequent analysis of results.
MAP = MAP = [(2 x diastolic)+systolic] / 3 CUTT OFF : > 90 mm Hg
76. SCREENING FOR CONGENITAL HEART DEFECT ( DUCTUS + TR)
SCREENING FOR ADVERSE FETAL OUTCOME( PAPP-A +DV +TR + SUA
77.
78. NIPT( Non invasive prenatal testing
Molecular techniques in prenatal diagnosis: This technique opens new horizon for noninvasive
prenatal testing. Various types of fetal cells have been identified in maternal circulation. These can
be
Free fetal cells in maternal circulation
Free nucleic acids (DNA and RNA) in maternal circulation.
Fetal cells in maternal circulation: Nucleated red blood cells could be used for prenatal diagnosis of
fetal aneuploidies. With an aneuploid fetus, Bianchi et al (1997) have reported a sixfold increase in
the number of fetal cells in the maternal blood but the isolation techniques are highly complex, so it
has limited application today.
Cell free fetal DNA in maternal circulation:
Studies demonstrated that Down syndrome pregnancies exhibit a 1.7-fold higher serum level of cff-
DNA than normal pregnancies.
Farina et al 2003 found that when added to the quadruple screening test in the 2nd trimester, fetal
DNA increased the detection rate for Down syndrome from 81 to 86% at a 5% FPR.
The technique has been tried successfully in fetal sexing for X-linked disorders and fetal Rh grouping
80. ADVANTAGES OF FIRST TRIMESTER
SCREENING
Information earlier, more options
Reduce number of invasive procedures
May identify other severe anomalies (or risk for) at time of scan and increased
risk of adverse pregnancy outcome—referral for 2nd Δ evals.
Good time to date pregnancy accurately
NT good for multiple gestation
81. LIMITATIONS
Accuracy of NT strongly dependant on experience of ultrasonographers
Not all women enter prenatal care in time for screening
Results of screen may arrive too late for CVS or early amnio
Extra cost for first trimester ultrasound
Can not detect NTD or AWD, still need MSAFP
82. Nasal bone
Absence of the nasal bone is more common if:
The gestation is 11 than 13 weeks
The fetal nuchal translucency is high
The mother is Black
Facial angle
In euploid fetuses the mean facial angle decreases
with CRL from 84° at CRL 45 mm to 76° at CRL of 84
mm
The facial angle is above the 95th centile in:
Euploid fetuses 5%
Fetuses with trisomy 21 45%
Fetuses with trisomy 18 55%
83. Reversed a-wave
At 11-13 weeks reversed a-wave is found in about:
Euploid fetuses 3%
Fetuses with trisomy 21 65%
Fetuses with trisomy 18 55%
Fetuses with trisomy 13 55%
Trisomy 21
Effective first-trimester screening for trisomy 21 is
provided by a combination of maternal age, fetal NT
thickness, FHR and maternal serum free ß–hCG and
PAPP-A:
Detection rate 90%
False positive rate 3.0%
84. app a free beta hcg
0-68% detection of DS
0% detection of Tri 18
.5% false positive rate
lso drawn at 11-14 weeks
ome centers quote 87% detection of DS when
ombined with maternal age
both PAPP-A and B-hCG are very low MoM =
ncreased risk for tri 18, triploidy, fetal anomalies or
erinatal complications