Жирэмсний эрт үеийн хүндрэлийн хэт авиан оношилгоо.pptx

Baldandorj Khavalkhaan
Baldandorj KhavalkhaanObstetrician and gynecologist en onlinecourse
Ultrasound in early pregnancy
complications
Prepared by Baldandorj Kh
Resident, Urguu Maternity Hospital, Mongolia
Obs & Gynae Ultrasound rotation: December 2022
Points for discussion
• NORMAL
Aim of early obstetric ultrasound
• ABNORMAL
Location
Structure
Viability
Dating
Number
•Assessment of other pelvic masses ????
•Screening for fetal abnormalities ????
•Assisting CVS and amniocentesis????
Structure & Viability in 1st trimester pregnancy
 Gestational sac
 Yolk sac
 Embryo/fetus
 Presence of cardiac activity
Aim of early obstetric ultrasound
Structure & Viability in 1st trimester pregnancy
Aim of early obstetric ultrasound
Gestational sac
Visible at 4-5wks GA with TVUS & at 6 wks
GA with TAUS.
Eccentric echogenic ring with anechoic
center .
Measure by Mean Sac Diameter.
GS size increases by about 1mm/day in early
pregnancy
Discriminatory zone: serum hCG level in
which GS is expected to be visible by US :
hCG >2000 mIU/ml by TVUS& hCG >6000
mIU/ml by TAUS
Structure & Viability in 1st trimester pregnancy
Aim of early obstetric ultrasound
Yolk sac:
• bright ring with anechoic center located
inside GS seen at 5wk GA & persists to
11-12 weeks.
• Embryo/fetus: seen by TVUS as
thickening of yolk at 6wks GA.
• Presence of cardiac activity: usually
seen around the time fetal pole is
present, further confirming viability (6th
wks)
Жирэмсний эрт үеийн хүндрэлийн хэт авиан оношилгоо.pptx
Structure & Viability in 1st trimester pregnancy
Aim of early obstetric ultrasound
Yolk sac:
• bright ring with anechoic center located
inside GS seen at 5wk GA & persists to
11-12 weeks.
• Embryo/fetus: seen by TVUS as
thickening of yolk at 6wks GA.
• Presence of cardiac activity: usually
seen around the time fetal pole is
present, further confirming viability (6th
wks)
Confirming IUP
Structure & Viability in 1st trimester pregnancy
1) Double decidual sac sign 2) Intradecidual sign 3) Double bleb sign
Хос бөгжний шинж
Dating
Structure & Viability in 1st trimester pregnancy
Early dating of pregnancy
 5 – 9 weeks : use of mean GS diameter
 6 – 12 weeks : use of CRL (most accurate dating of early
pregnancy)
 After 12 weeks : use of BPD
Dating
Structure & Viability in 1st trimester pregnancy
Formulas to Calculate gestational age
 MGSD (mm) + 30 = gestational age
(days) (between 5 and 9 weeks)
 CRL (mm) + 42 = gestational age
(days) (between 6 and 12weeks)
Diagnosis of multiple pregnancypregnancy
Structure & Viability in 1st trimester pregnancy
Types of multiple pregnancy
Diagnosis of multiple pregnancypregnancy
Structure & Viability in 1st trimester pregnancy
Zygosity= Conception type by DNA test
Chrionicity= Placentation type prenatally by Ultrasound &
postnatally by examining membranes
Жирэмсний эрт үеийн хүндрэлийн хэт авиан оношилгоо.pptx
Жирэмсний эрт үеийн хүндрэлийн хэт авиан оношилгоо.pptx
Diagnosis of multiple pregnancypregnancy
Structure & Viability in 1st trimester pregnancy
Chrionicity
• Number of sacs
• Placenta
• Sex
• Intertwin membrane
• Lambda sign & T sign
Diagnosis of multiple pregnancypregnancy
Other rules of Ultrasound
Structure & Viability in 1st trimester pregnancy
Confirm fetal number .
Confirm viability.
Diagnosis of vanishing twin syndrome.
Exclude any malformation or conjoined twins (especially at
age > 35y = genetic amniocentesis)
Needed with other procedures
CVS
fetal reduction
Other rules of Ultrasound
Structure & Viability in 1st trimester pregnancy
Confirm fetal number .
Confirm viability.
Diagnosis of vanishing twin syndrome.
Exclude any malformation or conjoined twins (especially at
age > 35y = genetic amniocentesis)
Needed with other procedures
• CVS
• fetal reduction
Abnormal early (first trimester) pregnancy
Structure & Viability in 1st trimester pregnancy
 Failed early pregnancy.Failed early pregnancy.
 Pregnancy of uncertain viability (i.e. IU pregnancy in a
situation with no enough criteria (usually on ultrasound
grounds) to confidently categorize a pregnancy as a
miscarriage).
 Pregnancy of unknown location.
 Ectopic pregnancy
 Trophoblastic disease
 Subchrionic hemorrhage
 Incomplete abortion (retained products of conception)
Failed early pregnancy & & Pregnancy of
uncertain viability
Structure & Viability in 1st trimester pregnancy
Doubilet et al., N Engl J Med. 2013 Oct 10;369(15):1443-51
Failed early pregnancy & & Pregnancy of uncertain viability
 TVUS criteria of :
Doubilet et al., N Engl J Med. 2013 Oct 10;369(15):1443-51
US poor prognostic indicators of pregnancy include:
 No yolk sac, where:
 MSD > 8 mm
 embryo seen
 Irregular gestational sac
 Low position of the gestational sac
Structure & Viability in 1st trimester pregnancy
Pregnancy of unknown location (PUL)
PUL = +ve pregnancy test + no IU or Ext.U
pregnancy in US scan
Differential diagnosis is:
1.Very early pregnancy, not detected with ultrasound
2.Complete miscarriage
3.Unidentified ectopic pregnancy
Жирэмсний эрт үеийн хүндрэлийн хэт авиан оношилгоо.pptx
Structure & Viability in 1st trimester pregnancy
Ectopic pregnancy
Structure & Viability in 1st trimester pregnancy
Ectopic pregnancy
Specific for Etopic:
-Embryo in adnexa
Less specific (must correlate with B-hCG):
-Empty uterus
-Adnexal mass
• Classic=thick echogenic ring separate from ovary
• Tubal pregnancy >2-3cm at risk for rupture
-Pelvic free fluid
-Pseudogestational sac
True VS Pseudo-gestational sac
True Gs (DDSS) Pseudogestational sac of ectopic pregnancy
Sagittal view
VS
Pseudo Gestational sac
Beak sign
Fluid collection (or sac) shows a small “beak sign” that connects with or points
toward the uterine cavity line
HETEROTOPIC PREGNANCY
Hemorrhage and debris in Cul-de-sac
Free fluid
Debris
Transverse of Cul de sac & Uterus
Бусад төрлийн Умайн гаднах жирэмсэн
Hemorrhage and debris in Cul-de-sac
Умайн хүзүүний умайн гаднах жирэмсэн
 GS within the cervix .
 Abnormally low sac position.
 Colour Doppler: hypervascular trophoblastic ring in the cervical
region .
Sonographic features of Caesarean scar ectopic pregnancy (CSEP)
 Empty uterus
 Empty cervical
canal
 GS in the anterior
part of the lower
uterine segment
 Absence of
myometrium
between the
bladder wall and
the GS
Molar pregnancy
( Snow storm+ Theca-lutein cysts )
Subchorionic hematoma
Retained products of conception (incomplete abortion)
Thickened Nuchal Tanslucency (NT):
Thickened Nuchal Tanslucency (NT):
 Used for screening (SS) for Down’s
syndrome in first trimester
 Serial screening: Pregnancy associated
plasma protein levels, hCG levels, NT
thickness
 Measured during 11-14 wks gestational age
 Seen on sagittal image as increased
subcutaneous non-septated fluid in posterior
fetal neck
 Measurement >3mm usually considered
abnormal, however exact cut off
measurements are dependent on maternal
age/gestational age
 Detection rate of screening for Down’s
Syndrome in first trimester:
 Sequential screening with nt: 82-87%
 Nt alone: 64-70%
Safety of ultrasound in pregnancy
 General perception is that ultrasound is safe (It is not ionising radiation)
 However, bioeffects can be either thermal or mechanical (i.e. cavitations) with high
power ultrasound
 One RCT of repeated routine ultrasound with Dopplers in the 3rd trimester found a
small but significant decrease in birth weight in the exposed cohort
 A meta analysis showed males exposed to ultrasound in uterus are more likely to
be left-handed
 Ultrasound is no substitute for a good history
 ALWAYS do an abdominal scan with ( Full bladder) before using the vaginal probe
with ( Empty bladder)
 You will always be better than sonographers because you know the anatomy and
pathology
 Avoid premature conclusions
 Systematic scan should be performed
 US scans are useful to be combined with HCG tests before decision.
 With ultrasound , an early intervention or conservative management in pregnancy
can be determined.
 General perception is that ultrasound scan is safe in pregnancy.
The cross-over sign (COS)
In a sagittal view of the uterus, a
straight longitudinal line is drawn
connecting the internal cervical os and
the uterine fundus trough the
endometrium, the gestational sac is
identified and its superior–inferior (S–I)
diameter perpendicular to the
endometrial line is traced.
• COS-1 – the gestational sac is implanted within the Cesarean scar (CS) and at least two-
thirds of the S–I diameter of the gestational sac is above the endometrial line towards the
anterior uterine wall.
• COS-2 – the gestational sac is implanted within the CS and less than two-thirds of the S–I
diameter of the gestational sac is above the endometrial line.
 Cases in the latter group are further divided into the presence (COS-2+) or absence (COS-2–) of an
intersection between the S-I diameter of the ectopic gestational sac and the endometrial line.
First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018
First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018
 COS-1=higher
risk of
developing
placenta
percreta (More
AIP)
 COS-2=less
severe types of
AIP, such as
placenta accreta.
Introduction
• The COS has been suggested to have the potential to stratify the risk of women with CSP
evolving towards AIP:
 Women with COS-1 were shown to be at higher risk of developing placenta percreta
 Women with COS-2 were more likely to be affected by less severe types of AIP, such
as placenta accreta.
• Evidence for whether first-trimester ultrasound can identify women affected by AIP who
are at higher risk of intra- and postsurgical complications is still lacking.
First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018
Aim of the study
To ascertain whether ultrasound assessment of COS in the
first-trimester can predict surgical outcome in women with AIP
First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018
Methods
• Study Design
Retrospective study
• Setting
Single-center trial, Arnas Civico Hospital, Palermo, Italy. (Jan. 2007–Dec.
2015)
• Participants
All women referred with AIP during the study period for whom early first-
trimester ultrasound images (6–8 weeks’ gestation) indicated CSP.
First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018
Methods
• Study protocol
- Assessment of COS was carried out as reported previously.
- After prenatal diagnosis of AIP, parents were counseled regarding the
severity of their clinical condition, treatment options and related risk.
- In general, women with severe types of AIP were delivered at around 34
weeks of gestation and those with a less severe variants at 36 weeks.
- All cases of AIP included in the study were treated with Cesarean
hysterectomy and preoperative temporary occlusion of internal iliac arteries
with a balloon catheter and insertion of a ureteral stent.
- Final diagnosis of the type of AIP was made after surgery and hysterectomy,
based on pathological examination of the removed uterus.
First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018
First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018
Methods
• Primary Outcomes
- Estimated blood loss during surgery.
- Need for and amount of packed red blood cells and fresh frozen plasma units
required either during or after surgery.
- Operative time.
- Intra-surgical complications.
- Gestational age at birth.
- Delivery at <34 weeks of gestation.
- Length of hospital stay and maternal admission to intensive care unit.
First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018
Results - General characteristics of 68 women with AIP
according to type of COS
The three groups did not show any significant difference with
respect to: maternal age, parity and number of previous CS
(P = 0.0001)
Жирэмсний эрт үеийн хүндрэлийн хэт авиан оношилгоо.pptx
First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018
Results - Pregnancy and operative outcomes
• Pregnancies with COS-1 were delivered earlier than those with either COS-2+ (P
= 0.0001) or COS-2− (P = 0.0001)
• Pregnancies with COS-2+ were delivered earlier than those with COS-2– (P =
0.01).
• Iatrogenic preterm birth at <34 weeks’ gestation was higher in pregnancies with
COS-1 than those with COS-2+ (P = 0.0001) or COS-2− (P = 0.0001).
• There was no difference in the length of hospital stay among COS categories.
• None of the women who underwent surgery was admitted to an intensive care
unit.
First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018
Discussion
• Key findings
- Assessment of COS in the first trimester may help in stratifying women at higher
risk for intra- and postoperative complications.
• Implications for practice= практик зөвлөмж
- First-trimester diagnosis is critical, as many CSPs are misdiagnosed as
threatened miscarriage, miscarriage or simply intrauterine pregnancy. This may
lead to curettage for presumed failed pregnancy, resulting in profuse bleeding and
emergency surgical interventions.
- Assessment of COS can be used to predict the evolution of CSP towards the
most severe variants of AIP, such as placenta percreta, and assist in solving the
dilemma whether termination of pregnancy should be the only therapeutic option
offered to women with a first-trimester diagnosis of CSP.
First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018
Discussion
• Implications for practice (continued)
- Classification of AIP according to the degree of placental invasion is
retrospective and not always useful in clinical practice.
- The likelihood of intra- or pos-tsurgical complications is strictly dependent
upon the extent and location, rather than depth, of placental invasion.
- Assessment of the topography of placental is therefore fundamental and
constitutes the optimal approach to identify women at higher risk of intra-
surgical complications.
First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018
Discussion
• Strengths of study
- All cases were managed according to an established protocol for AIP
- All women were operated on by a single surgeon with decades of experience in
managing AIP disorders, thus considerably reducing the heterogeneity in the
outcome measures explored.
• Limitations of study
- Small number of included cases.
- Retrospective design of the study.
- Inclusion of only women with CSP progressing through the second and third
trimesters – study does not address how to identify cases with CSP that will need
intervention during the first- or early second-trimester of pregnancy.
- All cases were operated on by the same team, thus reducing the external validity
of the reported findings.
Thank you for your time
1 de 54

Recomendados

Early pregnancy ultrasonographic evaluation por
Early pregnancy ultrasonographic evaluationEarly pregnancy ultrasonographic evaluation
Early pregnancy ultrasonographic evaluationFaculty of Medicine - Benha University
17.6K vistas49 diapositivas
Early Pregnancy Loss a Simplified Ultrasound Approche Dr/ Ahmed Walid Anwar M... por
Early Pregnancy Loss a Simplified Ultrasound Approche Dr/ Ahmed Walid Anwar M...Early Pregnancy Loss a Simplified Ultrasound Approche Dr/ Ahmed Walid Anwar M...
Early Pregnancy Loss a Simplified Ultrasound Approche Dr/ Ahmed Walid Anwar M...Walid Ahmed
393 vistas35 diapositivas
Usg por
UsgUsg
Usgjyotiraj2001
340 vistas43 diapositivas
First timester ultrasound. por
First  timester ultrasound.First  timester ultrasound.
First timester ultrasound.magdy abdel
502 vistas26 diapositivas
Gynaecology - Early Pregnancy Complication por
Gynaecology - Early Pregnancy ComplicationGynaecology - Early Pregnancy Complication
Gynaecology - Early Pregnancy ComplicationMichelle Fynes
2.2K vistas89 diapositivas

Más contenido relacionado

Similar a Жирэмсний эрт үеийн хүндрэлийн хэт авиан оношилгоо.pptx

First trimester ultrasound por
First trimester ultrasoundFirst trimester ultrasound
First trimester ultrasoundRoshan Valentine
5.8K vistas87 diapositivas
USG.ppt por
USG.pptUSG.ppt
USG.pptAsikin Sakri
4 vistas38 diapositivas
Postterm pregnancy por
Postterm pregnancyPostterm pregnancy
Postterm pregnancyALIYU USMAN MUHAMMAD
10.1K vistas19 diapositivas
ESTIMATION OF GESTATIONAL AGE por
ESTIMATION OF GESTATIONAL AGEESTIMATION OF GESTATIONAL AGE
ESTIMATION OF GESTATIONAL AGEOsama Warda
4.9K vistas30 diapositivas
radiology & imaging in OB/GYN por
radiology & imaging in OB/GYNradiology & imaging in OB/GYN
radiology & imaging in OB/GYNtariggally
9.6K vistas35 diapositivas
HOW TO CALCULATE GESTATIONAL AGE por
HOW TO CALCULATE GESTATIONAL AGEHOW TO CALCULATE GESTATIONAL AGE
HOW TO CALCULATE GESTATIONAL AGEOsama Warda
21.8K vistas30 diapositivas

Similar a Жирэмсний эрт үеийн хүндрэлийн хэт авиан оношилгоо.pptx(20)

ESTIMATION OF GESTATIONAL AGE por Osama Warda
ESTIMATION OF GESTATIONAL AGEESTIMATION OF GESTATIONAL AGE
ESTIMATION OF GESTATIONAL AGE
Osama Warda4.9K vistas
radiology & imaging in OB/GYN por tariggally
radiology & imaging in OB/GYNradiology & imaging in OB/GYN
radiology & imaging in OB/GYN
tariggally9.6K vistas
HOW TO CALCULATE GESTATIONAL AGE por Osama Warda
HOW TO CALCULATE GESTATIONAL AGEHOW TO CALCULATE GESTATIONAL AGE
HOW TO CALCULATE GESTATIONAL AGE
Osama Warda21.8K vistas
Multiple pregnancy lecture_r_yan por Ryan Mulyana
Multiple pregnancy lecture_r_yanMultiple pregnancy lecture_r_yan
Multiple pregnancy lecture_r_yan
Ryan Mulyana1.2K vistas
Isuog practice guidelines performance of first trimester fetal ultrasound scan por kaleemullahabid
Isuog practice guidelines performance of first trimester fetal ultrasound scanIsuog practice guidelines performance of first trimester fetal ultrasound scan
Isuog practice guidelines performance of first trimester fetal ultrasound scan
kaleemullahabid5K vistas
High-risk approach with screening and assessment por Anamika Ramawat
High-risk approach with screening and assessmentHigh-risk approach with screening and assessment
High-risk approach with screening and assessment
Anamika Ramawat87.5K vistas
Assessment gestational age por Gayathri R
Assessment gestational ageAssessment gestational age
Assessment gestational age
Gayathri R7K vistas
Prenatal Assessment of Gestational Age - Case Presentation por Nawras AlHalabi
Prenatal Assessment of Gestational Age - Case Presentation Prenatal Assessment of Gestational Age - Case Presentation
Prenatal Assessment of Gestational Age - Case Presentation
Nawras AlHalabi6.3K vistas
Mternal death review lecture by dr. evelina r. castro 102413 por Jesart De Vera
Mternal death review lecture by dr. evelina r. castro   102413Mternal death review lecture by dr. evelina r. castro   102413
Mternal death review lecture by dr. evelina r. castro 102413
Jesart De Vera1.1K vistas
Anc por benefit
AncAnc
Anc
benefit266 vistas
Presentation1.pptx, ultrasound examination of the 1st trimester pregnancy. por Abdellah Nazeer
Presentation1.pptx, ultrasound examination of the 1st trimester pregnancy.Presentation1.pptx, ultrasound examination of the 1st trimester pregnancy.
Presentation1.pptx, ultrasound examination of the 1st trimester pregnancy.
Abdellah Nazeer16.8K vistas
Recurrent pregnancy loss - Uterine factors por Anu Manivannan
Recurrent pregnancy loss - Uterine factorsRecurrent pregnancy loss - Uterine factors
Recurrent pregnancy loss - Uterine factors
Anu Manivannan128 vistas
Cervical insufficiency por ketkii T
Cervical insufficiencyCervical insufficiency
Cervical insufficiency
ketkii T271 vistas
Role of Progesterone in Preterm Labour por Sujoy Dasgupta
Role of Progesterone in Preterm LabourRole of Progesterone in Preterm Labour
Role of Progesterone in Preterm Labour
Sujoy Dasgupta879 vistas

Más de Baldandorj Khavalkhaan

Ихэс түрүүлэлт Placenta previa.pptx por
Ихэс түрүүлэлт Placenta previa.pptxИхэс түрүүлэлт Placenta previa.pptx
Ихэс түрүүлэлт Placenta previa.pptxBaldandorj Khavalkhaan
832 vistas65 diapositivas
Өндгөвчний урагдал Апоплексия Ovarian apoplexy.pptx por
Өндгөвчний урагдал Апоплексия Ovarian apoplexy.pptxӨндгөвчний урагдал Апоплексия Ovarian apoplexy.pptx
Өндгөвчний урагдал Апоплексия Ovarian apoplexy.pptxBaldandorj Khavalkhaan
302 vistas22 diapositivas
Кесар мэс заслаар төрүүлэх эмнэлзүйн заавар.pdf por
Кесар мэс заслаар төрүүлэх эмнэлзүйн заавар.pdfКесар мэс заслаар төрүүлэх эмнэлзүйн заавар.pdf
Кесар мэс заслаар төрүүлэх эмнэлзүйн заавар.pdfBaldandorj Khavalkhaan
97 vistas8 diapositivas
Ихсийн дутмагшил & Ураг амьгүй болох & Ургийн бүтэлт бүтэх & Амьгүй төрөлт.pptx por
Ихсийн дутмагшил & Ураг амьгүй болох & Ургийн бүтэлт бүтэх & Амьгүй төрөлт.pptxИхсийн дутмагшил & Ураг амьгүй болох & Ургийн бүтэлт бүтэх & Амьгүй төрөлт.pptx
Ихсийн дутмагшил & Ураг амьгүй болох & Ургийн бүтэлт бүтэх & Амьгүй төрөлт.pptxBaldandorj Khavalkhaan
552 vistas91 diapositivas
Дутуу төрөлт ба Интерлейкин-6 por
Дутуу төрөлт ба Интерлейкин-6Дутуу төрөлт ба Интерлейкин-6
Дутуу төрөлт ба Интерлейкин-6Baldandorj Khavalkhaan
44 vistas3 diapositivas
Фибронектин.docx por
Фибронектин.docxФибронектин.docx
Фибронектин.docxBaldandorj Khavalkhaan
50 vistas6 diapositivas

Más de Baldandorj Khavalkhaan(19)

Өндгөвчний урагдал Апоплексия Ovarian apoplexy.pptx por Baldandorj Khavalkhaan
Өндгөвчний урагдал Апоплексия Ovarian apoplexy.pptxӨндгөвчний урагдал Апоплексия Ovarian apoplexy.pptx
Өндгөвчний урагдал Апоплексия Ovarian apoplexy.pptx
Кесар мэс заслаар төрүүлэх эмнэлзүйн заавар.pdf por Baldandorj Khavalkhaan
Кесар мэс заслаар төрүүлэх эмнэлзүйн заавар.pdfКесар мэс заслаар төрүүлэх эмнэлзүйн заавар.pdf
Кесар мэс заслаар төрүүлэх эмнэлзүйн заавар.pdf
Ихсийн дутмагшил & Ураг амьгүй болох & Ургийн бүтэлт бүтэх & Амьгүй төрөлт.pptx por Baldandorj Khavalkhaan
Ихсийн дутмагшил & Ураг амьгүй болох & Ургийн бүтэлт бүтэх & Амьгүй төрөлт.pptxИхсийн дутмагшил & Ураг амьгүй болох & Ургийн бүтэлт бүтэх & Амьгүй төрөлт.pptx
Ихсийн дутмагшил & Ураг амьгүй болох & Ургийн бүтэлт бүтэх & Амьгүй төрөлт.pptx
Умайн хүзүүний дутмагшил болон Пессари pessary эмчилгээ #дутуу төрөлт por Baldandorj Khavalkhaan
Умайн хүзүүний дутмагшил болон Пессари pessary эмчилгээ #дутуу төрөлтУмайн хүзүүний дутмагшил болон Пессари pessary эмчилгээ #дутуу төрөлт
Умайн хүзүүний дутмагшил болон Пессари pessary эмчилгээ #дутуу төрөлт
уян зүү, ясны хатгалт, шингэн сэлбэлт.pptx por Baldandorj Khavalkhaan
уян зүү, ясны хатгалт, шингэн сэлбэлт.pptxуян зүү, ясны хатгалт, шингэн сэлбэлт.pptx
уян зүү, ясны хатгалт, шингэн сэлбэлт.pptx
Бэртэл гэмтлийн үеийн тусламж Насандэлгэр Ариунзаяа Балдандорж.pptx por Baldandorj Khavalkhaan
Бэртэл гэмтлийн үеийн тусламж Насандэлгэр Ариунзаяа Балдандорж.pptxБэртэл гэмтлийн үеийн тусламж Насандэлгэр Ариунзаяа Балдандорж.pptx
Бэртэл гэмтлийн үеийн тусламж Насандэлгэр Ариунзаяа Балдандорж.pptx
Умайн лейомиомийн оношилгоо эмчилгээний орчин үеийн дэвшилтэт аргууд_ олон ул... por Baldandorj Khavalkhaan
Умайн лейомиомийн оношилгоо эмчилгээний орчин үеийн дэвшилтэт аргууд_ олон ул...Умайн лейомиомийн оношилгоо эмчилгээний орчин үеийн дэвшилтэт аргууд_ олон ул...
Умайн лейомиомийн оношилгоо эмчилгээний орчин үеийн дэвшилтэт аргууд_ олон ул...
#Түрүү булчирхайн хоргүй-томрол.pptx por Baldandorj Khavalkhaan
#Түрүү булчирхайн хоргүй-томрол.pptx#Түрүү булчирхайн хоргүй-томрол.pptx
#Түрүү булчирхайн хоргүй-томрол.pptx
Жирэмсний хордлого, Жирэмсний дотор муухайралт.docx por Baldandorj Khavalkhaan
Жирэмсний хордлого, Жирэмсний дотор муухайралт.docx Жирэмсний хордлого, Жирэмсний дотор муухайралт.docx
Жирэмсний хордлого, Жирэмсний дотор муухайралт.docx
Кесар мэс заслын дараах сорвины бүтцийн өөрчлөлт.docx por Baldandorj Khavalkhaan
Кесар мэс заслын дараах сорвины бүтцийн өөрчлөлт.docxКесар мэс заслын дараах сорвины бүтцийн өөрчлөлт.docx
Кесар мэс заслын дараах сорвины бүтцийн өөрчлөлт.docx

Último

The basics - information, data, technology and systems.pdf por
The basics - information, data, technology and systems.pdfThe basics - information, data, technology and systems.pdf
The basics - information, data, technology and systems.pdfJonathanCovena1
146 vistas1 diapositiva
ICS3211_lecture 08_2023.pdf por
ICS3211_lecture 08_2023.pdfICS3211_lecture 08_2023.pdf
ICS3211_lecture 08_2023.pdfVanessa Camilleri
231 vistas30 diapositivas
Solar System and Galaxies.pptx por
Solar System and Galaxies.pptxSolar System and Galaxies.pptx
Solar System and Galaxies.pptxDrHafizKosar
106 vistas26 diapositivas
Computer Introduction-Lecture06 por
Computer Introduction-Lecture06Computer Introduction-Lecture06
Computer Introduction-Lecture06Dr. Mazin Mohamed alkathiri
105 vistas12 diapositivas
CONTENTS.pptx por
CONTENTS.pptxCONTENTS.pptx
CONTENTS.pptxiguerendiain
62 vistas17 diapositivas
Relationship of psychology with other subjects. por
Relationship of psychology with other subjects.Relationship of psychology with other subjects.
Relationship of psychology with other subjects.palswagata2003
52 vistas16 diapositivas

Último(20)

The basics - information, data, technology and systems.pdf por JonathanCovena1
The basics - information, data, technology and systems.pdfThe basics - information, data, technology and systems.pdf
The basics - information, data, technology and systems.pdf
JonathanCovena1146 vistas
Solar System and Galaxies.pptx por DrHafizKosar
Solar System and Galaxies.pptxSolar System and Galaxies.pptx
Solar System and Galaxies.pptx
DrHafizKosar106 vistas
Relationship of psychology with other subjects. por palswagata2003
Relationship of psychology with other subjects.Relationship of psychology with other subjects.
Relationship of psychology with other subjects.
palswagata200352 vistas
EIT-Digital_Spohrer_AI_Intro 20231128 v1.pptx por ISSIP
EIT-Digital_Spohrer_AI_Intro 20231128 v1.pptxEIT-Digital_Spohrer_AI_Intro 20231128 v1.pptx
EIT-Digital_Spohrer_AI_Intro 20231128 v1.pptx
ISSIP386 vistas
The Accursed House by Émile Gaboriau por DivyaSheta
The Accursed House  by Émile GaboriauThe Accursed House  by Émile Gaboriau
The Accursed House by Émile Gaboriau
DivyaSheta223 vistas
Classification of crude drugs.pptx por GayatriPatra14
Classification of crude drugs.pptxClassification of crude drugs.pptx
Classification of crude drugs.pptx
GayatriPatra14101 vistas
11.28.23 Social Capital and Social Exclusion.pptx por mary850239
11.28.23 Social Capital and Social Exclusion.pptx11.28.23 Social Capital and Social Exclusion.pptx
11.28.23 Social Capital and Social Exclusion.pptx
mary850239312 vistas
AUDIENCE - BANDURA.pptx por iammrhaywood
AUDIENCE - BANDURA.pptxAUDIENCE - BANDURA.pptx
AUDIENCE - BANDURA.pptx
iammrhaywood117 vistas
Psychology KS5 por WestHatch
Psychology KS5Psychology KS5
Psychology KS5
WestHatch119 vistas
Dance KS5 Breakdown por WestHatch
Dance KS5 BreakdownDance KS5 Breakdown
Dance KS5 Breakdown
WestHatch99 vistas
How to empty an One2many field in Odoo por Celine George
How to empty an One2many field in OdooHow to empty an One2many field in Odoo
How to empty an One2many field in Odoo
Celine George87 vistas
Drama KS5 Breakdown por WestHatch
Drama KS5 BreakdownDrama KS5 Breakdown
Drama KS5 Breakdown
WestHatch98 vistas

Жирэмсний эрт үеийн хүндрэлийн хэт авиан оношилгоо.pptx

  • 1. Ultrasound in early pregnancy complications Prepared by Baldandorj Kh Resident, Urguu Maternity Hospital, Mongolia Obs & Gynae Ultrasound rotation: December 2022
  • 2. Points for discussion • NORMAL Aim of early obstetric ultrasound • ABNORMAL Location Structure Viability Dating Number •Assessment of other pelvic masses ???? •Screening for fetal abnormalities ???? •Assisting CVS and amniocentesis????
  • 3. Structure & Viability in 1st trimester pregnancy  Gestational sac  Yolk sac  Embryo/fetus  Presence of cardiac activity Aim of early obstetric ultrasound
  • 4. Structure & Viability in 1st trimester pregnancy Aim of early obstetric ultrasound Gestational sac Visible at 4-5wks GA with TVUS & at 6 wks GA with TAUS. Eccentric echogenic ring with anechoic center . Measure by Mean Sac Diameter. GS size increases by about 1mm/day in early pregnancy Discriminatory zone: serum hCG level in which GS is expected to be visible by US : hCG >2000 mIU/ml by TVUS& hCG >6000 mIU/ml by TAUS
  • 5. Structure & Viability in 1st trimester pregnancy Aim of early obstetric ultrasound Yolk sac: • bright ring with anechoic center located inside GS seen at 5wk GA & persists to 11-12 weeks. • Embryo/fetus: seen by TVUS as thickening of yolk at 6wks GA. • Presence of cardiac activity: usually seen around the time fetal pole is present, further confirming viability (6th wks)
  • 7. Structure & Viability in 1st trimester pregnancy Aim of early obstetric ultrasound Yolk sac: • bright ring with anechoic center located inside GS seen at 5wk GA & persists to 11-12 weeks. • Embryo/fetus: seen by TVUS as thickening of yolk at 6wks GA. • Presence of cardiac activity: usually seen around the time fetal pole is present, further confirming viability (6th wks)
  • 8. Confirming IUP Structure & Viability in 1st trimester pregnancy 1) Double decidual sac sign 2) Intradecidual sign 3) Double bleb sign Хос бөгжний шинж
  • 9. Dating Structure & Viability in 1st trimester pregnancy Early dating of pregnancy  5 – 9 weeks : use of mean GS diameter  6 – 12 weeks : use of CRL (most accurate dating of early pregnancy)  After 12 weeks : use of BPD
  • 10. Dating Structure & Viability in 1st trimester pregnancy Formulas to Calculate gestational age  MGSD (mm) + 30 = gestational age (days) (between 5 and 9 weeks)  CRL (mm) + 42 = gestational age (days) (between 6 and 12weeks)
  • 11. Diagnosis of multiple pregnancypregnancy Structure & Viability in 1st trimester pregnancy Types of multiple pregnancy
  • 12. Diagnosis of multiple pregnancypregnancy Structure & Viability in 1st trimester pregnancy Zygosity= Conception type by DNA test Chrionicity= Placentation type prenatally by Ultrasound & postnatally by examining membranes
  • 15. Diagnosis of multiple pregnancypregnancy Structure & Viability in 1st trimester pregnancy Chrionicity • Number of sacs • Placenta • Sex • Intertwin membrane • Lambda sign & T sign
  • 16. Diagnosis of multiple pregnancypregnancy
  • 17. Other rules of Ultrasound Structure & Viability in 1st trimester pregnancy Confirm fetal number . Confirm viability. Diagnosis of vanishing twin syndrome. Exclude any malformation or conjoined twins (especially at age > 35y = genetic amniocentesis) Needed with other procedures CVS fetal reduction
  • 18. Other rules of Ultrasound Structure & Viability in 1st trimester pregnancy Confirm fetal number . Confirm viability. Diagnosis of vanishing twin syndrome. Exclude any malformation or conjoined twins (especially at age > 35y = genetic amniocentesis) Needed with other procedures • CVS • fetal reduction
  • 19. Abnormal early (first trimester) pregnancy Structure & Viability in 1st trimester pregnancy  Failed early pregnancy.Failed early pregnancy.  Pregnancy of uncertain viability (i.e. IU pregnancy in a situation with no enough criteria (usually on ultrasound grounds) to confidently categorize a pregnancy as a miscarriage).  Pregnancy of unknown location.  Ectopic pregnancy  Trophoblastic disease  Subchrionic hemorrhage  Incomplete abortion (retained products of conception)
  • 20. Failed early pregnancy & & Pregnancy of uncertain viability Structure & Viability in 1st trimester pregnancy Doubilet et al., N Engl J Med. 2013 Oct 10;369(15):1443-51
  • 21. Failed early pregnancy & & Pregnancy of uncertain viability  TVUS criteria of : Doubilet et al., N Engl J Med. 2013 Oct 10;369(15):1443-51
  • 22. US poor prognostic indicators of pregnancy include:  No yolk sac, where:  MSD > 8 mm  embryo seen  Irregular gestational sac  Low position of the gestational sac
  • 23. Structure & Viability in 1st trimester pregnancy Pregnancy of unknown location (PUL) PUL = +ve pregnancy test + no IU or Ext.U pregnancy in US scan Differential diagnosis is: 1.Very early pregnancy, not detected with ultrasound 2.Complete miscarriage 3.Unidentified ectopic pregnancy
  • 25. Structure & Viability in 1st trimester pregnancy Ectopic pregnancy
  • 26. Structure & Viability in 1st trimester pregnancy Ectopic pregnancy Specific for Etopic: -Embryo in adnexa Less specific (must correlate with B-hCG): -Empty uterus -Adnexal mass • Classic=thick echogenic ring separate from ovary • Tubal pregnancy >2-3cm at risk for rupture -Pelvic free fluid -Pseudogestational sac
  • 28. True Gs (DDSS) Pseudogestational sac of ectopic pregnancy Sagittal view VS Pseudo Gestational sac Beak sign Fluid collection (or sac) shows a small “beak sign” that connects with or points toward the uterine cavity line
  • 30. Hemorrhage and debris in Cul-de-sac Free fluid Debris Transverse of Cul de sac & Uterus
  • 31. Бусад төрлийн Умайн гаднах жирэмсэн Hemorrhage and debris in Cul-de-sac
  • 32. Умайн хүзүүний умайн гаднах жирэмсэн  GS within the cervix .  Abnormally low sac position.  Colour Doppler: hypervascular trophoblastic ring in the cervical region .
  • 33. Sonographic features of Caesarean scar ectopic pregnancy (CSEP)  Empty uterus  Empty cervical canal  GS in the anterior part of the lower uterine segment  Absence of myometrium between the bladder wall and the GS
  • 35. ( Snow storm+ Theca-lutein cysts )
  • 37. Retained products of conception (incomplete abortion)
  • 39. Thickened Nuchal Tanslucency (NT):  Used for screening (SS) for Down’s syndrome in first trimester  Serial screening: Pregnancy associated plasma protein levels, hCG levels, NT thickness  Measured during 11-14 wks gestational age  Seen on sagittal image as increased subcutaneous non-septated fluid in posterior fetal neck  Measurement >3mm usually considered abnormal, however exact cut off measurements are dependent on maternal age/gestational age  Detection rate of screening for Down’s Syndrome in first trimester:  Sequential screening with nt: 82-87%  Nt alone: 64-70%
  • 40. Safety of ultrasound in pregnancy  General perception is that ultrasound is safe (It is not ionising radiation)  However, bioeffects can be either thermal or mechanical (i.e. cavitations) with high power ultrasound  One RCT of repeated routine ultrasound with Dopplers in the 3rd trimester found a small but significant decrease in birth weight in the exposed cohort  A meta analysis showed males exposed to ultrasound in uterus are more likely to be left-handed  Ultrasound is no substitute for a good history  ALWAYS do an abdominal scan with ( Full bladder) before using the vaginal probe with ( Empty bladder)  You will always be better than sonographers because you know the anatomy and pathology  Avoid premature conclusions  Systematic scan should be performed  US scans are useful to be combined with HCG tests before decision.  With ultrasound , an early intervention or conservative management in pregnancy can be determined.  General perception is that ultrasound scan is safe in pregnancy.
  • 41. The cross-over sign (COS) In a sagittal view of the uterus, a straight longitudinal line is drawn connecting the internal cervical os and the uterine fundus trough the endometrium, the gestational sac is identified and its superior–inferior (S–I) diameter perpendicular to the endometrial line is traced. • COS-1 – the gestational sac is implanted within the Cesarean scar (CS) and at least two- thirds of the S–I diameter of the gestational sac is above the endometrial line towards the anterior uterine wall. • COS-2 – the gestational sac is implanted within the CS and less than two-thirds of the S–I diameter of the gestational sac is above the endometrial line.  Cases in the latter group are further divided into the presence (COS-2+) or absence (COS-2–) of an intersection between the S-I diameter of the ectopic gestational sac and the endometrial line. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign Calì et al., UOG 2018
  • 42. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign Calì et al., UOG 2018  COS-1=higher risk of developing placenta percreta (More AIP)  COS-2=less severe types of AIP, such as placenta accreta.
  • 43. Introduction • The COS has been suggested to have the potential to stratify the risk of women with CSP evolving towards AIP:  Women with COS-1 were shown to be at higher risk of developing placenta percreta  Women with COS-2 were more likely to be affected by less severe types of AIP, such as placenta accreta. • Evidence for whether first-trimester ultrasound can identify women affected by AIP who are at higher risk of intra- and postsurgical complications is still lacking. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign Calì et al., UOG 2018
  • 44. Aim of the study To ascertain whether ultrasound assessment of COS in the first-trimester can predict surgical outcome in women with AIP First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign Calì et al., UOG 2018
  • 45. Methods • Study Design Retrospective study • Setting Single-center trial, Arnas Civico Hospital, Palermo, Italy. (Jan. 2007–Dec. 2015) • Participants All women referred with AIP during the study period for whom early first- trimester ultrasound images (6–8 weeks’ gestation) indicated CSP. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign Calì et al., UOG 2018
  • 46. Methods • Study protocol - Assessment of COS was carried out as reported previously. - After prenatal diagnosis of AIP, parents were counseled regarding the severity of their clinical condition, treatment options and related risk. - In general, women with severe types of AIP were delivered at around 34 weeks of gestation and those with a less severe variants at 36 weeks. - All cases of AIP included in the study were treated with Cesarean hysterectomy and preoperative temporary occlusion of internal iliac arteries with a balloon catheter and insertion of a ureteral stent. - Final diagnosis of the type of AIP was made after surgery and hysterectomy, based on pathological examination of the removed uterus. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign Calì et al., UOG 2018
  • 47. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign Calì et al., UOG 2018 Methods • Primary Outcomes - Estimated blood loss during surgery. - Need for and amount of packed red blood cells and fresh frozen plasma units required either during or after surgery. - Operative time. - Intra-surgical complications. - Gestational age at birth. - Delivery at <34 weeks of gestation. - Length of hospital stay and maternal admission to intensive care unit.
  • 48. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign Calì et al., UOG 2018 Results - General characteristics of 68 women with AIP according to type of COS The three groups did not show any significant difference with respect to: maternal age, parity and number of previous CS (P = 0.0001)
  • 50. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign Calì et al., UOG 2018 Results - Pregnancy and operative outcomes • Pregnancies with COS-1 were delivered earlier than those with either COS-2+ (P = 0.0001) or COS-2− (P = 0.0001) • Pregnancies with COS-2+ were delivered earlier than those with COS-2– (P = 0.01). • Iatrogenic preterm birth at <34 weeks’ gestation was higher in pregnancies with COS-1 than those with COS-2+ (P = 0.0001) or COS-2− (P = 0.0001). • There was no difference in the length of hospital stay among COS categories. • None of the women who underwent surgery was admitted to an intensive care unit.
  • 51. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign Calì et al., UOG 2018 Discussion • Key findings - Assessment of COS in the first trimester may help in stratifying women at higher risk for intra- and postoperative complications. • Implications for practice= практик зөвлөмж - First-trimester diagnosis is critical, as many CSPs are misdiagnosed as threatened miscarriage, miscarriage or simply intrauterine pregnancy. This may lead to curettage for presumed failed pregnancy, resulting in profuse bleeding and emergency surgical interventions. - Assessment of COS can be used to predict the evolution of CSP towards the most severe variants of AIP, such as placenta percreta, and assist in solving the dilemma whether termination of pregnancy should be the only therapeutic option offered to women with a first-trimester diagnosis of CSP.
  • 52. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign Calì et al., UOG 2018 Discussion • Implications for practice (continued) - Classification of AIP according to the degree of placental invasion is retrospective and not always useful in clinical practice. - The likelihood of intra- or pos-tsurgical complications is strictly dependent upon the extent and location, rather than depth, of placental invasion. - Assessment of the topography of placental is therefore fundamental and constitutes the optimal approach to identify women at higher risk of intra- surgical complications.
  • 53. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign Calì et al., UOG 2018 Discussion • Strengths of study - All cases were managed according to an established protocol for AIP - All women were operated on by a single surgeon with decades of experience in managing AIP disorders, thus considerably reducing the heterogeneity in the outcome measures explored. • Limitations of study - Small number of included cases. - Retrospective design of the study. - Inclusion of only women with CSP progressing through the second and third trimesters – study does not address how to identify cases with CSP that will need intervention during the first- or early second-trimester of pregnancy. - All cases were operated on by the same team, thus reducing the external validity of the reported findings.
  • 54. Thank you for your time