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Jan Charmaine Almonte-Saret M.D., FPOGS, FPSUOG
equal or less than 13 weeks
Indications and advantages:- confirmation of intrauterine pregnancy/
early pregnancy failure- best estimation of G.A.- Evaluation of vaginal bleeding- Evaluation of ectopic pregnancy- Confirmation of multiple pregnancy- Evaluation of pelvic, ovarian or uterine
pathology
GUIDELINES FOR DATING PREGNANCYSTAGE OF DEVELOPMENT
GESTATIO-NAL AGE (WEEKS)
LEVEL OF B-HCG
Gestational sac 5 weeks 1,000-2,000 mIU/L
Gestational sac with yolk sac
5.5 weeks 7,200 mIU/L
Gestational sac with yolk sac & embryo
6 weeks 10,800 mIU/L
NUCHAL TRANSLUCENCY
11 to 14 wks =/> 3 mm Screening for fetal chromosomal
abnormalities screening for trisomy 21
NON-BIOMETRIC PARAMETERS
Uncertain of menstrual dates Measurement disparity in late trimester Narrow down error in estimation gestational
age
TRANSCEREBELLAR DIAMETER (TCD)- Numerically equivalent to the number of weeks
of gestation
NON-BIOMETRIC PARAMETERS
COLONIC GRADE• >/= 16 weeks- grade 1, anechoic lumen
• at 26 weeks & more- grade 2- lumen appears more echoic
• >/= 36 weeks- grade 3, lumen becomes brigther
DISTAL FEMORAL EPIPHYSES (DFE)• at least 32-33 weeks
PROXIMAL TIBIAL EPIPHYSES (PTE)• Seen at 35 weeks
PROXIMAL HUMERAL EPIPHYSES (PHE)
• at 38 weeks or more• reliable predictor of term gestation
SECOND & THIRD TRIMESTER
SIGNIFICANCE OF THE RATIOS
Cephalic Index (CI)-
BPD/OFD X 100 (74-83) > 83- brachycephaly –may suggest a
genetic abnormality < 74 – dolichocephaly – seen with
oilgohydramnios & breech presentation
FL/AC RATIO –evaluating skeletal dysplasia
- < 0.16 suggestive of a lethal type
HC/ AC RATIO- determines growth lag; high ratio –implies fetal malnutrition/IUGR
FL/BPD RATIO- can be used as one of the screening parameters for Down’s syndrome ( short femur & normal BPD= high ratio)
- Gold standard for antepartum fetal surveillance
WHEN TO REQUEST?-Antepartum testing started @ 26-28 weeks if
with maternal complications-@ 32-34 weeks for high risk patients
HOW FREQUENT? - Repeated weekly- Most authors suggest 2x/week BPS
&NST for:1. IDDM2. GDM with previous stillborn3. IUGR4. Post term pregnancy5. Preeclampsia
What are the signs of fetal hypoxia?Chronic Hypoxia (compensated)
1. Oligohydramnios2. Asymmetric (head-sparing) IUGR
Acute Hypoxia (non-compensated)1. Abnormal fetal heart rate changes
Non-reactive NST (+) CST
MODIFIED BPS-uses 2 parameters, NST ( acute marker of fetal compromise) & AFV (chronic marker)
BIOPHYSICALPARAMETER
CNS CENTER GESTATIONAL AGE
Fetal tone Cortex- subcortical area
7.5-8.5 wks
Fetal movement Cortex- nuclei 9 wks
Fetal breathing Ventral surface of 4th ventricle
20-21 wks
Fetal Heart Reactivity
Medulla & Posterior Hypothalamus
24-26 wks
Nueral Control of Fetal Biophysical Activities
Note: In pregnancy complicated by IUGR,
DOPPLER VELOCIMETRY studies will enhance the perfomance of BPS – changes in Doppler findings occur 4 days prior to the deterioration of BPS
A sonologic procedure to assess maternal A sonologic procedure to assess maternal
and fetal vascular resistance and fetal vascular resistance
(vasoconstricted/vasodilated) (vasoconstricted/vasodilated) the state the state
of fetal perfusion. of fetal perfusion.
To whom should we request it for? 1. Diabetes 2. Maternal HPN 3. Autoimmune Diseases - SLE, APAS,
Collagen vascular disease 4. Anemia 5. Post term Pregnancy 6. Unexplained Recurrent Pregnancy losses
7. Discordant multifetal pregnancy8. IUGR
UTERINE ARTERY WHAT ARE THE ABNORMAL RESULTS? Presence of notching Increase indices (SD, RI, PI)
AND IT’S SIGNIFICANCE?- Increase in the utero-placental resistance
(vasoconstriction)- Higher chance of pregnancy
complications
UMBILICAL ARTERY vasoconstriction
increase intraplacental resistance
elevated indices
decreased fetal perfusion fetal hypoxia then IUGR
ABSENT END DIASTOLIC FLOW (AEDF)
highest risk to develop adverse perinatal outcome
the mean duration from AEDF to onset of fetal distress is 6-8 days
REVERSED END DIASTOLIC FLOW (REDF)
most extreme form of intraplacental vascular resistance
diagnosis to distress interval 4.2 +/- 1.4 days with perinatal moratality rate of 50%
MIDDLE CEREBRAL ARTERYWhat is an abnormal result?
DECREASED INDICES- brain sparing reflex
Remember: fetal hypoxia induces compensatory
reflex preferential blood flow to the brain (MCA dilatation=decreased indices) while vasoconstriction in the less vital organs
NOTE: A sudden restoration of MCA indices to
normal or higher or increasing indices from a serial decreasing pattern is omninous= failure of the fetal cerebral vessels to vasodilate = acute fetal brain injury
Patients who are at high risk to develop abnormally adherent placenta includes:
Multiparity Hx of previous CS Hx of previous curettage Placenta previa implanted anteriorly in the
LUS
1. Unusually intense blood flow within the sonolucent space beneath the placenta
2. Hypervascularization within the placenta and non placental tissues
3. Turbulence of flow in areas where placentas appears to have lost parenchyma and within placenta lacunae
Should be done routinely in a 20-24 weeks gestation
Lowers perinatal mortality Lethal malformations-corrected early or
appropriate timing of delivery to allow surgical intervention; if not amenable to surgery, early counseling
ADVANTAGES OF TVS OVER TAS
1. Patient discomfort
2.Clearer images
3. Eliciting pain and tenderness
4.Earlier diagnosis of pelvic pathology
5. Good for obese patients and with abdominal scars
DISADVANTAGES OF TVS OVER TAS
1. Discomfort & pain to pxs with intact hymen and postmenopausal
2. Large pelvic masses 3. Refusal of the procedure
MENSTRUAL CYCLE
ENDOMETRIUM OVARY
Menstrual phase
Thin echogenic line
Developing follicles (5-10)
Early proliferative
Isoechoic Leading follicles
Late proliferative
Trilaminar Dominant follicles (18-24)
Secretory phase
Thick & Hyperechoic
Corpus luteum
Evaluates tubal patency primary investigative tool for infertility
When it is performed?First part of the menstrual cycle (Day 10-12)
advantage of eliminating the risk of X-ray
exposure & hypersensitivity to radiographic contrast media
Evaluation of endometrial pathology Evaluation of ovaries for follicular growth Evaluation of pelvic organs & structures for
lessions and masses