this is what we presented at AICOG 2012 varanasi .............USG A WATCH DOG FOR PREGNANCY...................please let me know what more any one wants to see, i can keep uploading my presentations.....

1. ULTRASOUND AS A WATCH DOG
FOR PREGNANCY
narendra malhotra
jaideep malhotra
neharika malhotra
www.malhotrahospitals.com

2. http://en.wikipedia.org/wiki/watch dog
• Watchdog may refer to:
Dog
Guard dog,
a dog that barks to alert its owners of
an intruder's presence
WIKTIONARY
Noun
watchdog (plural watchdogs)
a guard dog
a person or organization that monitors and publicizes the behavior of
others (individuals, corporations, governments) to discover undesirable
activity.

3. PREGNANCY IS THE OWNER
AND THE “GREAT OBSTETRICAL SYNDROME” IS THE
INTRUDER
AND ULTRASOUND THE WATCH DOG
AND WE OBSTETRICIANS ARE THE DOG TRAINERS
so it becomes a very doggy-bitchy story and lecture

4. The Challenge of
Obstetrics

5. Obstetrical Disease
• Preterm labor
• Preterm Rupture of membranes
• Pre-eclampsia
• SGA/IUGR
• Fetal Death
In addition to the above ;first trimester preg failure,early anomalies ,late anomalies

6. The History of Obstetrics
• A search for a single test to predict each
obstetrical disorder has failed.
• The discovery of an effective treatment
and preventive strategy has not been
successful.

7. Diagnostic tools
Only one single
diagnostic tool has
proven to be the only
tool which can predict
problems and watch the
pregnancy like a watch
dog and indicate the
intruders of the “great
obstetrical syndrome”

8. Treatments available today
Disease Treatment
Preterm labor Tocolysis
Expectant
Preterm PROM
management
Antihypertensive
Pre-eclampsia
agents
IUGR Delivery
FAILED PREGNANCY AND LETHAL ANOMALIES……TERMINATION

9. “Great Obstetrical Syndromes”
• Multiple etiologies
• Long pre-clinical phase
• Fetal diseases
• Clinical manifestations are adaptive
• Symptomatic treatment is ineffective
• Genetic/environmental factors

10. Small for Gestational Age
Environmental Infection/
Inflammation
Genetic Endocrine
Maternal
Nutritional
Placental Unknown

11. Umbilical
vessels Chorionic Chorionic
vessels plate Amnion
Placental
Uteroplacental Basal Spiral septum
veins plate artery
Sadler TW Lagman’s Medical Embryology 1990

12. OBSTETRICAL ULTRASOUND HELPS
PICK UP ALL THESE PROBLEMS EARLY
• EARLY SCAN TO DETECT PREGNANCY AND
RULE OUT ECTOPIC
• FETAL CARDIAC ACTIVITY/VIABILITY SCAN
• CHORIONICITY IN MULTIPLE GESTATION
• 11-14 WEEKS GENETIC SCAN
• 20 WEEKS ANOMALY SCAN
• 24 WEEKS DOPPLER
• THIRD TRIMESTER GROWTH AND LIQUOR

13. Definite signs of Early Pregnancy
Failure
• Absence of cardiac activity in an embryo
-Embryonic demise
• Absence of yolk sac/embryo in a large GS
-Blighted ovum
FAILED PREGNANCY

14. Definite signs of Early Pregnancy
Failure
What is the descriminatory size for safe diagnosis?
Mean Sac diameter
CRL

15. GUIDELINES FOR DIAGNOSIS
OF EARLY PREGNANCY FAILURE
Society of American College
Royal College of Obstetricians and of Radiologists
Obstetricians Gynaecologists of (ACR) 2000
and Canada (SOGC) 2005
Gynaecologists • CRL > 5mm with no
• CRL > 5mm with no visible visible cardiac activity
(RCOG) 2006 cardiac activity, >9mm(TAS)
• MSD > 16mm without a
• CRL ≥ 6mm with no • MSD > 8mm without a visible visible embryo or yolk sac
visible cardiac activity yolk sac, 20mm (TAS)
• MSD ≥ 20mm without
AIUM, 2007
• MSD > 16mm without a • CRL > 5mm (TVS) with no
a visible embryo or visible embryo, (25mm (TAS)
yolk sac visible cardiac activity
LEVEL 11-2 a

16. GUIDELINES FOR DIAGNOSIS
OF EARLY PREGNANCY FAILURE
Australian Society Practice in the
Hongkong College Philippines
of Obstetricians for Ulltrasound in
and Gynaecologists Medicine (ASUM)
(HKCOG) 2004
• CRL > 5mm with no
• CRL > 5mm (TVS), >9mm • CRL > 6mm with no
visible cardiac activity
(TAS) with no visible visible cardiac activity
cardiac activity • MSD > 18mm without a
• MSD > 20mm without a
visible embryo or yolk sac
• MSD ≥ 20mm without a visible embryo or yolk sac
OB-GYN USG for practicing
visible embryo or yolk sac Clinician 2nd Ed
FOGSI GUIDELINES A FEW YEARS BACK
MSD >20without YS/E :CRL >6mm without cardiac activity
IFUMB/ICMU and ICOG

17. RECOMMENDATIONS
Empty GS = an MSD of 25 mm with out yolk sac
or embryo
Embryonic demise= A CRL of 7mm with
no cardiac activity
Wait for 7-10 days before a repeat scan if results are
below the descriminatory level.

18. Down syndrome screening
• NT (11-13+6wk), PAPP-A, beta-hCG
• Best at 12 wk for anomaly as well
• One-stop
• 90% sensitivity at 5% FP rate
• Addition of Doppler assessment of blood
flow in the ductus venosus and across the
tricuspid valve together with above can
identify more than 95% of all major
aneuploidies for a FP rate of less than 3%.

19. Why 13+6 wk?
• To provide women with affected
fetuses the option of first- rather
than second-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.

20. Other aneuploidies
NT Beta-hCG PAPP-A
Trisomy 21 increased increased decreased
Trisomy 18 increased decreased decreased
Trisomy 13 increased decreased decreased
Turner syndrome increased normal decreased
Tripoloidy (paternal) increased decreased mildy

21. Cardiac defect
• Major cardiac
defect in 7.6% of
chromosomally
normal fetuses
with NT>=3.5mm
• Indication for fetal
echocardiography
• Detailed cardiac
scan at 14 wk

22. OTHER MARKERS BY USG
ICT
DV
NB
CORD DIAMETER
WIDE ILIAC BONES
FACIAL ANGLE

23. STRUCTURAL ANOMALIES

24. ULTRASOUND IS A GOOD WATCH DOG
FOR FIRST TRIMESTER PREGNANCY
PROBLEM PREDICTION

25. The mid-trimester fetal ultrasound scan
Who should have one: everyone
……all pregnant women should
be offered an ultrasound scan
for the detection of fetal
anomalies and pregnancy
complications…….if problems
in unselected low risk have
also to be picked up….(no
clear evidence on usefulness)

26. The mid-trimester fetal ultrasound scan
When should the scan be performed?
• “18-22 weeks”
• Earlier scans date better
• Earlier scans require equipment, expertise and
time
• Later scans see better
• Later scans see more
• Local legislation

27. The mid-trimester fetal ultrasound scan
And now coming to the core stuff!
•Fetal biometry
and well being
•Anatomical
survey

28. The mid-trimester fetal ultrasound scan
Fetal biometry and well being
• Fetal biometry
• Amniotic fluid assessment
• Fetal movement
• Doppler ultrasonography
• Multiple gestation

29. Fetal biometry:parameters
• Biparietal diameter (BPD)
• Head circumference (HC)
• Abdominal circumference (AC)
• Femur (diaphysis) length (FL)
• Cerebellar transverse diameter

30. Fetal biometry
Parameters
• Standardised manner and strict quality criteria
• Audit of results
• Still images to document the measurements

31. Fetal well being
Estimated fetal weight
• The degree of deviation from normal at this
early stage of pregnancy that would justify
action (e.g. follow-up scan to assess fetal growth
or fetal chromosomal analysis) has not been
firmly established
• if gestational age is determined at an earlier
scan, EFW can be compared to dedicated
normal, preferably local, reference ranges for
this parameter

32. Fetal well being
Amniotic fluid assessment
• Amniotic fluid volume can be estimated
subjectively or by using sonographic
measurements
• Subjective estimation is not inferior to the
quantitative measurement techniques (e.g.
deepest pocket, amniotic fluid index) when
270
250
performed by experienced examiners
Amniotic Fluid Index
230
210
190
170
150
• Patients with deviations from normal
130
110 should have more detailed anatomical
90
70 evaluation and clinical follow-up
16 18 20 22 24 26 28 30 32 34 36 38 40
Week

33. Fetal well being
Fetal movement
• There are no specific movement
patterns at this stage of pregnancy
• Temporary absence or reduction of
fetal movements during the scan
should not be considered as a risk
• Abnormal positioning or unusually
restricted or persistently absent
fetal movements may suggest
abnormal fetal conditions such as
arthrogryposis

34. Fetal well being
Fetal movement
• The biophysical profile is not considered part of
a routine mid-trimester scan!
• Fetal brain is not yet mature enough to control
sympathetic and parasympathetic of fetal heart!

35. Fetal well being
Doppler ultrasonography
• The application of Doppler
techniques is not currently
recommended as part of the routine
second-trimester ultrasound
examination
• There is insufficient evidence to
support universal use of uterine or
umbilical artery Doppler evaluation
for the screening of low-risk
pregnancies

36. Fetal well being
Multiple gestations
• visualization of the placental cord
insertion
• distinguishing features (gender,
unique markers, position in
uterus)
• determination of chorionicity is
sometimes feasible in the second
trimester if there are clearly two
separate placental masses and
discordant genders. Chorionicity
is much better evaluated before
14–15 weeks (lambda sign or T-
sign).

37. The anatomical survey in second trimester
At a glance
Head Intact cranium Abdomen
Cavum septi pellucidi Stomach in normal position
Midline falx Bowel not dilated
Thalami Both kidneys present
Cerebral ventricles Cord insertion site
Cerebellum Skeletal
Cisterna magna No spinal defects or masses (transverse and
Face Both orbits present sagittal)
Median facial profile Arms and hands present, normal
Mouth present relationships
Upper lip intact Legs and feet present, normal relationships
Neck Absence of masses (e.g. cystic hygroma) Placenta
Position
Chest/Heart No masses present
Normal shape/size of chest and lungs Accessory lobe
Heart activity present Umbilical cord
Four-chamber view of heart in normal Three-vessel cord
position Genitalia
Aortic and pulmonary outflow tracts Male or female
No evidence of diaphragmatic hernia

38. Placenta
Guidelines for maturity and position
+
+
+
+ +
+
• Women with a history of uterine surgery and low anterior placenta or placenta previa are
at risk for placental attachment disorders. In these cases, the placenta should be examined
for findings of accreta, the most sensitive of which are the presence of multiple irregular
placental lacunae that show arterial or mixed flow
• Abnormal appearance of the uterine wall–bladder wall interface is quite specific for
accreta, but is seen in few cases. Loss of the echolucent space between an anterior
placenta and the uterine wall is neither a sensitive nor a specific marker for placenta
accreta

39. Maternal anatomy
Guidelines
• Currently, there is sufficient
evidence to recommend
routine cervical length
measurements with a
transvaginal scan at the mid
trimester even in an
unselected population
• Uterine fibroids and
adnexal masses should be
documented

40. THIRD TRIMESTER SCAN
Great obstetrical syndrome
• Preterm labor
• Preterm
Rupture of
membranes
• Pre-eclampsia
• SGA/IUGR
• Fetal Death
Fetal growth restriction

41. FGR may be
Symmetrical Asymmetrical
and body
Fetal brain (BPD & HC) Fetal brain (BPD & HC) and
(AC) and long bones are long bones are large when
proportionately small. compared to the AC (liver).
may occur when the fetus may occur when the fetus
experiences a problem during experiences a problem during
early development. later development
Chromosomal malformation
Constituently Small (Small Hypoxemic hypoxia
Mother Small Baby ) utero placental insufficiency

42. Accurate fetal biometry
to measure the size of
fetus – AC & EFW
Predictive tools rule
of 2

43. Accurate fetal biometry
to measure the size of
fetus – AC & EFW
Accurate measurement
of fetal growth - Indian
Predictive tools & customized
rule of 2 fetal growth charts

44. Accurate fetal biometry
to measure the size of
fetus – AC & EFW
Accurate measurement
of fetal growth - Indian
Predictive tools rule & customized fetal
of 2 growth charts
Accurate knowledge of fetal
physiology and intrauterine
environment - fetal
Doppler study & AFI ACHARYA
DR.PRASHANT

45. • Biometric tests (tests to measure size)
• Biometric tests are designed to
predict size and growth
AC, EFW

46. USG TOOLS – HOW EFFECTIVE ?
• Ratio measures, such as head to
abdominal circumference (HC/AC)
and femoral length to abdominal
circumference (FL/AC) ratios are
poorer than AC or EFW alone in
predicting IUGR

47. Ask for serial measurements
and plot the findings in
growth chart – not
single USG reading
2/3/2012 DR.PRASHANT ACHARYA 47

48. 2/3/2012 DR.PRASHANT ACHARYA 48

49. PROPOSED INDIAN CUSTOMISED GROWTH CHART
• The term 40 weeks birth • The term 40 weeks birth
weight of fetus is 3051 for weight of fetus is 3455 for
normal primi patient normal primi patient
having average weight 52 having average weight 64
Kgs & average height of Kgs & average height of
152 cms 163 cms

50. Role of Doppler study in FGR
• In diagnosing fetal
hypoxia by detecting
redistribution of
fetal blood flow
• Helps in deciding
the Timing of Doppler detects flow of RBCs in any
delivery vessel - Quantity and speed
• Measuring AFI

51. Uterine artery Doppler waveform
• Impaired placentation
• P I P I P (OBS SYNDROME)
50-67% Positive predictive value
>95 % negative predictive value

52. Impaired placentation
Uterine artery
Doppler
Good
diastolic flow
High resistance ,
persistence of diastolic
notching and even absent end
systolic forward flow can
persist through out pregnancy
if PLACENTATION IS
INADEQUATE
In 50-67 % is associated Early
diastolic
notch Poor diastolic
with complication of flow
P I P I P &PPIH
DR.PRASHANT ACHARYA 2/3/2012 52

53. Prediction & Prevention of
FGR by
UTERINE ARTERY DOPPLER
P I P I P GREAT OBSTETRICAL SYNDROME
Preeclampsia
IUD
Prematurity
IUGR
Placental abruption

54. UMBILICAL ARTERY FLOW
characteristic saw-tooth appearance of arterial flow in
one direction and continuous umbilical venous blood flow
in the other.
54

55. Absent / Reversed end diastolic volume
(AEDV/REDV)
• AEDV/REDV + PREMATURITY = high chances of HMD
• neonatal complications are Asphyxia ,ICH are increased
2/3/2012 DR.PRASHANT ACHARYA

56. When Umbilical artery Doppler
parameters are altered
Multi vessel Doppler
Hypoxia and
examination (MCA and re
DV) distributation
Bio Physical Profile Score CNS

57. Umbilical artery Doppler
• When end diastolic
flow is present ,
delay delivery until
at least 35 weeks,
provided other
surveillance
findings are
normal.

58. MCA abnormality expressed by the
compromised fetus
Brain sparing effect – Fetal anemia
Cerebral perfusion
increased ( RI & PI
decreased)
MCA supplies blood to Brain - the most important
organ of body-
MCA PSV evaluates speed of fetal RBCs flow which
has DIRECT application in FETAL ANEMIA

59. Middle cerebral artery
An early stage in fetal
adaptation to hypoxemia - central
redistribution of blood flow
( brain-sparing reflex)
increased blood flow to protect the
brain, heart, and adrenals
reduced flow to the peripheral and
placental circulations

60. FETAL AORTA
Aortic Isthmus
Descending aorta

61. • The aortic isthmus PI is increased and
absolute velocities (especially the TAMXV)
are reduced in intrauterine growth-restricted
fetuses
Aortic isthmus blood flow velocimetry provides important information on fetal cardiovascular
function, i.e. individual performance of ventricles, relative changes in upper (including brain)
and lower (including placenta) body resistances and fetal oxygenation, and has the potential
to become a valuable clinical tool for fetal evaluation

62. FETAL DECENDING AORTA
• it is important to be aware of the fact that
the brief reversal of flow during end-systole,
which is a normal finding in the third
trimester, can give falsely high PI values

63. DUCTUS VENOSUS (DV)
INFERIOR VENA CAVA FORAMEN OVALE
RIGHT HEPATIC VEIN
MIDDLE HEPATIC VEIN LEFT HEPATIC VEIN
DUCTUS VENOSUS
PORTAL VEIN
UMBILICAL VEIN

64. RA
RV
HV
DV
RA
RV
HV
DV
Growth Retardation

65. Ductus venosus (DV)
Final
verdict
• Sensitive to fetal oxygenation status
• Dilates as fetal hypoxia worsens
• In severe hypoxia –reversal of (a) wave
• Immediate delivery of Fetus- in abnormal
DV flow

66. • Reflects VOLUME
MANAGEMENT by RIGHT
atrium and is responsive to
fetal oxygenation
• Dilates as fetal hypoxia
worsens
• In severe hypoxia –reversal
of (a) wave ,due to atrial
contraction s/o cardiac
failure and decompansation
due to increase in severe
after load
• Needs immediate delivery of
Fetus
2/3/2012 DR.PRASHANT ACHARYA 66

67. Amniotic Fluid Index
• Reduction in AFI is Supporting evidence of a
hostile intrauterine environment
• Amniotic fluid volume monitoring is very
helpful in monitoring the physiological status
of the fetus rather than the anatomical
growth.

68. BPPS or Modified BPPS ??
• VAST
• AFI
• Instant, Easy and cost
effective
• Helps in delivering the fetus at
optimal gestational age

69. 3D 4 D AS WATCH DOGS

70. Take Home Message
• Worldwide, it is likely that much of the
ultrasonography currently performed is carried
out by individuals with little or no formal
training(hence misinterpretations)
• Performed with proper guidelines
ROUTINE USG IN PREGNANCY can
predict many problems and be a good watch dog
for fetal and maternal wellbeing