Prof. Aboubakr Elnashar Benha University Hospital, Egypt

Aboubakr Elnashar

1.2nd trimester miscarriage

2.Ante partum hemorrhage

3.PTL

4.PROM

5.Decreased or absent fetal movements

6.Trauma

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Causes:

1.Cervical incompetence

2.Fibroid

3.Uterine malformation

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Cervical incompetence •TVS: only technique used reliably to measure the

cervical length

[TAS: full bladder to visualize the cervix elongates the

cervix

TVS: an empty bladder and no distortion]

Aboubakr Elnashar

1. Cervix length < 25 mm

2. Funneling of int os:

-T, Y, V, U (correlation between the length of the cervix

and the changes in the internal os).

(Trust Your Vaginal Ultrasound)

-in response to pressure on the uterine fundus

-Serial evaluation/2 w

4. Protrusion of the membranes.

5. Fetal parts in the cervix or vagina

Aboubakr Elnashar

Aboubakr Elnashar

History-indicated cerclage (RCOG, 2011)

Indications

Three or more previous PTL and/or 2nd T

miscarriage.

Not an indication:

two or fewer PTL and/or 2nd T miscarriage.

Aboubakr Elnashar

Ultrasound-indicated cerclage (RCOG, 2011)

Indication:

History of one or more spontaneous 2nd T

miscarriage or PTL

TVS: cervix is 25 mm or less

Not indicated

No history of spontaneous 2nd T miscarriage or

PTL

Funnelling of the cervix

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Cervical cerclage is not recommended (RCOG, 2011)

1. Multiple pregnancies

{±detrimental

increase in 2nd T miscarriage or PTL}.

2. Uterine anomalies

3. Cervical surgery

cone biopsy

LLETZ

destructive procedures (laser ablation or diathermy)

multiple dilatation and evacuation.

Aboubakr Elnashar

Define:

Bleeding from genital tract after fetal viability

Causes:

1.Placenta praevia:

2.Abruptio placentae

3.Vasa praevia

4.Local causes

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IV. Complete Centralis III. Complete partial II. Marginalis I. Lateralis

Major Minor

TVS: Distance between lower edge of the placenta & internal os

<2 cm in the third trimester: CS especially if the

placenta is thick (RCOG, 2011)

Placenta praevia

Grading: Now obsolete in clinical practice

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US:

diagnose placenta praevia (RCOG,2011)

TVS

safe in the presence of PP

more accurate than TAS in locating the placenta (RCOG , 2005 ).

Aboubakr Elnashar

Placental abruption

Retroplacental Marginal

Subamniotic, intraplacental

Aboubakr Elnashar

US: (RCOG, 2011)

does not exclude abruption.

{Placental abruption is a clinical diagnosis

sensitivity is poor}

Sensitivity: 24%: fail to detect three-quarters of cases

Specificity: 96%: When suggests an abruption, the

likelihood that there is an abruption is high.

Fetal heart pulsation if fetal viability cannot be

detected using external auscultation.

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Regular contractions with cervical change before

37w

(ACOG, 2003)

1. Prediction

2. Management

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I. Prediction:

TVS is more accurate than digital examination

[Provides reliable length, dilation, funneling]

High NPV: 89% if > 2.5 cm

Risk PTD with cervix length

Accepted safe length is 3 cm

Cx length > 3cm: No risk of PTL

Cx length <2cm: 70% will deliver PT

Recommended

high risk/symptomatic patients

Not for routine screening

Aboubakr Elnashar

Length of the endocervix can be measured

using TVS

Aboubakr Elnashar

Antenatal corticosteroids (RCOG, 2010)

Single course of to women between 24+0 and

34+6W who are at risk of PTL.

should be given to all women for whom an elective

CS is planned prior to 38+6 w.

Elective CS should be performed at or after 39+0

w to reduce respiratory morbidity.

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II. Management: 1. Presentation

2. Fetal weight

Shepard:

BPD & AC

Accurate within 10-15 %

Hadlock:

FL & AC

3. Fetal wellbeing in high risk pregnancies,

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Tocolytic drugs: RCOG, 2011

Nifedipine and atosiban oxytocin receptor agonist have

comparable effectiveness in delaying birth for up to

seven days.

Compared with beta-agonists, nifedipine is

associated with improvement in neonatal outcome.

Nifedipine: initial oral dose of 20 mg followed by 10–

20 mg three to four times daily, adjusted according to

uterine activity for up to 48 h.

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Define:

Leakage of AF in absence of uterine activity

Latency: The interval between ROM & onset of

contractions

Types:

PretermPROM

TermPROM

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Management: useful: history PROM but negative speculum exam.

Cervix length, gestational age

•AFV

correlate with:

latency in PPROM

neonatal morbidity & mortality in 2nd PROM

•FBP:

reduced in chorioamnionitis.

sensitivity: 25%

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PPROMP (RCOG,2010)

Observe for signs of clinical chorioamnionitis.

Not necessary: Weekly high vaginal swab

weekly CBC or CRP {sensitivity is low}.

CTG is useful: fetal tachycardia: cl chorioamnionitis.

FBP and Doppler: limited value in predicting fetal

infection.

Antenatal corticosteroids should be administered

Delivery should be considered at 34 w

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I. Living

II. Fetal wellbeing

1. Foetal growth assessment

2. FBP

3. Doppler

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1. Fetal growth assessment

US/2w: HC and AC.

AC

most sensitive predictor of fetal growth.

increases 2cm/2w after 24 w in the average fetus.

measurements are plotted on centile charts.

fall in the growth velocity of AC indicates IUGR.

AC used to assess fetal growth

Aboubakr Elnashar

Aboubakr Elnashar

Score 2 Score 0

CTG >2 accelrations/40 min

<

F. movements >3/30 min <

F.breathing. movements (FBM)

30 sec sustained FBM/30 min

<

F.tone closed fist or flexion to extension movement

Neither

Am Fluid Volume

>1 cm pocket <

2. BPP

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3. Doppler

more useful test of fetal wellbeing than CTG or FBP.

Umbilical arterial blood flow

Middle cerebral artery

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a. Umbilical artery Doppler

Idea:

Umbilical Arterial Flow is normally low resistance.

In hypoxic states:

relative placental hypoxia:

reactive VC of umbilical artery tributaries:

higher resistance:

relative decrease in diastolic flow

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Doppler indices

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•Resistance index:

Best ability to predict abnormal outcomes

(RCOG,2002 Evidence level II)

Normal pregnancy: {progressive increase in end-diastolic velocity

{growth& dilatation of the umbilical circulation}:

Resistance index falls.

Fetal growth restriction and/or PET: > 0.72 is outside the normal limits from 26 w.

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•S/D should be <3.

small increases in S/D= 3-5: chronic intrauterine

disease manifest by IUGR.

Not strictly useful:

{1. low sensitivity.

2. Gestation age dependent}.

•Diastolic flow is absent {AED}or reversed (RED}

Fetal distress is almost certain:

Immediate BPP or NST or

Delivery may be indicated.

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Normal

Absent

Reversed

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b. Middle cerebral artery peak systolic velocity (MCA-

PSV)

The most significant breakthrough in the surveillance of

the potentially anemic fetus

Based on:

In fetal anemia:

Enhanced fetal cardiac output and

Decrease in blood viscosity:

Increased blood flow velocity

preferentially shunt blood to brain faster

most pronounced MCA PSV

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Frequency

•Initiated: 18 w

•Repeated: every 1–2 w as the clinical situation

MCA waveforms in an anemic fetus

requiring serial transfusions for severe Rh

(D) disease.

The peak systolic velocities of 62, 50, and

61 cm per second (top to bottom)

corresponded to fetal hematocrits of 19%,

44%, and 32%, before, at the time of, and a

week after the first intravascular

transfusion, respectively.

Aboubakr Elnashar

Aboubakr Elnashar

Advantage

More sensitive for predicting f anemia than the

ΔOD450 (Recent studies)

Alternative to serial amniocenteses

Excellent noninvasive tool for the monitoring of f

anemia.

Aboubakr Elnashar

Reduced Foetal movements (RCOG, 20011)

1. History

Risk factors for stillbirth and FGR.

Sudden change in fetal activity

2. Auscultate the fetal heart

Doppler device to exclude fetal death.

3. CTG

{exclude fetal compromise}

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4. US

RFM persists despite a normal CTG

risk factors for FGR/stillbirth.

AC

EFW {detect the SGA}

AFV

Doppler

Fetal morphology

Aboubakr Elnashar

5. ± BPP:

± a role in high risk pregnancies:

Systematic review of RCT:

does not support its use as a test of fetal wellbeing

Uncontrolled observational studies:

BBP has good NPV

Fetal death is rare with normal BPP.

Aboubakr Elnashar

Mother:

•Noninvasive

•Does not require transport of the mother out of the

ED.

•Detects free intraperitoneal fluid or hemorrhage

•FAST: The focused assessment with sonography for

trauma

routine in many trauma centers

high sensitivity and accuracy

Aboubakr Elnashar

Fetus:

•Safe

•Assess viability.

multiple gestations.

size, gestational age, and position of the fetus.

Aboubakr Elnashar

Indications of cerclage:

1. Three or more PTL and/or 2nd T miscarriage.

2. History of one or more spontaneous 2nd T

miscarriage or PTL and TVS: cervix is 25 mm or

less

Cervical cerclage is not recommended: multiple

pregnancies, uterine anomalies, cervical surgery

CS if placenta <2 cm from internal os in the 3rd T

Antenatal corticosteroids if elective CS is planned

prior to 38+6 w.

Aboubakr Elnashar

Umbilical a Doppler:

• RI >0.72 is outside the normal limits from 26 w. • S/D >3.

• Diastolic flow is absent or reversed: Fetal distress

is almost certain: Immediate BPP or NST or delivery

Middle cerebral artery peak systolic velocity: most

significant breakthrough in the surveillance of the

potentially anemic fetus

Aboubakr Elnashar

Thanks

elnashar53@hotmail.com

Aboubakr Elnashar