Download - ERKEN GEBELİK USG
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Erken gebelik ultrasonu
Cem Batukan
Acıbadem Üniversitesi Tıp Fakültesi
Kadın Hastalıkları ve Doğum AD
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1. Trimester US
• Fetus sayı ve yerleşimini belirlemek
– İntrauterin / ektopik
• Gebelik haftasını belirlemek
• Erken gebelik komplikasyonları saptamak
• Non-viable gebelikleri saptamak
• Kötü prognoza sahip gebelikleri saptamak
• Fetal anatomiyi değerlendirmek (>10 hafta)
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Normal intrauterin gebelik
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4+ hafta GA=04+3d
1 D 3.1mm
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5+ hafta
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6+ hafta
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Yüksek frekanslı TV prob: Fetal kardiyak aktivite
5w3d
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Koriyonisite / Amniyonisite
Monokoriyonik Diamniyotik
Gebelik kesesi ........... Koriyonisite Yolk sac ..................... Amniyonisite
Dikoriyonik Diamniyotik
Monokoriyonik Monoamniyotik
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Normal gestasyonel sac
Desidua parietalis
Desidua bazalis
Desidua kapsülaris
IUG: %30
İntradesidual sac sign
Double desidual sac sign
IUG: %50
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İntrauterin vs. ektopik gebelik
İntrauterin gebelik Ektopik gebelik
Kavite için sıvı kolleksiyonu
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Gestasyonel sac Ektopik
Ektopik
İntrauterin İntrauterin
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5 weeks
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Ektopik gebelik
Over
TV-Ultrasonografi: Ektopik gebeliklerin %77’i ilk muayenede,
%98’i ise sonraki muayenelerde preop saptanmaktadır
Servikal gebelik
Skar gebeliği
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PUL “Pregnancy of unknown location”
Pozitif gebelik testi +
Transvaginal ultrason ile intrauterin veya ekstrauterin gebelik lehine bulgu olmaması
Kirk ve Bourne, Pregnancy of unknown location, Obstet Gynecol Reprod Med, 2008
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PUL yönetimi
Kirk ve Bourne, Pregnancy of unknown location, Obstet Gynecol Reprod Med, 2008
Çoğu merkez min %50 veya %66 lık hCG artışını viable IU kriteri olarak kullanıyor 48 saatte min %35 hCG artışında da viable IU gebelik olabilir (Seeber et al., Fertil Steril, 2006)
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*
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Prob frekansı / Harmonik
Harmonic on
Harmonic off
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Gebelik haftasının belirlenmesi
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Pratik ve kolay: Erken gebeliğe ait US bulgularının
ortaya çıkma zamanı
4 - 4,5 hafta 5 - 5,5 hafta 6 – 6,5 hafta
Gebelik kesesi Yolk kesesi Fetal pol
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6-12 hafta arasında GH’nı belirlemek için en iyi yöntem CRL’yi ölçmek
3mm 14mm 25mm
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Yolk kesesine dikkat !
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Ortalama gestasyonel kese çapı
Rutinde gestasyonel kese çapını ölçerek gebelik haftası belirlenmeye çalışılmamalıdır
a*b*c/3 a
b
c
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Gebelik ne zaman non-viable kabul edilmeli?
• Fetal kardiyak aktivite için CRL sınır değer ?
• Anembriyonik gebelik için kriter ?
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Nonviable gebelik kriterleri
- The Society of Gynecologists of Canada (SGOC)
• Embryo >5 mm and absent fetal cardiac activity • Intrauterine mean gestational sac diameter >8 mm with absent yolk sac • Intrauterine mean gestational sac diameter >16 mm without fetal pole
- The American College of Radiologists (ACR)
• Embryonic crown-rump length >5 mm and absent fetal cardiac activity
- Royal College of Obstetricians and Gynaecologists (RCOG)
- Royal College of Radiologists (RCR)
• Intrauterine gestational sac with mean diameter ≥ 20 mm and no yolk sac • Fetal crown-rump length ≥ 6 mm with absent fetal cardiac activity
- Australasian Society forUltrasound in Medicine (ASUM)
• Mean gestational sac diameter ≥ 20 mm with absent embryonic structures • Embryonic crown-rump length ≥ 6 mm with absent fetal heart rate
- Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland
• Mean gestational sac diameter >20 mm with absent embryonic structures (embryo or yolk sac)
• Embryonic crown-rump length ≥ 7 mm with absent fetal heart rate
***Çalışmalar bu kriterlerin %1-2 yalancı pozitifliğe sahip olduğunu gösterdi
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Revised RCOG guideline, Obstet Gynecol, 2013
*
* Abdallah et al., Gestational sac and embryonic growth are not useful as criteria to define miscarriage: a multicenter observational study. UOG, 2011 ** >8mm; Government of South Australia
**
Pregnancy of unknown viability (PUV) MSD < 25 mm, yolk sac (-) MSD > 25mm, yolk sac (+)
CRL < 7 mm, FKA (-)
7-10 gün sonra US kontrol
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Gebelik akıbeti açısından kötü prognostik faktörler
• Gebelik haftası
• Beklenenden küçük gebelik kesesi
• Bradikardi
• Yolk sac anomalileri
• İntrauterin kanama
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Gebelik haftası ve abort riski A
bo
rt
us
7-14 hafta: Her hafta için yaklaşık %1 azalır
%10 %3
>40y %20
<35y %2
35-39y %14
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Gebelik kesesi büyüklüğü
- MSD – CRL farkı:1,2
<5mm ise gebelik kaybı oranı %80-95
5-8mm ise gebelik kaybı oranı %25
- 5. haftadan önce beklenenden küçük gestasyonel sac’ın prognostik önemi yok
1Dickey et al., Relationship of small gestional sac-crown-rump length difference… Obstet Gynecol, 1992. 2Bromic et al., Small sac size in the first trimester: A predictor of poor fetal outcome. Radiology, 1991
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Gebelik kesesi büyüklüğü
Gebelik kesesi çapı ile olumsuz gebelik prognozu ilişkisi CRL<10mm de anlamlı
Makrydimas et al., Fetal loss following ultrasound diagnosis of a live fetus at 6–10 weeks of gestation, UOG, 2003
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Vaka
8w0d
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Bradikardi
Bradikardi artmış abort riski ile
ilişkili
<6 hafta: kalp hızı dakikada 80-
100 olabilir
Özellikle 6-8. haftalar arasında
progresif bradikardi (<90 atım/dk)
olması düşük riskini arttırır.1,2
Kalp hızı 8. haftada normale
dönse dahi 12. haftaya kadar %25
abort riski devam eder.3
1Makrydimas et al., Fetal loss following ultrasound diagnosis of a live fetus at 6–10 weeks of gestation, UOG, 2003 2Jauniaoux et al., The role of ultrasound imaging in diagnosing..., UOG, 2005 3Doubilet et al., Outcome of first-trimester pregnancies with slow embryonic heart rate…, Radiology, 2005
95th centile
5th centile
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M-mode Doppler US
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Yolk kesesi büyüklüğü
<5mm vs. ≥ 5mm :1
Artmış abort riski (%14 vs. %34) (OR:3.5) Artmış preterm doğum riski ?
1Berdahl et al., Detection of enlarged yolk sac on early ultrasound is associated with adverse pregnancy outcomes, Fertil Steril, 2010
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Prognostik önemi tartışmalı olan yolk sac bulguları
Hiperekojen YS İrregüler YS Küçük YS
8-12. gebelik haftası <2mm
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İntrauterin hematom Subkoriyal hematom
Chorion leave
Chorion frondosum
Gebelik haftasına bağlı olmakla
birlikte abort riski %4-331 (RR:2-
2.5)
Birinci trimester sıklığı %4-222
Kanama plasenta arkasında
ve/veya endometrial kavite içine
olur
Vaginal kanama ile başvuran
hastaların %20-40’ında hematom,
hematomu olan kadınların ise
%70’inde kanama olmaktadır.3
1Pearlstone & Baxi, Subchorionic hematom: a review. Obstet Gynecol Surv, 1993 2Leite et al., Prognosis of very large intrauterine hematomas, J Ultrasound Med, 2006 3Jauniaux et al., Obstetric outcome after early pregnancy complication, Curr Opin Obstet Gynecol, 2010
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İntrauterin hematom Subkoriyal hematom
PL PL
*
*
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İntrauterin hematom Subkoriyal hematom
* *
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Subkoriyal hematom / Prognoz
• Büyüklük ve semptom (Vaginal kanama) olup olmaması prognozu etkilemiyor1
• Lokalizasyon: Retroplasental hematomlarda prognoz daha kötü?1
• Gebelik haftası: – <6 hafta: gebelik üzerine olumsuz etkisi yok2
– ≥7-12 hafta: abortus, preterm doğum, EMR, preeklampsi, ablasiyo plasenta, IUGG riski4
1Nagy et al., Clinical significance of subchorionic and retroplacental hematomas..., Obstet Gynecol, 2003 2Harville et al., Vaginal bleeding in very early pregnancy. Hum Reprod, 2003 3Jauniaoux et al., The role of ultrasound imaging in diagnosing..., UOG, 2005
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Koriyonik hematom (“Chorionic bump”)
Sıklığı %0.15-0.7
Koriyonik kavite içine olan konveks
polipoid kabarıklıklar
1. trimester kayıp riskini artırmıyor
2. trimester IUMF riskini 2-4 kat artırıyor
Büyüklük ve lokalizasyon gebelik
akıbetini etkilemiyor
Sana et al., Clinical significance of first-trimester chorionic bumps: a matched case–control study. UOG, 2013
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Koriyonik hematom (“Chorionic bump”)
5w5d, Bozulmuş gebelik?
Sana et al., Clinical significance of first-trimester chorionic bumps: a matched case–control study. UOG, 2013
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Erken embriyonik anatomi
Sequential appearance of embryonic structures and functions during the first-trimester pregnancy Timor-Tritsch et al. A close look at early embryonic development with the high-frequency transvaginal transducer. AJOG, 1988
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Erken embriyonik anatomi
Rhombensefalon
07w6d Serebellum
4. ventrikül
Sisterna magna
Beyin sapı
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08w5d
Rhombensefalik kavite (4.ventrikül) Mesensefalik kavite
(Acuad. Sylvii)
Diensefalik kavite (3. ventrikül)
Transvajinal US
E8
Erken ventriküler sistem
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Erken embriyonik anatomi
8w3d
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3D TV-US
8w6d
7w5d
Voluson E8; 6-12 MHz 3D/4D transvaginal transduser, GE