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TRANSCRIPT
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Imagingin Obstetric and Gynecology
A. Kurdi Syamsuri, Hatta Ansyori, Nuswil Bernolian
Division of Maternal-Fetal Medicine
Department of Obstetric and Gynecology
Dr. Moh. Hoesin General Hospital/
Faculty of Medicine University of Sriwijaya
Palembang, 2013
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Imaging
Ultrasonography
X-Rays, CT Scan, MRI Electronic Fetal Monitoring (EFM)
Cardiotocography (CTG)
Amniosintesis
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ULTRASOUND (US) EQUIPMENT
Types of ultrasound:
- 2-D (real-time)
- Doppler
- Color Doppler- 3-D static
- 3-D real-time (4-D)
Probe (transducer):
- Transabdominal (3
5 MHz)- Transvaginal (5 8 MHz)
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Obstetric US : TM 1
Is there any pregnancy ?
Intra /extra uterine ? Or both ?
Gestational age
Signs of fetal life
Evaluation of pregnancy complication Search for source of vaginal bleeding
Detection of fetal anomalies
Detection of multifetal pregnancy
Suspicious of chromosomal disorder
Evaluation of adnexa, pelvic tumor, location of IUD Prenatal diagnosis : CVS (chorionic villous sampling)
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Decidualisation, Gestational sac (GS), Yolk sac, Blightedovum ?
Crown-Rump Length (CRL), Heart beat
Fetal movement
Multifetal pregnancy, conjoint twin ?
Subchorionik bleeding
Suspi of fetal anomalies ( Anencephalus/ hygroma colli )
Susp of chromosomal disorder ( NT nuchal
translucency, nasal bone) Ectopic pregnancy
Adnexal tumor , uterine myoma
TM 1 Examination
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Evaluation: 1-2 weeks
Normal : 3 mm, if less, progesteron 6,5 mm : thalassemia
< 3, mm : Growth hormon
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Yolk sac
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cradio%5Cimages%5CLarge%5C46304630Fig_6_Lg_YSa.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cradio%5Cimages%5CLarge%5C4629Fig_5._Nl_YS.JPG&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cradio%5Cimages%5CLarge%5C46254625Fig_1._CRL_5.4mma.JPG&template=izoom2 -
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Diameter 10 mm without yolk sac Diameter 15 mm without fetal echo
Wait dan see ?
Blighted ovum (BO)
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Head extension
Appropriate gain/ zoom
Head to buttock/rump, exclude extremities and yolk sac
CROWN RUMP LENGTH (CRL)
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< 5 weeks 5 weeks 6-10 weeks 10-12 weeks
GS GS andYolk sac
CRL CRLBPD
> 12 weeks
BPD, Femur , etc.
CRL : Accurate for 6-10 weeks
Biometry
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Subchorionic Bleeding
Prognosis
Hematoma > 50%
GS floating intra uterin
GS in lower segment Bradycardia < 90 bpm
Evaluation 5-7 days
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Fetal anomalies
Anencephalus Hygroma colli
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NB : T-1 : Absent/exist?
T-2 : Hypoplastic/ absent ?
NT : < 3 mm
Susp of chromosomal abnormalities
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Gemellus : Chronionisitys and amnionisity
Twin peak sign
:
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Triplet
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Conjoint twin
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Suspect thalassemia
8-9 weeks Screening : Hb, MCV, MCH Hb elektroforesis, DNA
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Hydrops Fetalis
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Meningocele, omphalocele
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Pseudogestasional
Early diagnosis , early management : better outcome
Ectopic Pregnancy
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Mola hydatidiform
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Sign of life, number of fetus, presentation, and fetalmovement activity
Gestational age determination : preterm, term, posdate
Estimated Date of Delivery
Fetal growth and fetal well-being
Amniotic volume
Placenta and umbilical cord
Fetal Anatomy and Fetal functional
Multifetal pregnancy Uterine myoma (position), cervix and adnexa
TM 2-3 US EXAMINATION
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Fetal BiometryBPD, HC, AC, FL, EFW
HL, Cerebellum, OFD, OOD, IOD
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Single pocket: 2-8 cm
AFI : 4 quadrant : 5-25 cm
Amniotic Fluid
Polyhydramnion Oligohydramnuion
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PLACENTA
Bladder effect
Contraction effect
Plasenta previa trimester I
Plasenta previa - inkreta
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Umbilical Cord
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Fetal Heart
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Fetal Abdomen
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Extremities and Spine
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FETAL SEX
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Fetal Growth Chart
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Documentation
Date, identity, picture orientation
Permanent record : photo, CD,
video
Description : location, size, types
of abnormalities
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Conclusion
US examination in obstetric very helpful,
should be serial to assess fetal growth
Use the fetal growth chart Early detection
On indication, nor for massal screening
informed consent/ counselling
Referral system : Level 1, level 2, level 3
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GYNECOLOGICAL US
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Proliferation phase Secretion phase
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Imaging
Ultrasonography
X-Rays, CT Scan, MRI Electronic Fetal Monitoring (EFM)
Cardiotocography (CTG)
Amniosintesis
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Magnetic Resonance Imaging
MRI useful tool in both OB/GYN imaging
No reported harmful human effects from
its use, including any mutagenic effects /No demonstrable fetal heart pattern
changes during imaging
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MRI Systems
At $2 million, the most expensive equipment in the hospital
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Magnetic Resonance Imaging Indication- Any gestational age if no other
imaging studies can be performed
Maternal indication
1. Measurements of the pelvic inlet andmidpelvis in the case of breech presentation
2. Maternal disorder
- brain tumor, spinal trauma
- adrenal tumor (pheochromocytoma)
- uterine and ovarian mass
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Magnetic Resonance Imaging
Fetal indications
-Central nervous system and thoracic
abnormalities-observation of lecithin peak
(used MRspectroscopy---
in vivo analysis of lung maturity
id li f i i i
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Guidelines for Diagnostic Imagingduring Pregnancy
1.Woman should be counseled that X-ray
exposure from a single diagnostic
procedure dose not result in harmfulfetal effects. Specifically, exposure to lessthan 5rad has not been associated with an
increase in fetal anomalies or pregnancy
loss
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Guidelines for Diagnostic Imagingduring Pregnancy
2. Concern about possible effects of high-dose ionizing radiation exposure should notprevent medically indicated diagnostic X-
ray procedure from being performed on themother. During pregnancy, other imagingprocedures not associated with ionizingradiation, such as ultrasonography and
magnetic resonance imaging, should beconsidered instead of X-rays when possible
G id li f Di ti I i
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Guidelines for Diagnostic Imagingduring Pregnancy
3. US and MRI are not associated with
known adverse fetal effects.
However, until more information is available,
MRI is not recommended for use in the1st trimester
G id li f Di ti I i
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Guidelines for Diagnostic Imagingduring Pregnancy
4. Consultation with a radiologist may be
helpful in calculating estimated fetal dosewhen multiple diagnostic X-rays areperformed on a pregnant woman
G id li f Di ti I i
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Guidelines for Diagnostic Imagingduring Pregnancy
5. The use ofradioactive isotope of iodine
is contraindicated for therapeutic useduring pregnancy
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1. Plain Ray
a. Chest X-Ray
* Respiratory disorders
* Choriocarcinoma
b. Abdominal X-Ray
* Dermoid Cyst / Teratomas
* Fetal presentations and congenital malformations
* Pelvimetry2. Intravenous Pyelography (IVP)
* Ureteric obstructive lesions
e.g Calculi, uterine fibroids
* Congenital anomalies of the Urinary bladder,
ureters and Kidney
3. A Videocystourethrogram
* Stress incontinence
* Bladder diverticula
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Axial SSFSE T2W image
Coronal SSFSE T2W image
Hemorrhagic Cyst
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Axial T2W SSFSE
image
Leiomyoma
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Axial FSE T2W image
Benign Mucinous Cystadenoma
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Imaging
Ultrasonography
X-Rays, CT Scan, MRI Electronic Fetal Monitoring (EFM)
Cardiotocography (CTG)
Amniosintesis
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ELECTRONIC FETALMONITORINGAND
CARDIOTOCOGRAPHY
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Monitoring of FHR & Uterine Contractions(Cardio-toco-graphy)
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Reactive PatternBaseline FHR 120-160 bpm
2 accelerations in 20 minutes
Acceleration amplitude > 15 beats lasting > 15seconds
Variability 15 beats (5-10 beats in premature
fetuses)
No periodic or significant decelerations (>30
beats)
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Non-Reactive Pattern
Lack of reactive criteria over 40 minutes.
Always of concern ante-partum & delivery
is generally indicated.
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Patterns of The FHR
Normal Pattern
Baseline Tachycardia/Bradycardia
Reduced Variability Early Decelerations
Late Decelerations
Variable Decelerations Other Patterns e.g Sinusoidal
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FHR Accelerations
Are common periodic changes in labor and
are nearly always associated with fetal
movement.
Virtually always reassuring and almost
always confirm that the fetus is not acidotic
at that time.
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Variability
A useful indicator of fetal CNS integrity.
May serve as a barometer of the fetalresponse to hypoxia.
In most situations, decelerations of the
FHR will precede the loss of variability,indicating the cause of neurologicdepression.
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Variability
Factors such as a fetal sleep cycle or
medications may decrease the activity of the
CNS and the variability of the FHR.
Decreased variability in the absence of
decelerations is unlikely to be due to hypoxia.
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Early Decelerations Benign changes caused by fetal head
compression.
Seen in the active phase of labor.
They are usually shallow and symmetrical.
Reach their nadir at the same time as the peak
of the contraction.
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Baseline Tachycardia
Tachycardia may be associated with:
Severe and prolonged fetal hypoxia
maternal fever Fetal anemia
Intraamniotic infection i.e. chorioamnionitis
congenital heart disease
Hyperthyroidism
Prolonged Deceleration
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Prolonged Deceleration
An isolated, abrupt decrease in the FHR to
levels below the baseline that lasts at least
60-90 seconds.
Always of concern and may be caused by
virtually any mechanism that can lead to fetal
hypoxia.
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Variable Decelerations
Umbilical cord compression or, occasionally,
head compression.
Abrupt onset and return
Vary in depth, duration, and shape.
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Variable Decelerations
Frequently preceded and followed by small
accelerations of the FHR.
Coincide in timing and duration with the
compression which coincides with the timing of
the uterine contractions.
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Variable Decelerations
Generally associated with a favorable outcome.
Non-reassuring if:
Persistent.
Progressively deeper to less than 70 bpm
lasting greater than 60 seconds.
Persistently slow return to baseline .
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Late Decelerations
U-shaped, gradual onset and return, usually
shallow 10-30 beats per minute.
Reach their deepest point after the peak of thecontraction.
A result of CNS hypoxia; in more severe cases,
it may be the result of direct myocardialdepression.
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Sinusoidal Heart Rate Pattern
Regular oscillation of the baseline long-term
variability resembling a sine wave, lasting at
least 10 minutes.
Rare and associated with:
Severe chronic fetal anemia
Medications: e.g. pethidine
Severe hypoxia and acidosis.
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Imaging
Ultrasonography
X-Rays, CT Scan, MRI Electronic Fetal Monitoring (EFM)
Cardiotocography (CTG)
Amniosintesis
AMNIOSINTESIS
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AMNIOSINTESIS
A PROCEDURE TO OBTAIN THE AMNIOTIC FLUID BYINSERT THE NEEDLE THROUGH MATERNAL ABDOMEN
GUIDED BY THE ULTRASOUND
UNDERTAKEN AT 16 20 WEEKS OF PREGNANCY
EARLY DIAGNOSIS OF CHROMOSOMALABNORMALITIES, THALASSEMIA, ANOTHER GENETIC
DISEASES
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AMNIOSINTESIS
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THANK YOU