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Ashraf sadat Jamal Professor of OB/GYN Perinatologist Tehran University of Medical Sciences

The Role of ultrasound in Maternal Mortality. Ashraf sadat Jamal Professor of OB/GYN Perinatologist Tehran University of Medical Sciences. Definition. Any death occuring anytime during pregnancy and up to 40 days postpartum. Maternal Mortality. A Global Crisis

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Ashraf sadat Jamal Professor of OB/GYN Perinatologist Tehran University of Medical Sciences

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  1. The Role of ultrasound in Maternal Mortality Ashraf sadat Jamal Professor of OB/GYN Perinatologist Tehran University of Medical Sciences

  2. Definition • Any death occuring anytime during pregnancy and up to 40 days postpartum

  3. Maternal Mortality • A Global Crisis • Estimated at 529000/ year in the world • 99% of maternal Mortality occur in the developing countries • Over 80% could be prevented with timely intervention • The majority of them can be predicted

  4. MM Rate/country (Lancet 2007) • Sweden 3/100,000 • USA 11/100,000 • India 450 /100,000 • Haiti 670 /100,000 • Afghanistan 1800 /100,000

  5. Primary Causes WHO (2005) • Hemorrhage 25% • Infection 15% • Eclampsia 12% • Unsafe abortions 13% • Obstructed Labor 8% • Indirect causes 20%

  6. USA • Pulmonary emboli (thrombotic, amniotic) 20% • Hemorrhage 12.5% • Hypertensive disorders 12.3% • Cardiomyopathy 11.5% • Infection 10.7% • CVA 6.3%

  7. Pregnancy Related Deaths • Preventable causes: 1- hemorrhage 2- infection 3- medical chronic diseases in pregnancy • Unpreventable:rapid course, lack of uniformly effective th 1- amniotic fluid embolus 2- microangiopathic hemolytic syndrome 3- cerebrovascular accident

  8. Maternal mortality committee • lack of preconception care (medical dis) • Patient action (poor prenatal care) • System factors (health care system) • Quality of care (hemorrhage): inadequate collaboration, lack of guidelines, inadequate training

  9. Average interval to maternal mortality • Untreated OB condition time in hospital • Ruptured Uterus 24 h • Antepartum hemorrhage 12 h • Postpartum hemorrhage 2 h

  10. Maternal Morbidity • Over 300 million women in developing world suffer from short, long term illness related to pregnancy • 100,000 new cases of fistula develop each year in Africa • Most are pushed out of society • About 90% contemplate suicide

  11. Pregnancy care in developing countries • Antenatal care is the most important service • Antenatal care  a platform to promote health and ensure safe delivery • Risk Assessment: History Clinical findings Ultrasound • At least 15 visits • Ultrasound? 15 U/S

  12. Prenat Diagn 2011; 31: 3–6. EDITORIAL A model for a new pyramid of prenatal care based on the 11 to 13 weeks’ assessment Kypros H. Nicolaides

  13. OB Hemorrhage • Ectopic pregnancy • Abortions • Placental localization, abnormalities: Pl. Previa Placenta Accreta • Placenta Abruption • Retained placenta postpartum

  14. Placenta Accreta • Morbidly adherent placenta (MAP) • Depth of invasion is of clinical importance • Amount of placental tissue involved in attachment: total pl. accreta partial pl. accreta focal pl. accreta 79 % accreta 14 % increta 7 % percreta

  15. Cause • Substantial rise of C/S • 1/2500 1980 • 1/535 2002 • 1/210 2006

  16. Risk Factors • Cesarean deliveries 40% accreta • Placenta previa • Advancing maternal age • Multiparity • Uterine leiomyomas • Uterine anomalies • Asherman syndrome • Hypertensive dis. in pregnancy • Smoking • Endometrial ablation, irradiation

  17. Pathogenesis • Scarring process after surgery • Abnormal vascularization • Secondary localized hypoxia • Defective decidualization • Excessive trophoblastic invasion

  18. Clinical presentation • Asymptomatic • Vaginal bleeding, cramping • Hematuria • Catastrophic presentation: 1- acute abdominal pain 2-hypotension 3-hypovolemic shock (from uterine rupture secondary to placenta percreta) This scenario 1st trimester to full term

  19. Sonographic Findings • In the first trimester : • Low implantation of GS risk of MAP • Multiple irregular vascular spaces in placenta • C/S scar pregnancy

  20. CSP sonographic features • Empty uterine cavity, empty cervical canal • Placenta or GS embedded in/on scar • Triangular GS filling niche of the scar<8w • Round or oval GS >8w • Absent or thin myometrial layer with bladder • Prominent, vascular pattern with color Doppler

  21. Low GS

  22. C/S scar Pregnancy

  23. Patient counseling • Terminate the pregnancy • Continue the pregnancy with accepting the risk of complications: massive hemorrhage shock, uterine rupture with fetal loss hysterectomy, massive transfusion

  24. Conclusion • Previous C/S in early first trimester pregnancy have TVS for location of GS • Anteriorly attached low-lying gestation considered CSP until proved otherwise • Before first trimester termination, think about CSP

  25. Placenta accreta in second and third trimester • Multiple vascular lacunae 80 %- 90% sen • Loss of normal hypoechoic retroplacental zone (angle dependent, can be absent in normal ant PL). • Uterine serosa-bladder interface disruption • Thickening, irregularity, increased vascularity on color Doppler imaging

  26. Second and third trimester • Extension of the villi into myometrium, serosa or bladder • Retroplacental myometrial thickness <1mm • Turbulent blood flow on Doppler sonography • Multiple vascular lacunae or Swiss cheese appearance is most important finding in third trimester, when >4 = 100 % DR

  27. Multiple vascular lacunae 18 weeks

  28. Diagnosis • 2-D ultrasound, sensitivity 90% (primary screening) • History of C/S and placenta previa • MRI 94% sensitivity, less accuracy < 24 week • Depth of invasion with MRI • 3-D color Doppler imaging high sensitivity • Placental vessel architecture with 3-D power Doppler differentiate accreta from percreta

  29. Prenatal care MAP • Correction of Iron deficiency • Antenatal corticosteroids between 23-34w • Anti-D immune globulin in Rh-negative • Avoidance of pelvic exam, rigorous activity • Consideration of bed rest and/or hospitalization in the third trimester • Schedule elective surgery between 34-36

  30. Management MAP • Multidisciplinary team with preoperative plan • Tertiary care center • Blood bank • Operating room capability of fluoroscopy for radiology intervention • ICU for postoperative care

  31. Prenatal identification of invasive placentation using ultrasound: systematic review and meta-analysis D’Antonio et al., UOG 2013 Discussion points • Is there a need to set up a multi-disciplinary clinic for the prenatal diagnosis and subsequent management of invasive placentation? • If yes, should all women with an anterior low-lying placenta and previous history of Cesarean delivery or uterine surgery be referred to this clinic? • How should we develop the objective criteria for the diagnosis of invasive placentation (i.e. color Doppler abnormalities), thus allowing objective structured training of fetal medicine subspecialists?

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