Emergency ultrasonography in 2nd 3rd timester

1. Prof. Aboubakr Elnashar
Benha University Hospital, Egypt
Aboubakr Elnashar

2. 1.2nd trimester miscarriage
2.Ante partum hemorrhage
3.PTL
4.PROM
5.Decreased or absent fetal movements
6.Trauma
Aboubakr Elnashar

3. Causes:
1.Cervical incompetence
2.Fibroid
3.Uterine malformation
Aboubakr Elnashar

4. 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

5. 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

6. Aboubakr Elnashar

7. 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

8. 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
Aboubakr Elnashar

9. 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

10. Define:
Bleeding from genital tract after fetal viability
Causes:
1.Placenta praevia:
2.Abruptio placentae
3.Vasa praevia
4.Local causes
Aboubakr Elnashar

11. 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
Aboubakr Elnashar

12. 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

13. Placental abruption
Retroplacental Marginal
Subamniotic, intraplacental
Aboubakr Elnashar

14. 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.
Aboubakr Elnashar

15.  Regular contractions with cervical change before
37w
(ACOG, 2003)
1. Prediction
2. Management
Aboubakr Elnashar

16. 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

17. Length of the endocervix can be measured
using TVS
Aboubakr Elnashar

18. 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.
Aboubakr Elnashar

19. II. Management:
1. Presentation
2. Fetal weight
Shepard:
BPD & AC
Accurate within 10-15 %
Hadlock:
FL & AC
3. Fetal wellbeing in high risk pregnancies,
Aboubakr Elnashar

20. 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.
Aboubakr Elnashar

21. Define:
Leakage of AF in absence of uterine activity
Latency: The interval between ROM & onset of
contractions
Types:
PretermPROM
TermPROM
Aboubakr Elnashar

22. 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%
Aboubakr Elnashar

23. 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
Aboubakr Elnashar

24. I. Living
II. Fetal wellbeing
1. Foetal growth assessment
2. FBP
3. Doppler
Aboubakr Elnashar

25. 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

26. Aboubakr Elnashar

27. 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
Aboubakr Elnashar

28. 3. Doppler
more useful test of fetal wellbeing than CTG or FBP.
Umbilical arterial blood flow
Middle cerebral artery
Aboubakr Elnashar

29. 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
Aboubakr Elnashar

30. Doppler indices
Aboubakr Elnashar

31. •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.
Aboubakr Elnashar

32. •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.
Aboubakr Elnashar

33. Normal
Absent
Reversed
Aboubakr Elnashar

34. 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
Aboubakr Elnashar

35. 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

36. Aboubakr Elnashar

37. 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

38. 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}
Aboubakr Elnashar

39. 4. US
RFM persists despite a normal CTG
risk factors for FGR/stillbirth.
 AC
EFW {detect the SGA}
AFV
Doppler
Fetal morphology
Aboubakr Elnashar

40. 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

41. 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

42. Fetus:
•Safe
•Assess viability.
multiple gestations.
size, gestational age, and position of the fetus.
Aboubakr Elnashar

43. 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

44.  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

45. Thanks
elnashar53@hotmail.com
Aboubakr Elnashar