1. NEW IN PIH

9. Placental Circulation

12. Monitoring of the Fetus

13. Doppler Parameters Umbilical Artery S/D > 3 Absent End Diastolic Velocity

14. MCA S/D > 4

16. The answer lies in the anatomy of placental villi

17. Placental Circulation

19. Placental circulation in case of normal spiral vessels

20. Increased resistance of the spiral arterioles

22. The circulation in placental lakes becomes sluggish

24. The Fetal vascular adjustments overcome this situation

27. Comparison of NST with the evaluation of centralisation of blood flow for prediction of neonatal compromise Journal of Ultrasound in Obstetrics and Gynaecology 1999;14; 38-41

28. Perinatal Morbidity Reactive NST + Normal Doppler 11.3% Reactive NST + Abnormal Doppler 37.5% Non reactive NST + Normal Doppler 52.4% Non reactive NST + Abnormal Doppler 60%

29. Odds ratio Non reactive NST Abnormal Doppler Significant neonatal complications 5.71 3.44 LSCS for fetal distress 4.73 2.84

30. International Society of Ultrasound in Obstetrics and Gynaecology Workshop on Second and Third Trimester Doppler 4-7 October,2001, Zagreb, Croatia

36. Why does the Doppler examination not have “cutting edge” And…..can we give it the edge ???

38. Placental Bed Umbilical Artery Umbilical Vein Lower Limbs Kidneys Descending Aorta Aorta Carotid Arteries DV Terminal IVC IVC RA LV

40. 1) Stage of Normoxemic centralisation

43. Cerebral circulation is maintained Placental Bed Umbilical Artery Umbilical Vein Lower Limbs Kidneys Descending Aorta Aorta Carotid Arteries DV Terminal IVC IVC RA LV

46. Umbilical Vein (LUV) Intra hepatic portion of UV Portal Sinus Right Portal vein Ductus Venosus IVC Left Portal vein Left Hepatic vein Right Hepatic vein Superior mesenteric vein & splenic vein Left Liver Lobe Right Liver Lobe

48. The Fetal vascular adjustments overcome this situation Faster fetal circulation turnover maintains the fetal vascular PO2 in the face of sluggish placental circulation

49. The fetal heart improves its inotropic force and helps to circulate the blood faster

54. Placental Bed Umbilical Artery Umbilical Vein Lower Limbs Kidneys Descending Aorta Aorta Carotid Arteries DV Terminal IVC IVC RA LV

56. (2)Stage of Hypoxemic centralisation

60. (3) Decompensation

63. What shifts the fetus from Stage of compensated hypoxia to Stage of decompensation

66. The answer lies in venous flow

71. Placental Bed Umbilical Artery Umbilical Vein Lower Limbs Kidneys Descending Aorta Aorta Carotid Arteries DV Terminal IVC IVC RA LV

73. 1) Stage of Normoxemic centralisation

78. Venturi Effect

81. Placental Bed Umbilical Artery Umbilical Vein Lower Limbs Kidneys Descending Aorta Aorta Carotid Arteries DV Terminal IVC IVC RA LV

86. (2)Stage of Hypoxemic centralisation

91. Fetal Demise…..

96. 1) Stage of Normoxemic centralisation Decision taken to conserve the pregnancy

100. 2) Stage of Hypoxemic centralisation Decision taken to deliver

104. Summary

111. Thank you