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Prenatal Evaluation of High Risk Pregnancies following Invitro-Fertilization: “Reduce Mother and Fetus Mortality Rates!” “Reduce Mother and Fetus Mortality.

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Presentation on theme: "Prenatal Evaluation of High Risk Pregnancies following Invitro-Fertilization: “Reduce Mother and Fetus Mortality Rates!” “Reduce Mother and Fetus Mortality."— Presentation transcript:

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2 Prenatal Evaluation of High Risk Pregnancies following Invitro-Fertilization: “Reduce Mother and Fetus Mortality Rates!” “Reduce Mother and Fetus Mortality Rates!” Irani Sh. * ( B.Sc.&PHD), Javam M. (B.Sc), Ahmadi F. (MD) Department of Reproductive Imaging at Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran

3  What’s the issue ?  The use of assisted-reproduction technologies has increased over the past decade ! Pregnancies following IVF are associated with higher risk of obstetric morbidities and perinatal mortality and several studies have demonstrated that the rate of prenatal complications is significantly more frequent in IVF- conceived pregnancies compared to spontaneous pregnancies.

4 ResultsPopulationCountryAuthor (year) Ante-partum hemorrhage congenital anomalies hypertensive disorders of pregnancy (HTN) preterm rupture of membranes (PROM) cesarean section (CS) low birth weight (LBW) perinatal mortality (P.M) preterm delivery (PTD) gestational diabetes small for gestational age Metha analysis (20 Studies) UK Shilpi pandy 2012 Multiple pregnancy P.M PTD LBW CS placenta previa (P.P) congenital abnormalities Reduction Review articlecanada Vicoriam (2006) Overall failure of pregnancy: 21,7% Twins: (%17/1) Death after positive FHR : 12,2% Twins: 7,3% 1597 single 1200 Twin 397 belgiumPhilippe Tummers (2003) CS PTD Less average birth weight 283croatiaDu valtka (2005) Bleeding ovarian torsion preeclampsia placental abruption PROM P.P -sweden Bengt kallen ( ) Single : HTN / bleeding / maternal complication Twins : CS / bleeding / preterm labor / LBW Single : 322 Twin : 78 Germany Odsenkuhn.R ( )

5  Thus, a proper prenatal evaluation is required in this group to protect mother and fetus health!  Sonographic examination during pregnancy is a helping method to detect pregnancy complications and to organize a proper “prenatal care” for IVF- conceived women.  We provide a clinical instruction for sonographic assessment of pregnancies following IVF and management of patients based on reports:

6  1 st trimester :  Goals of first ultrasound scan of IVF-resulted pregnancies: To assure a normal “intrauterine” pregnancy! To assure a normal “intrauterine” pregnancy! To rule out emergency conditions that are a threat to mother’s health: To rule out emergency conditions that are a threat to mother’s health: * Ectopic or Heterotopic Pregnancy is shown to be 5-10 times more prevalent * Ectopic or Heterotopic Pregnancy is shown to be 5-10 times more prevalent than general population! than general population! * Molar pregnancy & threatened abortion are also more frequent in this group * Molar pregnancy & threatened abortion are also more frequent in this group To establish gestational age “accurately” and to confirm fetus viability To establish gestational age “accurately” and to confirm fetus viability

7 To determine the number of fetuses and chorionicity-amnionicity in multiple pregnancies based on: To determine the number of fetuses and chorionicity-amnionicity in multiple pregnancies based on: the number of gestational sacs, amnions, and yolk sacs the number of gestational sacs, amnions, and yolk sacs D-D twins (DZ) (DZ) M-D twins (MZ) (MZ) M-M twins (MZ) (MZ)

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9  1 st trimester complications: 1. Bleeding  with IUP: Failed pregnancy (missed AB FHR -) Failed pregnancy (missed AB FHR -) Hemorrhage Hemorrhage Partial mole (less common) Partial mole (less common) An embryonic An embryonic Heterotopic pregnancy (rare) Heterotopic pregnancy (rare) Interestitial / cervical EP (rare) Interestitial / cervical EP (rare) Twin demise Twin demise  without IUP: Complete Abortion Complete Abortion Very early pregnancy Very early pregnancy Retained product of P. Retained product of P. Tubal ectopic Tubal ectopic Complete hydatyform Mole (less common) Complete hydatyform Mole (less common) Abdominal ectopic (rare) Abdominal ectopic (rare)

10 2. Pain: Hemorrhagic cyst Hemorrhagic cyst Corpus Luteum cyst Corpus Luteum cyst EP EP OHSS OHSS Adnexal torsion Adnexal torsion Appendicitis (less common) Appendicitis (less common)

11 3. Discrepancy between GA and ET-date:  GS without fetal pole  Fetal pole without FHR  Fetal pole with FHR  Multiple fetuses blighted ovum or not ? blighted ovum or not ? (GS diameter 20mm?) (GS diameter 20mm?) monitor sonography recommended monitor sonography recommended (based on previous exams) (based on previous exams) follow-up within weeks follow-up within weeks follow-up studies based on chorionicity follow-up studies based on chorionicity

12  1 st trimester Anomaly Screening Some embriologists believe that the risk of fetal anomalies in IVF-resulted embryos is a bit higher! Some embriologists believe that the risk of fetal anomalies in IVF-resulted embryos is a bit higher! Thus, a careful examination needs to be done for anomaly screening in this group. Thus, a careful examination needs to be done for anomaly screening in this group. First anomaly scan contains “Nuchal Translucency” measurement and look for structural abnormalities within 11 th -14 th weeks. First anomaly scan contains “Nuchal Translucency” measurement and look for structural abnormalities within 11 th -14 th weeks. Further investigations are recommended in case of increased risk. Further investigations are recommended in case of increased risk.

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14  2 nd & 3 rd trimesters : Second and third trimester have are vital periods of fetal growth. Second and third trimester have are vital periods of fetal growth. There are several complications which have adverse affects on this event. There are several complications which have adverse affects on this event. Sonography is helpful for early detection of risks for most of these complications such as vaginal bleeding, IUGR, preterm birth, etc. Sonography is helpful for early detection of risks for most of these complications such as vaginal bleeding, IUGR, preterm birth, etc.

15 1. Cervical Insufficiency : A prevalent cause of preterm birth A prevalent cause of preterm birth among these women among these women Early diagnosis & decision for cerclage Early diagnosis & decision for cerclage placement can reduce PTB rate. placement can reduce PTB rate. Screening method: Screening method: - Serial cervical length measurement by means of TAS or TVS (preferred) - Serial cervical length measurement by means of TAS or TVS (preferred) - At least twice during 2 nd trimester (before 20 th week) - At least twice during 2 nd trimester (before 20 th week)

16 2. Bleeding:  Common reasons: Placenta previa Placenta previa Marginal sinus previa Marginal sinus previa Placenta accreta spectrum Placenta accreta spectrum  Less common: Succenturiate lobe Succenturiate lobe Placenta accreta Placenta accreta Placenta abruption Placenta abruption Cesarean section rupture Cesarean section rupture Marginal previa

17 3. PROM & oligohydroamnios: Maximum Vertical pocket<2cm, AFI < 5cm Maximum Vertical pocket<2cm, AFI < 5cm Early oligohydroamnios: <25 week Early oligohydroamnios: <25 week Prolonged oligohydroamnios : >14 days Prolonged oligohydroamnios : >14 days D.D: PROM / IUGR /Renal agenesis /bladder outlet obstruction / TTTS in multiples D.D: PROM / IUGR /Renal agenesis /bladder outlet obstruction / TTTS in multiples Serial monitoring sonographies are essential Serial monitoring sonographies are essential

18 4. Growth Restriction:  Fetal weight < %10 percentile  IUGR differential diagnosis approach: Rule out fetal anomaly as cause for IUGR Rule out fetal anomaly as cause for IUGR Amniocentesis if fetal anomaly suspected Amniocentesis if fetal anomaly suspected Consider maternal medical history Consider maternal medical history Assess amniotic fluid Assess amniotic fluid Assess fetal / placental circulation Assess fetal / placental circulation Differentiate between symmetric vs. asymmetric IUGR Differentiate between symmetric vs. asymmetric IUGR Doppler Examination Doppler Examination Biophysical profile (BPP) if needed Biophysical profile (BPP) if needed

19 5. Gestational Diabetes and Pre-eclampsia: - Consider fetal growth and probable discrepancy - Mention to placenta size and shape - Assess A.F.I - Use Color Doppler to check blood circulation if needed - BPP if prescribed

20 6. Multiple Gestations:

21  Discrepancy between multiples: “Consider Chorionicity!” “Consider Chorionicity!” Follow up sonography every 2 weeks Follow up sonography every 2 weeks

22  TTTS:

23  Recommendation for US exams:

24  Conclusion: Prenatal sonography is an accurate, non-invasive, and cost-effective tool that helps midwives and obstetricians to evaluate mother and fetus health and detection of pregnancy complications to give better prenatal care for pregnant women, especially for those who became pregnant after IVF treatment. Prenatal sonography is an accurate, non-invasive, and cost-effective tool that helps midwives and obstetricians to evaluate mother and fetus health and detection of pregnancy complications to give better prenatal care for pregnant women, especially for those who became pregnant after IVF treatment. A proper “prenatal care” can be organized based on sonography reports. A proper “prenatal care” can be organized based on sonography reports.

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