2Irani Sh.* (B.Sc.&PHD), Javam M. (B.Sc), Ahmadi F. (MD) Prenatal Evaluation of High Risk Pregnancies following Invitro-Fertilization:“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
3What’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.
5Thus, 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:
61st trimester :Goals of first ultrasound scan of IVF-resulted pregnancies:To assure a normal “intrauterine” pregnancy!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 prevalentthan general population!* Molar pregnancy & threatened abortion are also more frequent in this groupTo establish gestational age “accurately” and to confirm fetus viability
7the number of gestational sacs, amnions, and yolk sacs To determine the number of fetuses and chorionicity-amnionicity in multiple pregnancies based on:the number of gestational sacs, amnions, and yolk sacsD-D twins(DZ)M-D twins(MZ)M-M twins(MZ)
91st trimester complications: 1. Bleedingwith IUP:without IUP:Failed pregnancy (missed AB FHR -)HemorrhagePartial mole (less common)An embryonicHeterotopic pregnancy (rare)Interestitial / cervical EP (rare)Twin demiseComplete AbortionVery early pregnancyRetained product of P.Tubal ectopicComplete hydatyform Mole (less common)Abdominal ectopic (rare)
102. Pain: Hemorrhagic cyst Corpus Luteum cyst EP OHSS Adnexal torsion Appendicitis (less common)
113. Discrepancy between GA and ET-date: GS without fetal poleFetal pole without FHRFetal pole with FHRMultiple fetusesblighted ovum or not ?(GS diameter <20mm or >20mm?)monitor sonography recommended(based on previous exams)follow-up within weeks 11-14follow-up studies based on chorionicity
121st trimester Anomaly Screening 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.First anomaly scan contains “Nuchal Translucency” measurement and look for structural abnormalities within 11th-14th weeks.Further investigations are recommended in case of increased risk.
142nd & 3rd trimesters :Second and third trimester have are vital periods of fetal growth.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.
151. Cervical Insufficiency: A prevalent cause of preterm birthamong these womenEarly diagnosis & decision for cerclageplacement can reduce PTB rate.Screening method:- Serial cervical length measurement by means of TAS or TVS (preferred)- At least twice during 2nd trimester (before 20th week)
184. Growth Restriction: Fetal weight < %10 percentile IUGR differential diagnosis approach:Rule out fetal anomaly as cause for IUGRAmniocentesis if fetal anomaly suspectedConsider maternal medical historyAssess amniotic fluidAssess fetal / placental circulationDifferentiate between symmetric vs. asymmetric IUGRDoppler ExaminationBiophysical profile (BPP) if needed
195. 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
23Recommendation for US exams: 1. Early first trimester ( 6 𝑡ℎ to 8 𝑡ℎ week of gestation): To confirm intra uterine pregnancy (IUP) and to rule out ectopic pregnancy (EP), to ensure fetal heart activity, diagnosis of multiple pregnancy and estimation of gestational age.2. Late first trimester ( 11 𝑡ℎ to 14 𝑡ℎ week): To evaluation fetal growth, to assess fetal structural malformations (like Anencephaly, etc.) and detection of anomaly markers (measuring nuchal translucency) to find out high risk patients.3. Second trimester ( 18 𝑡ℎ to 22 𝑡ℎ week): Evaluation of fetal growth, to assess fetal structural malformations and anomaly markers (measuring nuchal fold & nasal bone) to detect high risk patients, diagnosis of cervical insufficiency and need to “cerclage placement”.4. Third trimester ( 28 𝑡ℎ to 32 𝑡ℎ week): Evaluation of fetal growth and weight, measuring amniotic fluid index (AFI), assessment of fetal structural abnormalities (such as hydrocephaly, etc.) and Biophysical Profile (if needed).
24Conclusion: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.