ECOGRAFIA DEL TERCER TRIMESTRE Presentación: situación actual de los conocimientos Alfredo Perales Marín Hospital U.P. La FE

 Introducción a los temas planteados en la mesa: Ecografía en el 3 er trimestre CIR vs PEG Ecografía en la sala de partos  Otras áreas de interés en el 3 er trimestre: Cardiopatías Medición del cervix Hidronefrosis

NICE New Routine Doppler ultrasound should not be used in low-risk pregnancies Suspected fetal malpresentation should be confirmed by an ultrasound assessment. The evidence does not support the routine use of ultrasound scanning after 24 weeks …therefore it should not be offered. NICE Antenatal care routine care for the healthy pregnant woman. Clinical Guideline. March 2008 COCHRANE Based on existing evidence, routine late pregnancy ultrasound in low-risk or unselected populations does not confer benefit on mother or baby. It may be associated with a small increase in caesarean section rates Bricker L, Neilson JP, Dowswell T. Routine ultrasound in late pregnancy (after 24 weeks’ gestation). Cochrane Database of Systematic Reviews 2009,.

American Institute of Ultrasound in Medicine. AIUM practice guideline for the performance of obstetric ultrasound examinations. J Ultrasound Med 2010; 29:157–166. AIUM Practice Guideline for the Performance of Obstetric Ultrasound Examinations Standard Second- or Third-Trimester Examination …includes an evaluation of fetal presentation, amniotic fluid volume, cardiac activity, placental position, fetal biometry, and fetal number, plus an anatomic survey. The maternal cervix and adnexa should be examined as clinically appropriate when technically feasible. Limited Examination A limited examination is performed when a specific question requires investigation. …..to confirm fetal heart activity in a bleeding patient or to verify fetal presentation in a laboring patient. Specialized Examinations A detailed anatomic examination is performed when an anomaly is suspected on the basis of history, biochemical abnormalities, or the results of either the limited or standard scan. Other specialized examinations might include fetal Doppler sonography, biophysical profile, a fetal echocardiogram, or additional biometric measurements. This guideline was developed by the American Institute of Ultrasound in Medicine (AIUM) in collaboration with the American College of Radiology (ACR) and the American College of Obstetricians and Gynecologists (ACOG),

Romosan G, Henriksson E, Rylander A. Valentin L.Diagnostic performance of routine ultrasound screening for fetal abnormalities in an unselected Swedish population in 2000–2005Ultrasound Obstet Gynecol 2009; 34: 526–533 Routine ultrasound screening for fetal abnormalities at 18 and 32 More accurate control of fetal morphology and for a % increase in diagnostic sensibility of 2 nd trimester ultrasounds. Verrotti C, Caforio E, Gramellini D, Nardelli GB. Ultrasound screening in second and third trimester of pregnancy: an update ACTA BIOMED 2007; 78: >1%

Existing data do not provide conclusive evidence that the use of routine umbilical artery Doppler ultrasound, or combination of umbilical and uterine artery Doppler ultrasound in low-risk or unselected populations benefits either mother or baby. At present, Doppler ultrasound examination should be reserved for use in high-risk pregnancies Doppler (AU, AUt, ACM) - Alfirevic Z, Stampalija T, Gyte GML. Fetal and umbilical Doppler ultrasound in normal pregnancy. Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.: CD DOI: / CD pub3. - Alfirevic Z, Stampalija T, Gyte GML. Ecografía Doppler umbilical y fetal en embarazos de alto riesgo (Revision Cochrane traducida). En: Biblioteca Cochrane Plus 2010 Número 1. Oxford: Update Software Ltd. Disponible en:

Screening and triage of IUGR Imdad A, Yakoob MI, Siddiqui S, Bhutta ZA. Screening and triage of intrauterine growth restriction (IUGR) in general population and high risk pregnancies: a systematic review with a focus on reduction of IUGR related stillbirths. BMC Public Health 2011, 11(Suppl 3):S1 Expert opinion suggests that detection and management of IUGR with the help of maternal BMI, symphysial-fundal height measurement and targeted ultrasound could be effective in reducing IUGR related stillbirths by 20%.

Diagnóstico diferencial de los fetos PEG SEGO. Crecimiento intrauterino restringido. 2008

Doppler assessment significantly decreases the likelihood of labor induction, cesarean delivery, and perinatal deaths. Antepartum surveillance with Doppler of the umbilical artery should be started when the fetus is viable and IUGR is suspected. Doppler studies of vessels other than the umbilical artery, as part of assessment of fetal well-being in pregnancies complicated by IUGR, should be reserved for research protocols. Society for Maternal-Fetal Medicine Publications Committee, Berkley E, Chauhan SP, Abuhamad A. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol Apr;206(4):300-8

Torkildsen EA, Salvesen KÅ, Eggebø TM. Prediction of delivery mode with transperineal ultrasound in women with prolonged first stage of labor. Ultrasound Obstet Gynecol Jun;37(6): Fetal head-perineum distance and angle of progression measured with 2D or 3D ultrasound can predict labor outcome, with similar predictive values for the two techniques. Molina FS, Nicolaides KH. Ultrasound in Labor and Delivery. Fetal Diagn Ther 2010;27:61–67 Angulo de progresión Distancia de Progresión Dirección de la cabeza Ecografía en trabajo de parto Bamberg C, Scheuermann S, Fotopoulou C, et al. Angle of progression measurements of fetal head at term: a systematic comparison between open magnetic resonance imaging and transperineal ultrasound. Am J Obstet Gynecol 2012;206:161.e1-5. The angle of progression measurements obtained by transperineal ultrasound and open MRI showed very good agreement.

ACOG Practice Bulletin No. 101: Ultrasonography in Pregnancy. Obstet Gynecol 2009; 113:451. Three-Dimensional Ultrasonography Despite these technical advantages, proof of a clinical advantage of three-dimensional ultrasonography in prenatal diagnosis in general is still lacking Until clinical evidence shows a clear advantage to conventional two-dimensional ultrasonography, three-dimensional ultrasonography is not considered a required modality at this time.

Bartha JL, Moya Hervías-Vivancos B. Three-dimensional power Doppler analysis of cerebral circulation in normal and growth-restricted fetuses. J Cerebral Blood Flow & Metabolism (2009) 29, 1609–1618 Angiografia 3d-Power Doppler All the fetal cerebral 3D vascular indices are increased in fetuses with FGR. In these fetuses, there were more cases suggesting hemodynamic redistribution than expected by conventional Doppler studies.

Angiografia 3d-Power Doppler Existe una correlación positiva entre VI-VFI y edad gestacional al parto, peso al nacimiento, Apgar y pHa.

3D/4D in the prenatal diagnosis of congenital heart defects. Cardiac examination from 4D-STIC volumes showed a high repeatability between and within observers in each trimester of pregnancy. Bennasar My cols.Intra- and interobserver repeatability of fetal cardiac examination using four-dimensional spatiotemporal image correlation in each trimester of pregnancy. Ultrasound Obstet Gynecol Mar;35(3): D-STIC echocardiography performed by experienced operators can be used in fetuses at risk for cardiac anomalies in order to reliably provide reassurance of normality or to accurately diagnose major structural heart defects. Bennasar y cols. Accuracy of four-dimensional spatiotemporal image correlation echocardiography in the prenatal diagnosis of congenital heart defects. Ultrasound Obstet Gynecol Oct;36(4): D fetal echocardiography with STIC may facilitate the examination of the fetal heart and could potentially increase the detection rate of CHDs. Espinoza J. Contemporary clinical applications of spatio-temporal image correlation in prenatal diagnosis. Curr Opin Obstet Gynecol Apr;23(2):94-102

….however, overall 3D/4D ultrasound modalities had added value in only about 6% of cases of fetal anatomical cardiovascular anomalies.. Yagel S y cols. Added value of three-/four-dimensional ultrasound in offline analysis and diagnosis of congenital heart diseaseUltrasound Obstet Gynecol 2011; 37: 432–437 3D/4D in the prenatal diagnosis of congenital heart defects. 181 diagnoses of CHD were made. In 12 of these, 3D/4D ultrasound added to the accuracy of our diagnosis… There were 12 missed diagnoses (12/193; 6.2%) at the time of scanning; these lesions were also not evident during review.

Ecografía y parto pretérmino

Screening to prevent spontaneous preterm birth: systematic reviews of accuracy and effectiveness literature with economic modelling. Health Technology Assessment NIHR HTA programme September 2009www.hta.ac.uk Honest H, Forbes CA, Durée KH, et al Screening to prevent spontaneous preterm birth: systematic reviews of accuracy and effectiveness literature with economic modelling. Health Technology Assessment NIHR HTA programme September Conclusions: …. Universal provision of high-quality ultrasound machines in labour wards is more strongly indicated for predicting spontaneous preterm birth among symptomatic women than direct management, although staffing issues and the feasibility and acceptability to mothers and health providers of such strategies need to be explored. …. Further research should include investigations of lowcost and effective tests and treatments …

¿Cribado universal longitud cervical? y.., Cervix límite ≥ 25 s Universal TVCL screening in midpregnancy thus appears to satisfy all the World Health Organization principles for screening Combs A. Editorial Vaginal progesterone for asymptomatic cervical shortening and the case for universal screening of cervical length Am J Obstet Gynecol February 2012 The issue of universal CL screening of singleton gestations without prior PTB for the prevention of PTB remains an object of debate. CL screening in singleton gestations without prior PTB cannot yet be universally mandated. Nonetheless, implementation of such a screening strategy can be viewed as reasonable, SMFM Publications Committee, with the assistance of Vincenzo Berghella. Progesterone and preterm birth prevention: translating clinical trials data into clinical practice. Am J Obstet Gynecol May 2012

Shipp TD, Nguyen HT, Bromley B, Lyons JG, Benacerraf BR. Importance of renal abnormalities first identified in the third trimester after normal findings on a detailed second-trimester structural fetal survey. J Ultrasound Med Nov;30(11): Renal abnormalities first identified in the 3 rd T after normal findings on a 2 nd T 4170 patients 3 rd T scans after normal 2 nd T 77 (1.8%) 3 rd T renal abnormality follow-up 49 of 77 (63.6%) 3 pelvic kidneys + 2 unilateral renal agenesis + 44 (89.8%) hydronephosis Obstruction at the ureteropelvic Junction 5 Not found or resolved spontaneously at follow- up postnatal sonography 14 of 44 children (31.8%) Reflux 9 of 44 (20.5%) (2 surgery) 21 of 44 (47.7%) (1 surgery) Persistent hydronephrosis 13 Obstruction at the ureterovesical junction 3

The anteroposterior diameter of the renal pelvis was the simplest and most sensitive technique for prenatal diagnosis of congenital hydronephrosis, allowing identification of 100% of cases Corteville JE, Gray DL, Crane JP. Congenital hydronephrosis: correlation of fetal ultrasonographic findings with infant outcome. Am J Obstet Gynecol. 1991;165: Congenital hydronephrosis: infant outcome s s Diametro Pélvis APHC(%) CPCR (%)HC(%) CPCR (%)HC(%) CPCR (%) < a a > HC Hidronefrosis congénita, CP/CR Cirugía postnatal y/o compromiso renal Fetal Hydroneprhosis.- Is the most common anomaly detected on antenatal ultrasound examination. Lee RS y cols Antenatal Hydronephrosis as a Predictor of Postnatal Outcome: A Meta- analysis Pediatrics 2006; 118: Radiographic criteria of the Society for Fetal Urology

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