adenomyosis - pathology课件

UltrasoundinthemanagementofIUGR DrPhilippaRamsayMBBSFRANZCOGDDUCOGU POWCampusCentreRPAMedicalCentreSydneyAdventistHospitalStLeonards Intra uterinegrowthrestrictionvsSmallforgestationalage Lowbirthweight LBW 37completedweeksgestation Intra uterinegrowthrestrictionvsSmallforgestationalage Intra uterinegrowthrestrictionAfetuswithpathologicallyimpairedgrowthofvaryingdegreesSmallforgestationalageAfetuswhoisbelowthetenthcentileforgestationalageforweight length headcircumference Intra uterinegrowthrestrictionvsSmallforgestationalage Intra uterinegrowthrestrictionpathologicallyimpairedgrowthmaybe10thcentileSmallforgestationalagepathologicallyimpairedgrowthconstitutionallysmall PerinatalproblemsassociatedwithIUGR Fetaldistressduringlabour 3 5x MeconiumaspirationNeonatalacidosisPolycythemiaHypoglycemiaNecrotizingenterocolitisImpairedgrowth development IUGR Morbidity Mortality ManningFA1995 Thirdtrimesterfetaldeath Stillbirthcomplicates5 1000birthsItisoftenunexplained 12 50 IncirpiMetal Stillbirthevaluation whattestsareneeded AmJObstetGynecol1998 178 1121 1125 Causesoflatefetaldeath Cordandplacentalcomplications10 20 Maternalhypertensivedisease5 25 Maternalmedicalcomplications5 10 Congenitalmalformations5 10 Intrauterineinfections5 15 Erythroblastosis3 15 unexplained50 PitkinRMetal Fetaldeath diagnosisandmanagement AmJObstetGynecol1987 157 583 589 RiskofneonataldeathfromIUGR CausesofIUGR 1 MaternaldiseaseChronichypertensionRenaldiseaseCardiacdisease Maternal fetalMalnutritionDrugsAlcoholTobacco CausesofIUGR 2 PrimaryfetalCongenitalmalformationsChromosomalanomaliesInfectionCMV rubella toxo PlacentaldysfunctionPlacentalinsufficiencyInfarction separationMultiplebirths Riskgroups PoornutritionPre eclampsiaRenaldiseaseHeartdiseaseInfection MultiplegestationsGeneticabnormalitieslowSEstatuspoormaternalweightgain REF GalbraithRSetal Theclinicalpredictionofintrauterinegrowthrestriction AmJObstetGynecol1979 133 281 Riskgroups 66 ofIUGRinfantsareassociatedwiththeseriskfactorsPerinatalmortalityishigheramongmembersofthesegroupsREF GalbraithRSetal Theclinicalpredictionofintrauterinegrowthrestriction AmJObstetGynecol1979 133 281 DetectingtheIUGRfetus a TestsoffetalsizeMother sweightMother sfundalheightFetalbiometryonultrasound Fundalheight SerialmeasurementsoffundalheightplateauMeasurements 2cmin4weeksDetects64 ofIUGRfetusesREF DaikokuNHetal Patternsofintrauterinegrowthretardation ObstetGynecol1979 54 211 Ultrasoundinthethirdtrimester Fetalnumber lie morphology biometry well beingLiquorvolumePlacentalpositionCervicallengthUterinefibroids scars Sonographicevaluation FetalbiometryBi parietaldiameterHeadcircumferenceAbdominalcircumferenceFemurlengthEstimatedfetalweight Calculationofestimatedfetalweight Hadlockformula Log10weight 1 326 0 00326ACxFL 0 0107HC 0 0438AC 0 158FLforbabies 1500g 2SD 14 8 forbabies 1500g 2SD 19 4 Ref HadlockFP HarristRB SharmanRSetal Estimationoffetalweightwiththeuseofhead bodyandfemurmeasurements aprospectivestudy AmJObstetGynecol1985 151 333 Sonographicevaluation PlacentalmorphologyGrannumscoringGrade1 111NotaspecificsignofIUGR DetectingtheIUGRfetus b Testsoffetalwell beingMaternalkickchartFlowstudiesBiophysicalprofileCardiotocography BloodflowstudiesinIUGR a Reducedfeto placentalperfusionReducedorabsentend diastolicflowintheumbilicalarteryb Redistributionofbloodflowtothebrain adrenal coronaryarteriesc AlteredbloodflowtotheuterusifPIH Bloodflowstudysequence Umbilicalartery raisedPIUmbilicalartery absentdiastolicflowMiddlecerebral reducedresistanceUmbilicalartery reverseddiastolicflowDuctusvenosus reverseddiastolicflowUmbilicalvein pulsatileflow Bloodflowstudiesinplacentalinsufficiency a UteroplacentalEffectsonPIUterinearteryincreaseArcuatearteryincreaseb Feto placentalUmbilicalarteryincreaseUmbilicalvein Umbilicalarteryflow thePIfallsthroughoutgestationafter16 40thereisalwaysend diastolicflownonotching RedistributionDuringFetalHypoxemia Bloodflowstudiesinplacentalinsufficiency a FetalEffectsonPIMiddlecerebraldecreaseInternalcarotiddecreaseThoracicaortaincreaseAbdominalaortaincreaseRenalarteryincreaseDuctusarteriosus Cerebralvessels end diastolicfrequenciesarevirtuallyalwayspresentintheinternalcarotidandothercerebralarteriesthePIfallssteeplyafter32weeks suggestingcentralizationofflowoccursinnormalpregnancytowardterm UterinearteryflowinIUGR highimpedancepersistentdicroticnotch failureofmodificationofmuscularspiralarteriestoachievealow resistanceuteroplacentalcirculation Uterinearteryflow rapidfallinthePIbetweenthe13thand20thweeksofgestationthenmoregentlefalltotermnotchinearlydiastolewhichdisappearsbyweek24duetoinvasionofuteroplacentalvesselsbytrophoblast Sonographicevaluation AmnioticfluidassessmentAmnioticfluidindexnormalrange5 25cmmoderateoligomenorrhoea5 8cmDeepestpooldepth 1cmor 2cm Sonographicevaluation BiophysicalprofileAmnioticfluidvolumeDeepestpooldepth 2cmFetalmovementsFetalbreathingmovementsFetaltoneCardiotocography ClinicalassessmentofIUGR SearchforunderlyingconditionkaryotypeultrasoundsearchforstructuralabnormalitiesTORCHtitresrenalfunctiontests Prevention TreatmentofIUGR TreatmentofIUGR Treatmentofunderlyingconditionstopsmoking improvenutritionrestRemovebabyfromunfavourableenvironment timelydeliverybeforefetaldemiseordamage MonitoringofIUGR Maternalkick chartUltrasoundbiometry10 14daysbiophysicalprofiletwice wkDopplerstudies AFItwice wk Preventionofpre eclampsia IUGR Inpre eclampsia maladaptationofspiralarteries endomethelialinjury secondarythrombosis Preventionofpre eclampsia IUGR Low doseaspirincanrectifytheintravascularimbalancebetweenprostacyclin thromboxaneshiftthebalancetoinhibitionofTXAsynthesis improveutero placentalbloodflow Preventionofpre eclampsia IUGR thefuture Screeningforbilateralnotchingortheuterinearteriesat16or24weeksgestation Treatwithlow doseaspirin ManagementofIUGRPreterminfant ManagementofIUGRTerminfant ManagementofIUGRAbnormalflows Managementdilemma whentodeliver TooearlyRiskiatrogenicprematurityToolateRiskperinatalasphyxiaordeathJustright Managementdilemma whatistheappropriatetriggerfordelivery MaternalFetalUmbilicalarterywaveformsMiddlecerebralarterywaveformsDuctusvenosuswaveformsBiophysicalprofile GRITDesign RCTin69centersin13countries 587babiesstudied GA24 36wks Isimmediatedeliveryindicated Isdelaydeleterious OutcomePNMandmorbidity GRIT BJOG 2003 GRIT Morbidity Mortality Lancet 2004 GRIT PerinatalMortality Lancet 2004 TheFetalCirculation DuctusVenosusFlow Modulatedby DuctusVenosusdiameterPortalvenousresistanceIncreasedHct increasedDVshuntHumoralfactors PGsNOAdrenergicstimulus TheDuctusVenosus DuctusVenosusFlowWaveform Hecher Circulation 1995 Copyright 1995AmericanHeartAssociation Hecher K etal Circulation1995 91 129 138 Flowvelocitywaveformsoftheductusvenosuswithlowpulsatility top andhighpulsatility bottom whichiscausedbyadecreaseofearlydiastolicforwardflow D andinparticularbyverylowvelocitiesduringatrialcontraction PathologicVenousDoppler LatesignofCVdecompensationReflectsdecreasedabilitytohandlevenousreturnIncreaseinRAPcausesa waveAccentuatedA wavemaybe TransmittedtoDVTransmittedtoUVPrecedesFHRdecels fetaldeathPresentin79 211 37 ofpretermIUGRHighlypredictiveofpH 7 2 LR 4 2 Baschat O G 2007 SurvivalinPretermIUGR Normalvs AbnormalDVDoppler BaschatO G 2007 DVDoppler PredictionofAdverseNeonatalOutcome Bilardo UltrO G 2004 DeliveryTriggerinIUGR Baschat UltrO G 2001 ShouldAbnormalDVTriggerDelivery Doespresagesfetaldeterioration YesDoesitleadtimevs BPPtesting By3daysDoesthisimproveperinataloutcome NodatafromR