Prof. Aboubakr Elnashar Benha University Hospital, Egypt Aboubakr Elnashar

1.2nd trimester miscarriage 2.Ante partum hemorrhage 3.PTL 4.PROM 5.Decreased or absent fetal movements 6.Trauma Aboubakr Elnashar

Causes: 1.Cervical incompetence 2.Fibroid 3.Uterine malformation Aboubakr Elnashar

Cervical incompetence TVS: only technique used reliably to measure the cervical length [TAS: full bladder to visualize the cervix elongates the cervix TVS: an empty bladder and no distortion] Aboubakr Elnashar

1. Cervix length < 25 mm 2. Funneling of int os: -T, Y, V, U (correlation between the length of the cervix and the changes in the internal os). (Trust Your Vaginal Ultrasound) -in response to pressure on the uterine fundus -Serial evaluation/2 w 4. Protrusion of the membranes. 5. Fetal parts in the cervix or vagina Aboubakr Elnashar

Aboubakr Elnashar

History-indicated cerclage (RCOG, 2011) Indications Three or more previous PTL and/or 2nd T miscarriage. Not an indication: two or fewer PTL and/or 2nd T miscarriage. Aboubakr Elnashar

Ultrasound-indicated cerclage (RCOG, 2011) Indication: History of one or more spontaneous 2nd T miscarriage or PTL TVS: cervix is 25 mm or less Not indicated No history of spontaneous 2nd T miscarriage or PTL Funnelling of the cervix Aboubakr Elnashar

Cervical cerclage is not recommended (RCOG, 2011) 1. Multiple pregnancies {detrimental increase in 2nd T miscarriage or PTL}. 2. Uterine anomalies 3. Cervical surgery cone biopsy LLETZ destructive procedures (laser ablation or diathermy) multiple dilatation and evacuation. Aboubakr Elnashar

Define: Bleeding from genital tract after fetal viability Causes: 1.Placenta praevia: 2.Abruptio placentae 3.Vasa praevia 4.Local causes Aboubakr Elnashar

IV. Complete Centralis III. Complete partial II. Marginalis I. Lateralis Major Minor TVS: Distance between lower edge of the placenta & internal os 2.5 cm Risk PTD with cervix length Accepted safe length is 3 cm Cx length > 3cm: No risk of PTL Cx length 2 accelrations/40 min < F. movements >3/30 min < F.breathing. movements (FBM) 30 sec sustained FBM/30 min < F.tone closed fist or flexion to extension movement Neither Am Fluid Volume >1 cm pocket < 2. BPP Aboubakr Elnashar

3. Doppler more useful test of fetal wellbeing than CTG or FBP. Umbilical arterial blood flow Middle cerebral artery Aboubakr Elnashar

a. Umbilical artery Doppler Idea: Umbilical Arterial Flow is normally low resistance. In hypoxic states: relative placental hypoxia: reactive VC of umbilical artery tributaries: higher resistance: relative decrease in diastolic flow Aboubakr Elnashar

Doppler indices Aboubakr Elnashar

Resistance index: Best ability to predict abnormal outcomes (RCOG,2002 Evidence level II) Normal pregnancy: {progressive increase in end-diastolic velocity {growth& dilatation of the umbilical circulation}: Resistance index falls. Fetal growth restriction and/or PET: > 0.72 is outside the normal limits from 26 w. Aboubakr Elnashar

S/D should be 3. Diastolic flow is absent or reversed: Fetal distress is almost certain: Immediate BPP or NST or delivery Middle cerebral artery peak systolic velocity: most significant breakthrough in the surveillance of the potentially anemic fetus Aboubakr Elnashar

Thanks elnashar53@hotmail.com Aboubakr Elnashar