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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5841_Библиотеки_им_академика_М_И_Перельмана
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Third Trimester 159
Fig. 5.27: Ductus venosus flow reflects acidosis.
Normal waveform with plenty of flow in diastole
Fig. 5.28: Abnormal waveform with a reduced
forward flow in diastole
160 Step by Step Ultrasound in Obstetrics
Fig. 5.29: Normal triphasic inferior vena cava flow
reflecting myocardial function
Fig. 5.30: Abnormal waveform with an increased
reversed flow in diastole
Third Trimester 161
4. The finding of a symmetrically small fetus with
absent end-diastolic frequencies in the umbilical
artery but with normal utero-placental waveforms
suggest the possibility of a primary fetal cause for
the growth retardation such as chromosomal
abnormality or a TORCH virus infection.
5
. Fetuses demonstrating absence of end-diastolic
frequencies but which are managed along standard
clinical lines have a 40% chance of dying and at
least a 25% morbidity rate from necrotizing
enterocolitis, hemorrhage or coagulation fracture
after birth. The time between loss of end-diastolic
frequencies and fetal death appears to differ for
each fetus, Following loss of end-diastolic
frequencies there are no other reliable changes in
the waveform that help in deciding when to deliver
the baby.
6. Reversed frequencies in end-diastolic are only
observed in a few fetuses prior to death. This finding
is a pre-terminal condition; few if any , fetuses will
service without some form of therapeutic
intervention.
7. Loss of end-diastolic frequencies precedes changes
in the cardiotocograph by some 7-42 days in fetuses
that have been shown to be small for gestational
age on real-time ultrasound. The occurrence of CTG
decelerations not related to contractions, together
with absent end-diastolic frequencies, carries an
extremely poor prognosis.
8. In case of IUGR Wladimiroff and colleagues (1986)
have described compensatory reduction in vascular
162 Step by Step Ultrasound in Obstetrics
resistance in fetal brain during fetal hypoxemia usually
called as ‘Brain sparing effect’ and is the earliest
Doppler based marker for IUGR compromised fetus.
9. Detection of elevated resistance to flow within fetal
descending aorta reflects the decreased vascular
resistance associated with high-risk pregnancy not
only within the placental vascular bed but also within
fetal abdominal viscera.
10. Increased resistance in fetal renal arteries with
growth retardation has been seen especially with
oligohydramnios.
11. Increased resistance in uterine artery as indicated
by an elevated index of resistance by persistence
of an early diastolic notch often precedes the onset
of growth retardation.
12. The details of normal and abnormal waveforms with
their representations and end points and
management protocols is discussed in detail in the
STEP BY STEP series on Ultrasound and Color
Doppler.
5.17 INDICATIONS OF DELIVERY
• Viable fetus AFI < 5
•
Absent end-diastolic flow or reversed end-diastolic flow
in umbilical artery after 35 weeks
• Abnormal ductus venosus flow > 35 weeks
• Abnormal biophysical profile
5.18 MODE OF DELIVERY
V aginal or cesarian section depends on cervical score, pelvis
and/or any other obstetric indication for cesarian section.
Third Trimester 163
5.19 ABNORMAL THIRD TRIMESTER
1. Placental aging
2
. Separation
3. Oligo/polyhydramnios
4. Cord around neck
5. Thinned lower segment
6. Abnormal presentation
7. IUGR
8. Abnormal biophysical score
9. Abnormal color Doppler studies
5.20 CHECK LIST
1. Calculate gestation from L.M.P .(keep card with you)
2
. Fundal height clinical size
3. Presentation and lie
4. BPD
5. HC
6. AC
7. FL
8. Other limbs
9. High circumference
10. Charts and assess growth
5.21 DILEMMAS
1. Will the ultrasound tell us the exact date of delivery
2.
All parameters give different EDD
3. Has the internal os opened
4. There is a cord around the neck: is it dangerous
5. Has the baby come in the final position
6. How many movements are normal
7. First ultrasound: please check for anomalies
8. Can we wait more
Index
A
Abnormal fetus 48
Abnormal second trimester 136
Abnormal third trimester 163
Amniotic fluid assessment 145
B
Biophysical profile 150
C
Classification of early pregnancy
loss 24
Color Doppler
indications for 153
interpretation of waveforms 153
Color Doppler in second trimester
135
Cranium 56
D
3D and 4D scan 135
E
Ectopic gestation 28
Extra-fetal evaluation 33, 119, 138
F
Fetal abdomen 93
Fetal biometry 119
Fetal evaluation 55, 138
Fetal growth 148
Fetal heart 93
Fetal orbits and face 57
Fetal skeleton 119
Fetal spine 78
Fetal thorax 78
Fetal wellbeing 149
First trimester embryonic/fetal
evaluation 15
abnormal intrauterine
pregnancy 23
complete abortion 33
incomplete abortion 33
molar change 39
extra fetal evaluation 33
impending early pregnancy
failure 23
normal parameter 23
I
Indications of delivery 162
IUGR/FGR 148
M
Machine 3
Malformations 56
Molar change 39
N
Nuchal skin 56
O
Oligohydramnios 147
166 Step by Step Ultrasound in Obstetrics
P
Placental check list 145
Polyhydramnios 147
Practice of ultrasound 8
mandatory proposed
certification 12
prerequisite criteria 11
theoretical aspects 8
training parameters 9
training schedule 10
R
Relevant history 1
Reporting 4
S
Sono-embryology chart 41
T
Transducers 3
Transvaginal decision 52
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