The Role of ultrasound in Maternal Mortality Ashraf sadat Jamal Professor of OB/GYN Perinatologist Tehran University of Medical Sciences

Definition Any death occuring anytime during pregnancy and up to 40 days postpartum

Maternal Mortality A Global Crisis Estimated at 529000/ year in the world 99% of maternal Mortality occur in the developing countries Over 80% could be prevented with timely intervention The majority of them can be predicted

MM Rate/country (Lancet 2007) Sweden 3/100,000 USA 11/100,000 India 450 /100,000 Haiti 670 /100,000 Afghanistan 1800 /100,000

Primary Causes WHO (2005) Hemorrhage 25% Infection 15% Eclampsia 12% Unsafe abortions 13% Obstructed Labor 8% Indirect causes 20%

USA Pulmonary emboli (thrombotic, amniotic) 20% Hemorrhage 12.5% Hypertensive disorders 12.3% Cardiomyopathy 11.5% Infection 10.7% CVA 6.3%

Pregnancy Related Deaths Preventable causes: 1- hemorrhage 2- infection 3- medical chronic diseases in pregnancy Unpreventable: rapid course, lack of uniformly effective th 1- amniotic fluid embolus 2- microangiopathic hemolytic syndrome 3- cerebrovascular accident

Maternal mortality committee lack of preconception care (medical dis) Patient action (poor prenatal care) System factors (health care system) Quality of care (hemorrhage): inadequate collaboration, lack of guidelines, inadequate training

Average interval to maternal mortality Untreated OB condition time in hospital Ruptured Uterus 24 h Antepartum hemorrhage 12 h Postpartum hemorrhage 2 h

Maternal Morbidity Over 300 million women in developing world suffer from short, long term illness related to pregnancy 100,000 new cases of fistula develop each year in Africa Most are pushed out of society About 90% contemplate suicide

Pregnancy care in developing countries Antenatal care is the most important service Antenatal care  a platform to promote health and ensure safe delivery Risk Assessment: History Clinical findings Ultrasound At least 15 visits Ultrasound? 15 U/S

Prenat Diagn 2011; 31: 3–6. EDITORIAL A model for a new pyramid of prenatal care based on the 11 to 13 weeks’ assessment Kypros H. Nicolaides

OB Hemorrhage Ectopic pregnancy Abortions Placental localization, abnormalities: Pl. Previa Placenta Accreta Placenta Abruption Retained placenta postpartum

Placenta Accreta Morbidly adherent placenta (MAP) Depth of invasion is of clinical importance Amount of placental tissue involved in attachment: total pl. accreta partial pl. accreta focal pl. accreta 79 % accreta 14 % increta 7 % percreta

Substantial rise of C/S Cause Substantial rise of C/S 1/2500 1980 1/535 2002 1/210 2006

Risk Factors Cesarean deliveries 40% accreta Placenta previa Advancing maternal age Multiparity Uterine leiomyomas Uterine anomalies Asherman syndrome Hypertensive dis. in pregnancy Smoking Endometrial ablation, irradiation

Pathogenesis Scarring process after surgery Abnormal vascularization Secondary localized hypoxia Defective decidualization Excessive trophoblastic invasion

Clinical presentation Asymptomatic Vaginal bleeding, cramping Hematuria Catastrophic presentation: 1- acute abdominal pain 2-hypotension 3-hypovolemic shock (from uterine rupture secondary to placenta percreta) This scenario 1st trimester to full term

Sonographic Findings In the first trimester : Low implantation of GS risk of MAP Multiple irregular vascular spaces in placenta C/S scar pregnancy

CSP sonographic features Empty uterine cavity, empty cervical canal Placenta or GS embedded in/on scar Triangular GS filling niche of the scar<8w Round or oval GS >8w Absent or thin myometrial layer with bladder Prominent, vascular pattern with color Doppler

Low GS

C/S scar Pregnancy

Patient counseling Terminate the pregnancy Continue the pregnancy with accepting the risk of complications: massive hemorrhage shock, uterine rupture with fetal loss hysterectomy, massive transfusion

Conclusion Previous C/S in early first trimester pregnancy have TVS for location of GS Anteriorly attached low-lying gestation considered CSP until proved otherwise Before first trimester termination, think about CSP

Placenta accreta in second and third trimester Multiple vascular lacunae 80 %- 90% sen Loss of normal hypoechoic retroplacental zone (angle dependent, can be absent in normal ant PL). Uterine serosa-bladder interface disruption Thickening, irregularity, increased vascularity on color Doppler imaging

Second and third trimester Extension of the villi into myometrium, serosa or bladder Retroplacental myometrial thickness <1mm Turbulent blood flow on Doppler sonography Multiple vascular lacunae or Swiss cheese appearance is most important finding in third trimester, when >4 = 100 % DR

Multiple vascular lacunae 18 weeks

Diagnosis 2-D ultrasound, sensitivity 90% (primary screening) History of C/S and placenta previa MRI 94% sensitivity, less accuracy < 24 week Depth of invasion with MRI 3-D color Doppler imaging high sensitivity Placental vessel architecture with 3-D power Doppler differentiate accreta from percreta

Prenatal care MAP Correction of Iron deficiency Antenatal corticosteroids between 23-34w Anti-D immune globulin in Rh-negative Avoidance of pelvic exam, rigorous activity Consideration of bed rest and/or hospitalization in the third trimester Schedule elective surgery between 34-36

Management MAP Multidisciplinary team with preoperative plan Tertiary care center Blood bank Operating room capability of fluoroscopy for radiology intervention ICU for postoperative care

Prenatal identification of invasive placentation using ultrasound: systematic review and meta-analysis D’Antonio et al., UOG 2013 Discussion points Is there a need to set up a multi-disciplinary clinic for the prenatal diagnosis and subsequent management of invasive placentation? If yes, should all women with an anterior low-lying placenta and previous history of Cesarean delivery or uterine surgery be referred to this clinic? How should we develop the objective criteria for the diagnosis of invasive placentation (i.e. color Doppler abnormalities), thus allowing objective structured training of fetal medicine subspecialists? 46