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

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

3. Maternal Mortality A Global Crisis
Estimated at / 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

4. MM Rate/country (Lancet 2007)
Sweden /100,000
USA /100,000
India /100,000
Haiti /100,000
Afghanistan /100,000

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

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

7. 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

8. 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

9. Average interval to maternal mortality
Untreated OB condition time in hospital
Ruptured Uterus h
Antepartum hemorrhage h
Postpartum hemorrhage h

10. 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

11. 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

12. 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

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

14. 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

15. Substantial rise of C/S
Cause
Substantial rise of C/S 1/ 1/ 1/

16. 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

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

18. 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

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

21. 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

22. Low GS

23. C/S scar Pregnancy

30. 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

31. 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

32. 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

33. 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

34. Multiple vascular lacunae 18 weeks

43. 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

44. 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

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

46. 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