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NEW  IN PIH
DR SAMEER DIKSHIT MD.DGO.FCPS.FICOG ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pathophysiology of PIH ,[object Object],[object Object]
 
 
 
Placental Circulation ,[object Object],[object Object]
Placental Circulation
Application of Doppler in PIH ,[object Object],[object Object]
Vessels studied ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Monitoring of the Fetus
Doppler Parameters Umbilical Artery  S/D > 3 Absent End Diastolic Velocity
MCA S/D > 4
Why should increased spiral arteriole resistance lead to increased UA resistance??? ,[object Object],[object Object],[object Object]
The answer lies in the anatomy of placental villi
Placental Circulation
[object Object],[object Object]
Placental circulation in case of normal spiral vessels
Increased resistance of the spiral arterioles
Effect of stenosis of spiral arterioles ,[object Object],[object Object],Increased Velocity Turbulent flow and dampened velocity
The circulation in placental lakes becomes sluggish
This affects the gas exchange at the level of tertiary Villus ,[object Object],[object Object]
The Fetal vascular adjustments overcome this situation
Decision to deliver...... ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Umbilical Artery Doppler Indices in Small for Gestational age fetuses J Ultrasound Med 2009 ,[object Object]
Comparison of NST with the evaluation of centralisation of blood flow for prediction of neonatal compromise Journal of Ultrasound in Obstetrics and Gynaecology 1999;14; 38-41
Perinatal Morbidity Reactive NST + Normal Doppler 11.3% Reactive NST + Abnormal Doppler 37.5% Non reactive NST + Normal Doppler 52.4% Non reactive NST + Abnormal Doppler 60%
Odds ratio Non reactive NST Abnormal Doppler Significant neonatal complications 5.71 3.44 LSCS for fetal distress 4.73 2.84
International Society of Ultrasound in Obstetrics and Gynaecology Workshop on Second and Third Trimester Doppler 4-7 October,2001, Zagreb, Croatia
[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
Use of Doppler for “point of action” ,[object Object],[object Object],[object Object]
 
IN PIH… ,[object Object],[object Object],[object Object],[object Object]
Why does the Doppler examination not have “cutting edge” And…..can we give it the edge ???
 
Placental Bed Umbilical Artery Umbilical Vein Lower Limbs Kidneys Descending Aorta Aorta Carotid Arteries DV Terminal IVC IVC RA LV
Effect of PIH on fetus- Fetal centralisation ,[object Object],[object Object],[object Object]
1) Stage of Normoxemic centralisation
The trans- villus gas exchange is affected ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
Cerebral circulation is maintained Placental Bed Umbilical Artery Umbilical Vein Lower Limbs Kidneys Descending Aorta Aorta Carotid Arteries DV Terminal IVC IVC RA LV
[object Object]
[object Object],Fetal Liver also chips in….
Umbilical Vein (LUV) Intra hepatic portion of UV Portal  Sinus Right Portal vein Ductus Venosus IVC Left Portal vein Left Hepatic vein Right  Hepatic vein Superior mesenteric vein & splenic vein Left Liver Lobe Right Liver Lobe
[object Object],[object Object],[object Object]
The Fetal vascular adjustments overcome this situation Faster fetal circulation turnover maintains the fetal vascular PO2 in the face of sluggish placental circulation
The fetal heart improves its inotropic force and helps to circulate the blood faster
[object Object]
 
[object Object]
[object Object]
Placental Bed Umbilical Artery Umbilical Vein Lower Limbs Kidneys Descending Aorta Aorta Carotid Arteries DV Terminal IVC IVC RA LV
[object Object],[object Object]
(2)Stage of Hypoxemic centralisation
[object Object],[object Object],[object Object]
[object Object],[object Object]
Most of the clinical tests pick up at this point ,[object Object],[object Object],[object Object],[object Object],[object Object]
(3) Decompensation
[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
What shifts the fetus from Stage of compensated hypoxia to Stage of decompensation
Is it because of worsening of utero-placental resistance?? ,[object Object],[object Object]
Is it because of increasing blood flow in the cerebral circulation?? ,[object Object],[object Object],[object Object],[object Object]
The answer lies in venous flow
 
[object Object]
[object Object]
[object Object]
Placental Bed Umbilical Artery Umbilical Vein Lower Limbs Kidneys Descending Aorta Aorta Carotid Arteries DV Terminal IVC IVC RA LV
 
1) Stage of Normoxemic centralisation
[object Object],[object Object],[object Object]
What keeps the two flows separate in the terminal IVC?? ,[object Object],[object Object]
[object Object],[object Object]
 
Venturi Effect
 
 
Placental Bed Umbilical Artery Umbilical Vein Lower Limbs Kidneys Descending Aorta Aorta Carotid Arteries DV Terminal IVC IVC RA LV
 
[object Object],[object Object],[object Object]
[object Object],[object Object]
Mount Everest in Utero ,[object Object],[object Object],[object Object]
(2)Stage of Hypoxemic centralisation
[object Object],[object Object],[object Object]
 
[object Object],[object Object]
 
Fetal Demise…..
Date 3 rd  May,2010; GA 32 weeks ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Date 3 rd  May,2010; GA 32 weeks ,[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object]
Date 3 rd  May,2010; GA 32 weeks ,[object Object],[object Object]
1) Stage of Normoxemic centralisation Decision taken to conserve the pregnancy
Date 31 st  May,2010; GA 36 weeks ,[object Object],[object Object],[object Object],[object Object]
Date 31 st  May,2010; GA 36 weeks ,[object Object],[object Object]
Date 31 st  May,2010; GA 36 weeks ,[object Object],[object Object]
2) Stage of Hypoxemic centralisation Decision taken to deliver
Other things to consider ,[object Object],[object Object],[object Object]
[object Object],[object Object]
[object Object],[object Object],[object Object]
Summary
Uterine Artery Doppler ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
Doppler for assessing fetal health ,[object Object],[object Object],[object Object]
[object Object],[object Object]
[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
Thank you

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