INSUOG 2019

HAND BOOK OF INSUOG
Design & Printed by : Dinkar - 08057108836

INSUOG 2019
HAND BOOK OF INSUOG
3rd - 5th May
Radission Blu, Agra

About us White Journal
ISUOG is the leading international society of Journal membership benefits
professionals in ultrasound for obstetrics and
The Journal membership includes an online
gynecology. Beginning in 1991 with the first issue
subscription to the UOG Journal. You will also receive
UOG Journal and the first World Congress, ISUOG has
all other membership benefits, including discounts to
now grown to over 15,700 members in 140
ISUOG courses, high quality education and web
countries. Join our growing global community and
resources. This membership is £115.
gain access to a broad range of educational
UOG Journal online:resources for all training and professional levels.
Our Vision • Online subscription to Ultrasound in Obstetrics
& Gynecology (UOG), the leading peerISUOG’s long term vision is that every woman in the
reviewed journal in its field with an impact factorworld has access to ultrasound, that every scan
of 5.654. The journal includes monthlyprovider is competent and that the diagnosis of
systematic reviews, referee commentaries andobstetric and gynecologic conditions is effective so
expert perspectivesthat women’s health outcomes improve.
High quality education:Our Mission
Our mission is to improve women’s health through • Reduced fees to ISUOG’s intensive education
the provision, advancement and dissemination of the courses, International Symposia and World
highest quality education, standards and research Congress
information around ultrasound in obstetrics and
• ISUOG support for teaching programs
gynecology.
• Opportunities to participate in ISUOG OutreachOur Values
projects
In our work, research and teaching we will
Web resources :demonstrate excellence, integrity, respect,
inclusiveness and passion. • Top World Congress online presentations from
2014-2017 on our On Demand platform.How to Become Member
ISUOG2018 presentations will be available to allTo become an ISUOG member, first take a look at the
members in April.different membership levels (basic membership,
journal membership and print journal membership) • 250+ online lectures categorised into 35
to decide which membership level is best for you. learning modules
Then click on Join us at the top right corner of our
• Earn CME credit from anywhere in the world, via
website. You will be asked for your contact details
ISUOG's online CME platform
and payment information.
• VISUOG: a visual encyclopedia for ultrasound inOnce you have paid, you will receive a confirmation
obstetrics and gynecologyemail and will be asked to set your login password.
You will also be able to find your receipts and • Fetal biometry calculators
payments at anytime by logging into your ISUOG
• Regular e-newslettersaccount and going to My ISUOG.
ISUOG
CONTACT US
International Society of Ultrasound in Obstetrics and Gynecology (ISUOG)
122 Freston Road, London W10 6TR, UK
Tel: +44 (0) 20 7471 9955 / Fax: +44 (0) 20 7471 9959, Email: info@isuog.org
INSUOG OFFICE
Paras – Advanced Center for Fetal Medicine
2 B Virvijay Society, Opp. Sanghvi Hight School,Vijaynagar Road, Naranpura,
Ahmedabad 380013 | Gujarat , Email: insuog2019@gmail.com
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OFFICE BEARERS
DR PRASHANT ACHARYA
(INDIA)
PROF. C.M. (KATIA) BILARDO
(NETHERLANDS)
PROF. TOM BOURNE
(UK)
PROF. JOSH COPEL
(USA)
PROF. DANIELA FISCHEROVA
(CZECH REPUBLIC)
PROF. MAURICIO HERRERA
(COLOMBIA)
PROF. JON HYETT
(AUSTRALIA)
PROF. CHRISTOPH LEES
(UK)
PROF. GUSTAVO MALINGER
(ISRAEL)
DR ANDREW NGU
(AUSTRALIA)
PROF. DANIELA PRAYER
(AUSTRIA)
DR NICK RAINE-FENNING
(UK)
PROF. LAURENT SALOMON
(FRANCE)
DR ANTONIA TESTA
(ITALY)
PROF. DIRK TIMMERMAN
(BELGIUM)
PROF. BORIS TUTSCHEK
(SWITZERLAND)
PROF. GEORGE YEO
(SINGAPORE)

WELCOME TO INSUOG 2019
A few founder members of ISUOG got together in India to from
to bring the latest in Obs Gyn Ultrasound to India
INSUOG with the aim
Dr. Jaideep Malhotra
Organizing Chairman
Dr. Narandra Malhotra
Organizing Chairman
Every two years INSUOG organizes a 3 day Obs Gyn
Ultrasound event in India with top expert faculty from INSUOG &
ISUOG
Welcome all delegats to the city of love & Taj for an academic
feast on Obstetrical & Gynecological Ultrasound
Welcome to INSUOG 2019, Agra
Dr. Prashant Acharya Dr. Nitin Chaubal Dr. Anita Kaul Dr. Ashok Khurana
Dr. Geeta Kolar Dr. Chander Lulla Dr. Jaideep Malhotra Dr. Narendra Malhotra
Dr. Prathima Radhakrishnan Dr. B. S. Ramamurthy Dr. P. K. Shah Dr. S. Suresh
Dr. Suseela Vavilala
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CONFERENCE OF INSUOG
PAST CONFERENCE
DELHI 2012 MUMBAI 2014 HYDERABAD 2016
AGRA 2019
BANGLURU 2021
Paras – Advanced Center for Fetal Medicine
2 B Virvijay Society, Opp. Sanghvi Hight School,
Vijay Nagar Road, Naranpura, Ahmedabad 380013 (Gujarat )
Email: insuog2019@gmail.com
Face Boog : isuog2016; insuog2018
PRESENT CONFERENCE
FUTURE CONFERENCE
INSUOG OFFICE
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KNOW YOUR INSUOG 2019 FACULTY
Dr. Alfred-Z Abuhamed
U.S.A
Dr. Karina Krajden Haratz
ISRAEL
Prof. Basky Thilaganathan
U.K.
Prof. Dirk Timmerman
BELGIUM
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INDIAN FACULTY INSUOG 2019
Dr. Dr. Jaideep Malhotra Dr. Prashant Acharya
Dr. Ashok Khurana Dr. Narendra Malhotra Dr. Prathima Radhakrishnan
Dr. B S Ramamurthy Dr. Nitin Chaubal Dr. S Suresh
Dr. Chander Lulla Dr. P K Shah Dr. Suseela Vavilala
Dr. Geeta Kolar
Anita Kaul
INDIAN SENIOR EXPERTS
YOUNG FUTURE
Dr. Dr. Mala Sibal Dr. Ratna Puri
Dr. Bhupendra Ahuja Dr. Manjeet Mehta Dr. R N Goel
Dr. Chinmayee Ratha Dr. Meenu Agarwal Dr. TLN Praveen
Dr. Indrani Suresh Dr. Nidhi Gupta Dr. Vanaj Mathur
Dr. Jyoti Chaubal Dr. P K Srivastava Dr. Vivek Kashyap
Dr. Kuldeep Singh Dr. Raju Sahetya Dr. Anupam Gupta
Alka Saraswat
Dr. Aditi Shah Dr. Pooja Lodha Dr. Sudarshan Suresh
Dr. Akshatha Sharma Dr. Preeti Tomar Dr. Supriya Seshadri
Dr. Anand Abishek Dr. Rachita Ramamurthy Dr. Sushma Gupta
Dr. Anita Shettikari Dr. Rachna Gupta Dr. Veena Acharya
Dr. Arti Manoj Dr. Rajas Chaubal Dr. Selvapriya
Dr. Ashok Todani Dr. Rishabh Bora Dr. Bela Bhatt
Dr. Mohit Shah Dr. Neharika M. Bora
INSUOG MEMBERS
INTERNATIONAL EXPERTS
Prof. Basky Thilaganathan Prof. Kirk Timmerman Dr. Mohd Wahaaj
Dr. Karina Krajden Haratz Dr. Alfred-Z Abuhamed
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PROGRAMME INSUOG 2019
Day 1 Friday | 3 May 2019 HALL – A (Mansion-I)
DIL-SE- DIL TAK - THE FETAL HEART
09:00-11:00
Live Relay
Coordinator Scan Room : Rahul Gupta
Faculty: Ashok Khurana, Rishabh Bora
Hall Coordinators: Suseela Vavilala, Nitin Chaubal
Workshop - II - Fetal Heart (Wipro GE)
Live Relay
Coordinator Scan Room : Rishabh Bora
Faculty : Chander Lulla , S Suresh
Hall Coordinators: Alfred Abuhamad, Nitin Chaubal, Geeta Kolar
11:00-11:30 Tea/Coffee Break
SESSION I
Moderators : Prashant Acharya & Bela Bhatt
11:30-12:00 Fetal Cardiac Evaluation at 11-14 weeks Alfred Abuhamad
12:15-12:30 Fetal Heart - The "X&V" Signs for Screening Anitha Shettikeri
12:30-13:00 Live Session - Abnormal Fetal Cardiac Anatomy - Autopsy Specimens Prashant Acharya
13:00-14:00 Lunch
SESSION II
Moderators :Suseela Vavilala & TLN Praveen
14:00-14:20 II Trimester Cardiac Evaluation Guidelines Nitin Chaubal
14:20-14:50 Cardiac Septal Defects - Identifying And Filling The Gaps Alfred Abuhamad
14:50-15:05 The Three Vessel View Suseela Vavilala
SESSION III – FETAL ANOMALIES
Moderators : Nitin Chaubal & Poonam Goyal
15:05-15:25 The 2nd Trim Anomalies Scan - The ISUOG Approach Preeti Tomar
15:25-16:00 Diagnosing And Management of The Fetal Thoracic Anomalies Basky Thilaganathan
16:00-16:20 Fetal Hand Anomalies Geeta Kolar
16:20-16:50 Understanding Fetal Obstructive Uropathy S Suresh
16:50-17:15 Fetal Upper GI tract Abnormalities - Challenges in Diagnosis Aditi Shah
17:15-17:20 Audience Interaction
17:20-18:05 Fetal Anomalies - What Next - Case Based Discussions
17:20-17:35 Thoracic Anomalies Prognostication Kuldeep Singh
17:35-17:50 Facial Cleft Sudarshan Suresh
17:50-18:05 Echogenic Kidneys Rajas Chaubal
Tea/Coffee Break
19:00 - 21:00 Inauguration Ceremony
M/C: Selvapriya Sarvanan, Sushma Gupta, Anupam Gupta, Rishabh Bora
Product Launch by WIPRO GE
2100 hrs onwards Live Band followed by Gala Dinner
Bela Bhatt, Sushma Gupta, Rashmi Chahar, Preeti Pathak
Workshop - I - 11-14 Weeks Scan (Normal Anatomy) (Wipro GE)

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Friday | 3 May 2019 HALL – B (Grand Ball Room-I)
Friday | 3 May 2019 HALL – C (Grand Ball Room-I)
Session I
Moderators : Jaideep Malhotra & Mohd Wahaaj
09:00-09:20 Tips and Tricks in Pelvic Ultrasound Mohit Shah
09:20-09:40 MUSA Dirk Timmerman
09:40-10:00 Adenomyosis – Possible Ultrasound Findings Dirk Timmerman
10:00- 10:20 Fibroid – Strategies for Diagnosis and Management Dirk Timmerman
Session II
Moderators : Jaideep Malhotra & Mohd Wahaaj
11:00-11:15 IETA Dirk Timmerman
11:15 -11:45 Solving the Dilemma – Endometrial Polyp, Hyperplasia or Malignancy Mala Sibal
11:45-12:00 Asherman’s Syndrome PK Shah
12:00-12:30 Ultrasound Evaluation of the Cervix and Vagina – Can GSV Help ? Mala Sibal
12:30-13:00 Uterine Anomaly Diagnosis and Management - Simplified Jaideep Malhotra
13:20-14:00 Lunch
Session III
Moderators : PK Shah & Selvapriya
14:00 –14:30 Locating the Pregnancy – Spectrum of Ectopics Dirk Timmerman
14:30–15:00 Gestational Trophoblastic Disease Supriya Seshadri
15:00–15:20 Follicle Monitoring Anupam Gupta
15:20–15:50 Differential Diagnosis in Acute Pelvic Pain P K Srivastava
15:50–16:00 Audience Interaction
16:00-18:00 Workshop - III - Infertility, Gynaecology and Obstertic Scans
Live Relay
Coordinator Scan Room : Rahul Gupta, Sarita Dixit
Faculty: PK Shah, Jaideep Malhotra
Hall Coordinators: Mala Sibal, PK Srivastava
Session I
Moderators : Anita Kaul & Chinmayee Ratha
09:00-09:15 256 shades of grey : Physical Principles and Optimal Presetting of the Ultrasound B S Ramamurthy
Machine for the CNS Evaluation
09:15-09:45 ISUOG Guidelines for Basic and Extended Examination of the CNS ( video) Suseela Vavilala
09:45-10:15 Wringing blood from the stone : How to Maximize the Information About the Fetal
Brain Using Axial Views Only Karina Krajden Haratz
10:15-10:45 Neurosonoembryology and First Trimester Diagnosis of CNS Anomalies Sudarshan Suresh
10:45-11:00 Audience interaction
Session II
Moderators : Anita Kaul & Chinmayee Ratha
11:30-12:00 Developmental Sonoanatomy of the Fetal Brain in Early Second Trimester (up to 18 weeks) Karina Krajden Haratz
12:00-12:30 Developmental Sonoanatomy of the Fetal Brain after 20 Weeks Geeta Kolar
12:30-13:00 Developmental Sonoanatomy of the Calvaria and the Spine and Neural Tube Defects Ashok Khurana
13:15-14:15 Lunch

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Session III
Moderators : Nitin Chaubal & Rishabh Bora
14:15-15:00 Anomalies of Ventral Induction: Forebrain Cleavage, Septal Anomalies and Callosal Anomalies Karina Krajden Haratz
15:00-15:30 Fetal Ventriculomegaly: Differential Diagnosis, Work-up and Management Chander Lulla
15:30-16:00 Closed Spinal Dysraphism - Diagnosis & Counseling Sudarshan Suresh
16:00-16:30 Genetic Counseling for Fetal CNS Anomalies - A Rational Approach Manjeet Mehta
Podium Presenters (Mixed Bag)
Moderators : S Suresh, Geeta Kolar, Suseela Vavilala
16:45-17:00 MRI Correlation of Fetal Anomalies Rishabh Bora
17:00-17:15 DV Agenesis Rajas Chaubal
17:15-17:30 DV Tiny & Tantalising Ashok Todani
17:30 -17:45 Understanding Arthrogryposis Rachita Ramamurthy
17:45- 18:00 Audience Interaction
18:00 Tea/Coffee Break
09:30-17:00 Simulator Room
Session I
Moderators : Prathima Radhakrishnan & Anitha Shettikeri
09:00-09:30 Hypoplastic Left Heart Syndrome: Approach to Diagnosis and Management Alfred Abuhamad
09:30-10:00 Mal-Aligned Septum BS Ramamurty
10:00-10:30 The Many Faces of Tetralogy of Fallot Alfred Abuhamad
10:30-11:00 Genetic Association And Counseling With Cardiac Defects Prathima Radhakrishnan
11:00-11:15 Fetal HQ ( New Technology) Christin Gabner
Session II
Moderators : Jyoti Chaubal & Anand Abhishek
11:45-12:15 Transposition of Great Arteries: Elusive Diagnosis with Significant Implications Alfred Abuhamad
12:15-12:45 Approach to Cardiac Chamber Size Discrepancy Jyoti Chaubal
12:45-13:15 Approach to Diagnosis of Systemic Venous Malformations Alfred Abuhamad
13:15-13:45 Understanding Heterotaxy Prashant Acharya
14:00-14:50 Lunch
Session III PLACENTA DOPPLER & GROWTH
Moderators : Chander Lulla & Mohit Shah
14:50-15:15 How I Define F.G.R. Basky Thilaganathan
15:15-15:40 FGR - Fetal Cardiac Function Chander Lulla
15:40-16:05 Maternal Cardiac Function, Preeclampsia And Placental Insufficiency Basky Thilaganathan
16:05-16:30 Fetal Growth in Diabetic pregnancies S Suresh
16:30-16:50 Ugly Placentas Basky Thilaganathan
16:50-17:20 Fetal Growth in Multiple Gestation Basky Thilaganathan
21:00 Fellowship, Karaoke, Dances followed by DJ and Dinner
M/C - Selvapriya Sarvanan, Bela Bhatt, Sushma Gupta, Rashmi Chahar, Preeti Pathak, Pooja Lodha
Hall D (Grand Ball Room-III)
Day 2 Saturday | 4 May 2019 HALL – A (Mansion-I)

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Saturday | 4 May 2019 HALL – B (Grand Ball Room-I)
Saturday | 4 May 2019 HALL – C (Grand Ball Room-II)
Session I - Workshop IV - IOTA Workshop
By : Dirk Timmerman, Mala Sibal & TLN Praveen
Moderators : Ashok Khurana & Divya A Sahetya
09:00–09:30 IOTA Basics Mala Sibal
09:30–10:15 Evaluation of Adnexal Masses - IOTA Models Dirk Timmerman
10:15–11:00 Tea/Coffee Break
11:00–11:30 Case Discussion of Adnexal Masses Mala Sibal & Dirk Timmerman
11:30–12:00 IOTA Test Mala Sibal & Dirk Timmerman
12:00–12:20 Evaluating Endometrioma Beyond Ground Glass Vivek Kashyap
12:20–12:40 Non-Ovarian Adnexal Masses TLN Praveen
13:00–14:00 Lunch
Session II
Moderators : Narendra Malhotra & Supriya Seshadri
14:00-14:20 Evaluating the Thin Endometrium Meenu Agarwal
14:20–14:45 Contrast in Gynecology Nitin Chaubal
Early Pregnancy Assessment - Panel Discussion
15:00-16:00 Panelists- TLN Praveen, Alka Saraswat, Sushma Gupta, Akshatha Sharma, Moderator: Ashok Khurana
Rachna Gupta, Nidhi Gupta, PK Shah
Case Based - Panel Discussion - FGR
16:00-17:00 Panelists - Suseela Vavilala, Jyoti Chubal, Basky Thilaganathan, Chander Moderator:
Lulla, Bhupendra Ahuja, Ashok Khurana Prathima Radhakrishnan
Workshop V - Gynaec, Infertility and Obstetric FGR Scans (Samsung)
17:00-19:00 Live Relay from Hospital
Hospital Coordinator /Scan Room: Neelam Maheshwari, Shally Gupta
Faculty :BS Ramamurthy, Kuldeep Singh, Neharika M Bora, Anupam Gupta
Hall Coordinators:Jaideep Malhotra, PK Shah
Session I
Moderators : BS Ramamurthy & Preeti Tomar
09:00-10:00 Midbrain-Hindbrain Malformations Revisited: From Megacisterna Magna to Tubulinopathies Karina Krajden Haratz
10:00-10:45 Maternal Infections and the Fetal Brain: CMV, Toxoplasmosis, Zika and Parvovirus Basky Thilaganathan
10:45-11:20 Intracranial Congenital Masses: Tumors and Arachnoid Cysts B S Ramamurthy
Session II
Moderators : Anita Kaul & Ankesh Sahetya
11:45-12:15 Prenatal Diagnosis of Cerebrovascular Malformations Karina Krajden Haratz
12:15-12:45 Fetal Brain Damage: Fetal Stroke (Ischemic and Hemorrhagic), Periventricular Anita Kaul
Pseudocysts and Periventricular Leukomalacia, Porencephaly, Hydranencephaly
12:45-13:00 Research Opportunities & Audience Interaction
13:00-14:00 Lunch

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Session III
Moderators : Suseela Vavilala & Veena Acharya
14:00-14:45 Malformations of Cortical Development Karina Krajden Haratz
14:45-15:15 Work-up in Macro and Microcephaly Karina Krajden Haratz
15:15-15:45 Midline Sagittal Brain Imaging BS Ramamurthy
16:00-16:30 MRI as a Complimentary Tool for Fetal Brain Assessment Ashok Khurana
16:30-17:15 Pitfalls in Fetal Neurosonography: Difficult Cases from the Faculty Karina Krajden Haratz
17:15-17:35 Genetic Ultrasound Markers : Prudence to be Apple Bhupendra Ahuja
17:35-17:55 Genetic Investigations in Fetal Syndromes: CMA , WES and Whole Genome Sequencing Ratna D Puri
17:55-18:15 Audience Intearction
09:30-17:00 Simulator Room
Session I
Moderators: Bhupendra Ahuja & Rachna Gupta
09:00-09:20 Optimising Prenatal Diagnosis. What ? When? Why? Narendra Malhotra
09:20-10:00 Screening for Aneuploidy -Pearls & Pain Points - A Meaningful Dialogue Suseela Vavilala with Anita Kaul
10:00-10:30 Recent Advances in Obstetric Imaging Prashant Acharya
10:30-10:50 Predicting preterm labour - Are we there yet? Chinmayee Ratha
POSTER SESSION
Judges : RN Goel, Vanaj Mathur, Poonam Goyal, Anshu Jindal
Session II
Moderators : Geeta Kolar & Rachna Gupta
11:30-12:00 Evaluating Skeletal Dysplasias Chander Lulla
12:00-12:30 Ambiguous Genitalia BS Ramamurthy
12:30-13:00 Fetal Face Ashok Khurana
Challenges In Fetal Medicine- Case Reviews
13:00-13:45 Experts - Prathima Radhakrishnan, Geeta Kolar, PK Shah, Basky Thilaganathan, Moderator: Anita Kaul
Raju Sahetya, Veena Acharya
13:45-14:00 Best Poster Presentation, Valedictory
14:00-15:00 Lunch
15:00-17:00 Workshop VI - Wipro GE Hand's on 3D-4D Workshop Reconstruction - Ashok Khurana
Hands on tarining on your Laptops / Load the software from GE Stall in morning)
Session I
Moderator: Jaideep Malhotra, Anurita Singh & Amit Tandon
09:00 – 09:30 Infertility Evaluation Mohd Wahaaj
09:30 – 10:00 Nuances of Polycystic Ovaries Supriya Seshadri
10:00 – 10:20 Endometrial Receptivity Bhupendra Ahuja
10:20 – 10:40 Oocyte Retrieval and Embryo Transfer Narendra Malhotra
10:40 – 11:00 Tea/Coffee Break
HALL D (Grand Ball Room III)
Sunday | 5 May 2019 HALL – A (Mansion-I)
Sunday | 5 May 2019 HALL – B (Grand Ball Room-I)

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Session II
Moderators: Anurita Singh & Amit Tandon
11:00 – 11:30 Multifetal Reduction Chander Lulla
11:30 – 11:50 Evaluating the LSCS Scar Jyoti Chaubal
11:50 – 12:15 Locating Intrauterine Devices on Ultrasound Anand Abhishek
12:15 – 12:45 Reporting in Gynecological Ultrasound P K Shah
12:45 – 13:00 Audience Interaction
13:00– 14:00 Lunch
14:00– 17:00 Oral Presentation Session by AOGS Podium Presenters on selected Abstracts
14:00– 14:10 Cesarean Scar Pregnancy : A Case Series Amit Tandon
14:10– 14:20 Congenital anomalies in twins- A Retrospective observational study Archana G
14:20– 14:30 Retrospective Analysis of Fetomaternal Outcomes In Multifetal Reduction : A Single Sravanthi Vadlamudi
Centre Experience
14:30– 14:40 Health & Psychosocial Problems In Women in Geriatric Age Group In North India Gayatri Gupta
14:40– 14:50 To Study The Prevalence of Positive DNA PCR OF HPV 16 And 18 in Sexually Active Richa Singh
Women With Degree of Cervical Dysplasia On PAP Smear
14:50– 15:00 Binder's phenotype - A rare or not so rare prenatal diagnosis with favourable Maneet Kaur
outcome - A series of 6 cases
15:00–15:10 Prenatal Series Of Cystic Placenta With A Live Fetus (PMMD - Placental Mesenchymal Jyoti Singh
Dysplasia Vs Molar Pregnancy) –Lessons Learnt For A Uniform Approach
15:10– 15:20 Aortic Isthmus Doppler Assessment and Its Association with Perinatal Outcome in Shalaka Bansode
Intrauterine Growth Restricted Fetuses
15:20– 15:30 Pattern Of Umbilical Coiling Index In Women Undergoing Delivery At A Tertiary Care Ekta Chaware
Centre In South Kerala
Session I
Moderators : Anita Kaul & Akshatha Sharma
09:00 - 09:30 Fetal Diagnostic Procedures - The Fundamentals Raju Sahetya
09:30-10:15 Fetal Therapy- Case Based A Meaningful Dialogue Anita Kaul with
Prathima Radhakrishnan
10:15-10:35 Managing Chorioangomas Geeta Kolar
10:35-11:20 Discordant Twins- IS Intervention Always Necessary? An Interactive Dialogue S Suresh with Suseela Vavilala,
Geeta Kolar
11:20 -1130 Audience Interaction
Session II
Moderators : Prashant Acharya, Selvapriya & Darshan Wadekar
12:00-13:00 Podium Presenters (Mixed Bag)
12:00-12:15 USG in Fetal Infections Pooja Lodha
12:15-12:30 Understanding the Fetal Thyroid Veena Acharya
Sunday | 5 May 2019 HALL – C

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12:30-12:45 Investigating Non immune Hydrops Akshatha Sharma
12:45-13:00 Understanding Centiles in Biometry Prashant Acharya
13:00-14:00 Interactive Quiz Selvapriya
Aditi Shah
Bela Bhatt
14:00-15:00 Lunch
(5 candidates each for 15 mins)
Workshop – VII- Training on Simulators - Simulator Room (Perkin Elmer/Lifecell)
10:00 - 12:00 Hands on CVS, Amniocentesis, Ovum Pickup, Embryo Transfer
Faculty : Raju Sahetya, Pooja Lodha, Bela Bhatt, Narendra Malhotra, Chander Lulla
Poster Session on 5th May | 11:00 hrs - 11:30 hrs
Pre Function Area
Poster
No. Presenting Author
1. Role of Imaging in rare obstructive reproductive tract anomalies Pranav Kumar Santhalia
2. Outcome of Fetuses with Antenatally Diagnosed Short Femur In an Indian Aradhana Aggarwal
Subset Population
3. Evaluation Of Diagnostic Accuracy of Clinical Examination In Detection of Suman Poddar
Non-Cephalic Presentation In Late Pregnancy
4. Fetal ear assessment at the 15 - 24 weeks scan and construction of an ear length Aarti Patil
nomogram by 2D ultrasound in euploid singleton fetuses in Indian population
5. Influence of presence of extracardiac defects and markers on the prevalence of Aditi Agarwal
chromosomal abnormalities in fetuses with congenital cardiac defects
6. Prevalence of first trimester markers in fetuses with aneuploidies and the Janani Alagiriswamy
relationship of number of markers to presence of aneuploidies a single centre
study in the Indian population
7. Role for therapeutic interventions in euploid fetuses with isolated pleural effusion Aarti Patil
8. Experience Of Influenza Virus H1n1 Infection In (Swine Flu) Pregnancy In A Tertiary Aprajita Kumari
Care Centre - A Case Series Of Five Cases
9. Diagnosis of CNS anomalies before 11 weeks of pregnancy. Deval Shah
10. Cesarean ectopic pregnancy (CSP) : the lurking danger in post cesarean failed Monika Anant
medical abortion.
11. Oligohydramnios - Are Pregnancies Getting Drier? Sarita Dixit
12. Role Of Ultrasound In Evolving Fetal Anomalies Rajesh Kamble
13. Performance of prenatal second trimester sonographic markers in screening for Navya Karnam Chandrakumar
trisomy 21- experience from an Indian centre
14. Prenatal Diagnosis Of Emanuel Syndrome Deepti Saxena
15. Prenatal diagnosis of fetal cardiac diverticulum - A case report Shalaka Bansode
16. Capability Of Tertiary Level Ultrasonography In Screening For Birth Defects Manpreet Sharma
Abstract Title Name of
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17. Fetomaternal Arterial Doppler In Early Onset Preeclampsia And Its Correlation With
Perinatal Outcome
18. Prenatal diagnosis of megacystis, microcolon, intestinal hypoperistalsis syndrome Nilesh Mhaske
in the first trimester ultrasound: a case report
19. Prenatal Diagnosis of Harlequin Ichthyosis: Case Report of a rare disorder with Jyotshna Rani Panigrahy
genetic study
20. Isolated Fetal Pleural effusion : 6 years of experience of Maternal and Reproductive Shruti Jain
Health Department , SGPGIMS
21. Assessment of fetal midbrain and hindbrain in mid-sagittal plane by 2D and 3D Deval Shah
ultrasound and comparison with nomograms
22. Fetus-in-Fetu Hari P S
23. Unilateral Cerebellar Hypoplasia: A Single Centre Experience Prerana Agarwal
24. Scoring System In Echogenic Kidneys To Prognosticate The Outcomes Dolly Chavda
25. Mutifetal Pregnancy Reduction - Is it Justified Ankan Singh
26. A Flood Of Genetic Testing Neharika M Bora
27. Truncal Translucency: A soft marker for embryonic aneuploidy Vipon Goel
28. Clinical Significance of Prenatal Double Bubble sign Sri Ramya Rayapureddy
29. Acceptance of anterior abdominal wall defect:Case Series from a tertiary centre Akila Venu
in South India
30. Prenatal series of cystic placenta with a live fetus (Pmmd - Placental Mesenchymal Jyoti Singh
Dysplasia / Molar Pregnancy) Lessons learnt for a uniform approach
31. To follow up the cases of antenatally detected micrognathia and assess the Kirti Kishore Sharma
completeness of investigations
32. Case Report- Thanatophoric Dysplasia Neharika M Bora
33. 3D in Mullerian Anomalies Rishabh Bora
34. To Evaluate the outcome of the fetal pleural effusion Sravanthi Patlolla
35. Severe FGR: Zero centile- study of maternal & perinatal outcome in a Tertiary Referral Archana M. Patil
Center, South India
36. Multifetal Reduction-Rising !!! Neharika M Bora
37. Conservative Management Of Ovarian Torsion Amit Tandon
38. A Rare Cause Of Secondary Postpartum Haemorrhage Ekta Chaware
39. A rare case report of peritoneal mature cystic teratoma with atypical imaging shilpi srivastava
findings
Shaili Tomer
16

4
Clinical Standards Committee hypertension) have a relatively greater significance .
Differences between earlyand late-onset PE are also seen inThe International Society of Ultrasound in Obstetrics and 7 8
risk factors , maternal vascular responsiveness , screeningGynecology (ISUOG) is a scientific organization that 9 10
performance and prevention effectiveness .encourages sound clinical practice, and high-quality teaching
and research related to diagnostic imaging in women’s Increasing insight into the pathophysiology of PE is
healthcare. The ISUOG Clinical Standards Committee (CSC) reflected in current screening strategies, which are based on
has a remit to develop Practice Guidelines and Consensus history, demographics, biomarkers (including blood pressure)
11
Statements as educational recommendations that provide and uterine artery Doppler .
healthcare practitioners with a consensus-based approach, There are currently more than 10 000 PubMed-indexed
from experts, for diagnostic imaging. They are intended to
articles related to PE screening, illustrating the vast interest in
reflect what is considered by ISUOG to be the best practice at
this topic. Fewer than one-fifth of these deal with early
the time at which they were issued. Although ISUOG has made
screening, this being a development of the last decade. The
every effort to ensure that Guidelines are accurate when
aim of these Guidelines is to review the latest evidence and,
issued, neither the Society nor any of its employees or
when possible, provide evidence-based recommendationsmembers accepts any liability for the consequences of any
regarding the role of ultrasound in screening and follow-up ofinaccurate or misleading data, opinions or statements issued
PE. The Guidelines focus on the technical/clinical aspects ofby the CSC. The ISUOG CSC documents are not intended to
screening, without extending to health economics and policyestablish a legal standard of care, because interpretation of
issues including the advisability and cost-effectiveness ofthe evidence that underpins the Guidelines may be influenced
screening. Moreover, these Guidelines were developed withby individual circumstances, local protocol and available
the assumption that the resources required forresources. Approved Guidelines can be distributed freely
implementation of screening and follow-up (equipment,with the permission of ISUOG (info@isuog.org).
examiners, expertise) are available. The steps and proceduresINTRODUCTION
described in these Guidelines are not intended to act as a
Hypertensive disease of pregnancy affects up to 10% of
1 legal standard for clinical service.
pregnant women and the pooled global incidence of pre-
2
TERMINOLOGY : SCREENING VS PREDICTIONeclampsia (PE) is approximately3% . Significant variations
between developed and developing countries can be Although the terms ‘screening’ and ‘prediction’ are
attributed to true differences or differences arising from data frequently used interchangeably, screening is in fact a wider
acquisition. PE and its complications are a major contributor to process, beginning with invitation of a population to1,3
maternal and perinatal morbidity and mortality worldwide . participate and ending with treatment for individuals identified
12
Given that timely and effective care can improve the outcome as being at high risk . Prediction, or the calculation of risk for3,4
of PE the development of effective prediction and preven- disease, is an integral element of the screening process, but it
tion strategies has been a major objective of prenatal care and is not equivalent to screening, as the latter also involves an
of research. intervention that is offered to individuals at high risk, and aims
PE is a multisystemic disease of multifactorial origin : it to alter the natural history of the screened condition and
13.
involves defective placentation, oxidative stress, auto ultimately to improve the outcome Screening in prenatal
immunity, platelet and thrombin activation, intravascular care has been commonly used to offer the option of timely
inflammation, endothelial dysfunction, an imbalance in termination of pregnancy to parents of fetuses with4,5
angiogenesis and maternal cardiac maladaptation . Defective untreatable conditions; this is an extension of the World Health
placental invasion is associated strongly with most cases of Organization’s scope of screening, which is prevention of4
early and severe PE . In contrast, defective placentation seems disease. For the purpose of these Guidelines, in the context of
to be less important for the development of PE that manifests PE, ‘screening’ is the preferred term when identification of
later in pregnancy, for example after 34 weeks. Compared
cases at risk may lead to prevention of its development,
with pregnancies affected by early-onset disease, in those
whereas ‘prediction’ is the preferred term when there is no
complicated with PE at or near term, placentae have a
evidence that identification of women at risk will eventually6,4
significantly lower frequency of histological abnormalities
improve their outcome.
and maternal factors (e.g. metabolic syndrome or chronic
ISUOG Practice Guidelines: role of ultrasound in screening for
and follow-up of pre-eclampsia
ISUOG GUIDELINES
1

2
as a screening marker.RELEVANT INFORMATION AVAILABLE TO THE EXAMINER
A 2008 meta-analysis indicated that increased PI, alone orRecommendation
combined with notching, is themost predictive Doppler index• Examiners involved in screening for PE should have up-to- 20
for PE . A considerable amount of evidence published sincedate knowledge regarding major risk factors for PE
then indicates the superiority of mean uterine artery PI as the(GOOD PRACTICE POINT).
preferred Doppler index for PE screening, and this is the index
Given that ultrasound screening for PE should not be 21–23
used for screening and prevention in the first trimester .
isolated from the general concept of prenatal care, it is
First trimesteradvisable that professionals who screen for PE have up-to-
Recommendationdate knowledge about proven risk factors and aim to identify
them during screening. A global assessment of risk should • Doppler examination of the uterine arteries at 11+0 to
encompass four broad areas, including personal risk profile 13+6weeks can be performed either transabdominally
(including age, ethnicity, parity, smoking, medical and or transvaginally, according to local preferences and
obstetric history and conception method), metabolic risk resources (GOOD PRACTICE POINT).
profile (including body mass index (BMI) and history of
Technical advice
diabetes), cardiovascular risk profile (including existing
• Screening by first-trimester uterine artery PI >90th centilecardiovascular conditions and measurement of mean arterial
detects 48% of women who will develop early PE andblood pressure) and placental risk profile (including uterine
11. 26% of those who will develop any PE, for a 10% screen-artery Doppler and maternal serum biomarkers)
positive rate (EVIDENCE LEVEL: 2++).
SCREENING FOR PRE-ECLAMPSIA USING ULTRASOUND
First-trimester Doppler examination of uterine arteries :
The use of ultrasound as a tool for screening/prediction of
technique. Doppler examination of the uterine arteries has
PE is based on the fact that defective placentation results in
been studied most extensively in the period from 11+0 to
incomplete transformation of the spiral arteries. Placental
13+6weeks. This is a common time for first-trimester
villous and vascular histopathological lesions are four-to-seven
ultrasound examination in many countries, and therefore14
times more common in PE than in non-PE pregnancies and
practical in terms of logistics. Earlier assessment has not been
are associated with increased resistance to uterine artery
studied extensively because trophoblast invasion is not yet15
blood flow . Measurement of impedance (or resistance) to
sufficiently advanced as to be assessable.
flow in the uterine arteries by Doppler assessment thus
For the first-trimester transabdominal assessment ofrenders quantifiable the incomplete transformation of the
uterine artery resistance, a midsagittal section of the uterusspiral arteries.
and cervix is obtained initially. Using color flow mapping, the
Which Doppler index to use
transducer is gently tilted sideways, so that the uterine arteries
Recommendation are identified with high-velocity blood flow along the side of
the cervix and uterus (Figure 1). The pulsed-wave Doppler• The pulsatility index (PI) should be used for examination of
sampling gate should be narrow (set at approximately 2 mm)uterine artery resistance in the context of PE screening
and positioned on either the ascending or descending branch(GRADE OF RECOMMENDATION : B).
of the uterine artery at the point closest to the internal cervicalAs described in the ISUOG Practice Guidelines on the use 24
16 os, with an insonation angle <30º . In order to verify that theof Doppler ultrasonography in obstetrics , the systolic/
uterine artery is being examined, the peak systolic velocitydiastolic ratio (S/D), resistance index (RI) and PI are the three
should be >60 cm/s. The PI is measured when at least threebest-known indices with which to describe arterial flow- 25,26
identical waveforms are obtained . Detailed methodologyvelocity waveforms. PI is the index most commonly used; its
can be found in a practical advice paper published in thisadvantage over RI in evaluation of the uterine artery Doppler 27
journal . Following this approach, uterine artery PI can bewaveform is that PI includes in its calculation the averaged 25
measured in more than 95% of cases .value of all maximum velocities during the cardiac cycle, rather
than just two points in the cardiac cycle as for RI. Furthermore,
PI is more stable and it does not approach infinity when there
16
are absent or reversed diastolic values .
Uterine artery notching has also been used in screening
17
for PE , the presence of bilateral notches being associated
with indications of maternal endothelial dysfunction (lower
18
flow-mediated dilatation of the brachial artery) . Despite its
theoretical plausibility as a screening marker, bilateral notching
is not uncommon in normal first-trimester pregnancies,
19
occurring in 43% of cases , which reduces its specificity.
Likewise, uterine artery notching in the second trimester has
Figure 1 Transabdominal Doppler ultrasound examination of uterine artery insimilar sensitivity to that of increased PI, but for a higher screen-
the first trimester. The uterine artery loop is located in a paracervical section,17
positive rate , and there may be a degree of subjectivity in and at least three identical waveforms are recorded, using an insonation angle
defining notching, which further limits the value of this finding as close to 0º as possible.

3
Transvaginal assessment of uterine artery resistance be that transvaginal ultrasound allows closer proximity of the
30
follows the same principles. The woman is placed in the transducer to the vessel and lower insonation angles . The
lithotomy position, with her bladder empty, and a transvaginal 95th centile of the mean uterine artery PI obtained
probe is used to obtain a sagittal view of the cervix. The probe transvaginally has been reported as approximately 3.10 for
is then moved laterally until the paracervical vascular plexus is CRLs up to 65 mm, progressively declining thereafter to reach
33
seen, and the uterine artery is identified at the level of the 2.36 at a CRL of 84mm .
internal cervical os. Measurements are taken with an angle of In women who do not develop PE, uterine artery PI may28
insonation <30º . be affected by maternal factors, including ethnic origin
Recommendation (African origin is associated with increased PI), BMI
(decreasing PI with increasing BMI) and previous PE• Standardized methodology, as described in these 26
(associated with increased PI) . The association betweenGuidelines, should be followed for assessment of the
decreasing PI and increasing BMI is not clear; the vasodilatoryuterine artery Doppler indices (GOOD PRACTICE POINT).
effect of increased levels of estrogens in these women on the
Adherence to a standardized methodology is essential to
uterine circulation has been postulated as a potential
ensure reproducible measurements. Studies evaluating the 26,34
cause . An absolute numerical cut-off for uterine artery PI
reproducibility of this technique have shown interobserver
may, therefore, not reflect accurately uterine artery resistance,
intraclass/concordance correlation coefficients of
29,30 and it has been suggested that first-trimester uterine artery PI
0.80–0.85 . However, limits of agreement were found be
should be expressed as multiples of the median (MoM) rather
as high as ±35% for the transvaginal and ± 40% for the 35
than absolute values .
transabdominal approach30. On this basis, the reproducibility
Recommendationof the method should be interpreted as being poor to
31
moderate . Besides differences caused by observers, • Mean uterine artery PI should be the Doppler index of
Doppler indices may change during an examination, due to choice for screening in the first trimester (GRADE OF
factors such as uterine contractions and changes in heart rate. RECOMMENDATION: B).
Although the effect of such factors cannot be prevented, In one of the early studies using the current standard27
adherence to a standardized protocol of examination is methodology for assessing uterine artery Doppler in the first
imperative to minimize the operator-dependent variability, as trimester, a mean PI >95th centile had a sensitivity of 27% for
systematic error in measurements can affect the screen- PE and a sensitivity of 60% for PE requiring delivery before32
25positive rate 32weeks . Subsequent studies used the lowest uterine artery
Technical advice PI (i.e. PI of the side with least resistance) because the point
estimates for the area under the receiver–operating• The 95th centile for mean uterine artery PI obtained using
characteristics curve (AUC) were marginally better when thea transabdominal approach between 11+0 and
lowest rather than the mean PI was used in the regression13+6weeks is 2.35 (EVIDENCE LEVEL: 2+). 36
model (0.91 vs 0.90 for early PE) . However, the confidence
• Uterine artery resistance is higher on transvaginal
intervals for the AUCs overlapped, and the superiority of the
compared with transabdominal measurement; the 95th
lowest PI was not confirmed by another large study (AUC,
centile for mean uterine artery PI obtained using a
0.79 for mean and 0.76 for lowest PI for the outcome of early
transvaginal approach is approximately 3.10 for crown– 37
PE, with overlapping CIs) . Both techniques are acceptable,
rump lengths (CRL) up to 65 mm, gradually declining with
but the mean uterine artery PI is the index most commonly
increased CRL thereafter (EVIDENCE LEVEL: 2+).
used for first- and second-trimester uterine artery Doppler
• The uterine artery PI may also be affected by maternal examination, and the default reference values in most
factors, including ethnic origin, BMI and previous PE commercial software apply to this.
(EVIDENCE LEVEL: 2++).
Bilateral notching has been associated with a 22-fold
Recommendation increased risk for PE and an almost nine-fold increased risk for
38
• Given that maternal factors can affect uterine artery PI, its small-for-gestational-age (SGA) neonate ; however, it may be
inclusion in a multifactorial screening model should, observed in around 50% of pregnant women at 11+0 to
19,25,39
whenever feasible, be preferred over its use as a 13+6weeks . This marker therefore has a very low
standalone test with absolute cut-offs (GRADE OF specificity for PE.
RECOMMENDATION : B). A recent meta-analysis reported that first-trimester
The 95th centile of mean uterine artery PI obtained using a Doppler examination of the uterine arteries can predict 47.8%
transabdominal approach is about 2.35 for the period 11+0 of cases of early PE (7.9% false-positive rate), 39.2% of cases
25 25
to 13+6weeks , with no change or only a small trend to of early fetal growth restriction (6.7% false-positive rate) and
30 30,33,
decrease over this period. In two comparative studies 26.4% of cases of PE at any stage (6.6% false-positive rate),
40
the transvaginal approach gave significantly higher readings when using as a cut-off the 90th centile of PI or RI . However,
compared with the transabdominal approach, with mean PIs combined screening (including maternal factors, maternal
of 1.98 vs 1.8333 and 1.60 vs 1.5230. The reason for this may mean arterial blood pressure, uterine artery Doppler and

placental growth factor (PlGF) measurement) has superior Similar to the first trimester, when the uterine arteries are
predictive performance (as detailed later) and, if available, examined transvaginally, the PI readings are higher compared
should be preferred over Doppler-based screening. with those obtained using the transabdominal approach. In a
comparative series of 96 women between 20 and 26weeks,Second trimester
the mean uterine artery PI was 1.07 with the transvaginal and
Recommendation
0.96 with the transabdominal approach. The median angle of
• Doppler examination of the uterine arteries at the insonation was lower using transvaginal ultrasound (10.0º vs
second-trimester scan can be performed either 17.5º); however, PI being a ratio, the most likely reason for the
transabdominally or transvaginally, according to local differences between transabdominal and transvaginal values is
preferences and resources (GOOD PRACTICE POINT). the different anatomical location of the examination. Both
Second-trimester Doppler examination of uterine techniques have similar reproducibility (interobserver
arteries: technique. Uterine artery flow resistance can be concordance coefficient, 0.86 vs 0.81; limits of agreement,
30
assessed either transabdominally or transvaginally. The ±35%) .
transabdominal technique is similar to that of the first trimester, The 95th centile of the mean uterine artery PI at 23 weeks
the main difference being that right and left uterine arteries are obtained with a transabdominal approach has been reported
identified at the apparent crossover with the external iliac as 1.4441, and that obtained with a transvaginal approach as
arteries, rather than paracervically. After the arteries are 1.5843. The 95th centile of the mean uterine artery PI
identified, pulsed-wave Doppler is used to obtain the decreases by about 15% between 20 and 24weeks, and by
44waveforms. When at least three similar consecutive <10% between 22 and 24weeks .
waveforms are obtained, PI is measured, and the presence or
41 In unilaterally located placentae, resistance to uterine flow
absence of early diastolic notching is recorded .
on the contralateral side is commonly increased. A unilaterally
In the transvaginal technique, the woman is asked to increased PI does not appear to be associated with a higher
45empty her bladder and is placed in the dorsal lithotomy risk for PE if the mean PI is within normal limits .
position. The ultrasound probe is inserted into the anterior
Performance of second-trimester prediction of PE. The
fornix, and the cervix is identified in the midsagittal plane. The
predictive performance of uterine artery Doppler is better for
probe is then moved into the lateral fornix and the uterine
early-onset PE; a study of more than 32 000 women indicated
arteries are identified on either side using color Doppler at the
that, for a false-positive rate of 10%, uterine artery PI alone can
level of the internal cervical os. Pulsed-wave Doppler is used
predict 85% of cases of early-onset PE, compared with 48%
to obtain three similar consecutive waveforms. PI can then be 46
of late-onset cases when combined with maternal factors .
measured and the presence or absence of early diastolic
17 Furthermore, the risk for early PE appears to increase with
notching can be recorded . Examination of the uterine artery
increasing uterine artery resistance; a mean PI of 1.6 was
Doppler waveform following this approach is feasible in 99%
42 associated with a positive likelihood ratio (LR+) of 3.07, a
of women .
mean PI of 1.8 with a LR+ of 8.00 and a mean PI of 2.2 with a
46As in the first trimester, using either a transabdominal or a LR+ of 27.08 (transvaginal measurements) . In general,
transvaginal approach, care should be taken to maintain the uterine artery Doppler velocimetry tends to predict better the
angle of insonation <30º and the peak systolic velocity>60 more severe and complicated cases. For example, mean PI
cm/s to ensure that the uterine artery rather than the arcuate >1.65 (on transvaginal ultrasound) was found to predict 41%24
artery is being examined . of all PE cases, but, when subgroups were analyzed, the
Technical advice prediction rate was 69% for PE with fetal growth restriction
• As in the first trimester, uterine artery PI in the second and 24% for PE with normal fetal growth17. This finding can be
trimester is higher when measured transvaginally explained by the fact that high impedance in the uterine
(EVIDENCE LEVEL: 2++). arteries reflects defective placentation, which has a
concomitant deleterious effect on fetal growth.• The 95th centile formean uterine artery PI is 1.44 for the
transabdominal approach and 1.58 for the transvaginal Bilateral diastolic notching in the uterine artery Doppler
approach at 23 weeks (EVIDENCE LEVEL: 2+). waveform is also associated with increased risk for
17,41,42,46,47
PE . However, for the same false-positive rate, uterine• The 95th centile of the mean uterine artery PI decreases 42
artery PI is associated with better sensitivity than is notching ,by about 15% between 20 and 24weeks, and by <10%
rendering unnecessary its addition to screening, although notbetween 22 and 24weeks (EVIDENCE LEVEL: 2++). 47
all studies support this .
Recommendation
In terms of maternal health, a study of 491 women
• Mean uterine artery PI should be used for prediction of
undergoing transthoracic echocardiography at the time of
PE. In case of a unilateral placenta, a unilaterally increased
second-trimester screening for PE, showed that women with
PI does not appear to increase the risk for PE if the
mean uterine artery PI >90th centile (which was 1.25 in that
mean PI is within normal limits (GRADE OF RECOMMEN-
study) had a higher prevalence of previously undiagnosed,
DATION: B).
functionally significant, cardiac defects (4.4%) compared with
4

women with normal mean uterine artery PI (0.3%). This As well as cross-sectional measurements of Doppler
48
prevalence was particularly high among migrant women . indices, their longitudinal changes have been studied in the
prediction of PE. A study examining sequentially uterine arteryThird trimester
Doppler at 11–14 and 19–22weeks (n =870) reported that
Technical advice
73% of cases with increased PI in the first trimester had
• Although uterine artery velocimetry can be assessed normalized by the second trimester.Women with increased PI
transvaginally, the most common method of uterine artery in both first and second trimesters were at highest risk (37.5%)
Doppler examination in the third trimester uses a for adverse pregnancy outcome, i.e. growth restriction or
transabdominal approach (EVIDENCE LEVEL: 4). hypertensive disorder. In contrast, women with normal PI in
• The 95th centile for mean uterine artery PI is 1.17 the first trimester had a 95% chance of normal measurements
obtained using a transabdominal approach at in the second trimester, and this was the group with the lowest
53
30–34weeks (EVIDENCE LEVEL: 2+). incidence of adverse outcome (5.3%) .
Recommendations Another index that has been tested is the difference
• There are currently no randomized trials on the impact of between second-trimester and first-trimester uterine artery PI,
third-trimester screening for PE on maternal, fetal and both expressed in MoM for the corresponding gestational
neonatal outcomes; consequently, its implementation ages. An increasing gap between first- and second-trimester
into routine practice cannot be recommended at present uterine artery PI MoM, reflecting defective spiral artery
(GOOD PRACTICE POINT). transformation, appeared to be the most accurate predictor
54
for early (AUC, 0.85) and preterm (AUC, 0.79) PE . Another• Mean uterine artery PI should be used for prediction of
study on 104 women with increased uterine artery PI atPE, if this is offered in the third trimester (GRADE OF
20–22weeks reported that abnormal findings persisted atRECOMMENDATION: B).
26–28weeks in 59.6% of cases; women with persistently
The standard method for Doppler examination of the
increased PI had a greater risk for PE (16% vs 1%), SGA (32%
uterine arteries in the third trimester is by a transabdominal
24,41 vs 1%) and admission to a neonatal intensive care unit (26% vs
approach, similar to the second trimester 55
4%), compared with women in whom the PI normalized .
In a large,multicenter study in the UK, the 90th and 95th
A problem with sequential assessment of Doppler is that
centiles for mean uterine artery PIs between 30+0 and
49 the window of opportunity for preventative intervention (i.e.
34+6weeks were 1.03 and 1.17, respectively . Mean uterine
gestational age<16 weeks) is missed if intervention is delayed
artery PI >95th centile (5% false-positive rate) alone could
pending a subsequent scan.
predict 54% of PE before 37 weeks and 14% of PE ≥ 37
Placental volumeweeks. The corresponding rates for mean PI >90th centile
(10% false-positive rate) were 68% and 14%, respectively, Recommendation
highlighting the poor performance of Doppler studies alone in • Although placental volume and vascularization indices49
predicting term PE . The same group assessed the have been assessed as predictors for PE, they cannot be
effectiveness of screening at 35–37weeks, finding that uterine recommended for screening purposes given that their
artery Doppler alone was a poor predictor for PE; even when reproducibility is limited, they require special equipment
it was combined with maternal factors, the detection rate was and they are time-consuming (GOODPRACTICE POINT).
26% for a 5% false-positive rate and 37% for 10% false- Shortly after the introduction of three-dimensional50
positive rate . ultrasound, first-trimester placental volume was tested as a
Reversed uterine artery diastolic flow has been reported potential predictor of PE. In one of the initial studies, placental
sporadically in the third trimester and, in cases with placental volume at 12weeks was compared with uterine artery
insufficiency, was associated with adverse outcome, such as Doppler examination at 22weeks; the predictive51,52
progression to eclampsia or intrauterine demise performances of these two methods were: 20% and 28%,
Longitudinal changes in Doppler indices respectively, for PE without SGA; 31% and 46%, respectively,
for PE with SGA; and 50% and 50%, respectively, for earlyTechnical advice
PE56. Similarly, placental volume had predictive performance
• Increased uterine artery resistance persisting from first
comparable to that of first-trimester mean uterine artery PI for
trimester to second trimester may identify women at
PE (56% vs 50%) and for PE requiring delivery before 32weeks
highest risk for PE (EVIDENCE LEVEL: 2++).
(67% vs 67%)57. However, these findings have not been
Recommendation 58,59
confirmed by other studies . Three-dimensional placental
58–62• Given that preventive strategies (e.g. low-dose aspirin) vascularization indices have also been evaluated ;
for reducing the risk of PE are effective if started in the first however, they can be affected by attenuation due to depth
trimester, their use should be commenced as soon as and tissue interfaces, the use of different ultrasound settings
possible in women identified as being high-risk, without and the lack of robust reproducibility (intra- and interobserver
waiting to assess the evolution of Doppler in the second intraclass correlation coefficients,<0.48 and<0.66,
63trimester (GOOD PRACTICE POINT). respectively) , all of which limit their clinical applicability.
5

Although good reproducibility is reported for placental and PlGF at 11–13 weeks predicted 75% of cases of PE<37
964,65
volume calculation , normal values vary considerably (first- weeks and 47% of cases of PE≥ 37 weeks . The same
21, 76
trimester mean placental volume has been reported to range protocol was used in the context of the ASPRE trial ; in this
59,61,64–66
from 45 to 74mL . Moreover, placental volume trial, combined screening was followed by randomization to
calculation is currently a non-automated measurement subject aspirin or placebo in those at high risk. This algorithm,
to operator variability, and can be time-consuming, combining maternal factors, mean arterial pressure, mean
depending on the number of frames used for volume uterine artery PI and PlGF, achieved a 100% detection rate for
67
analysis . PE developing <32 weeks, 75% detection for PE developing
<37 weeks and 43% detection for PE developing ≥ 37COMBINED SCREENING STRATEGIES
weeks, for a 10% false-positive rate. The fetal fraction of cell-
Recommendations
free DNA in the maternal circulation is also significantly
• A combination of maternal factors, maternal arterial associated with maternal and fetal risk factors for PE, and there
blood pressure, uterine artery Doppler and PlGF level at is a significant relationship between low fraction and
7711–13 weeks appears to be the most efficient screening increased risk for PE ; however, its impact on first-trimester
model for identification of women at risk of PE (GRADE screening has not been evaluated in prospective studies.
OF RECOMMENDATION: B).
Similar to the first trimester, a second-trimester model
• Given the superiority of combined screening, the use of using uterine artery PI, maternal factors (including BMI, ethnic
Doppler cut-offs as a standalone screening modality origin, previous obstetric history, smoking status, type of
should be avoided if combined screening is available conception, medical history) and mean arterial blood
(GRADE OF RECOMMENDATION: B). pressure may detect as many as 100% of women who will
• The transabdominal approach is preferred for calculating develop early PE for a false-positive rate of 10%; the sensitivity
first-trimester individual patient risk, asmost screening for late PE and gestational hypertension is 56.4% and 54.1%,
78
algorithms were developed using this approach (GOOD respectively .
PRACTICE POINT). In the third trimester, a combination of maternal factors
Maternal risk factors (history, demographics, and sFlt-1 level may predict 83% and 38% of PE before and
cardiovascular and metabolic profile) and placental markers after 37weeks, respectively, for a false-positive rate of 5%; the
(uterine artery resistance and biomarkers) for the corresponding figures for a 10% false-positive rate are 94%
49
development of PE have been identified. Therefore, the and 51%, respectively . Prior screening in the first and/or
current trend in screening involves combining the presence or second trimesters does not further improve prediction
79
absence of multiple risk factors in order to calculate a accuracy over that of third-trimester screening alone . Ethnic
personalized risk and then tailoring management accordingly, origin affects the sensitivity and false-positive rate of third-
11
similar to screening for chromosomal abnormalities . On a trimester prediction, with both being higher in women of
80
population basis, combined screening aims at improving on Afro-Caribbean origin . Maternal and biochemical markers
the sensitivity of single-marker screening and, at the same time, become more important for the prediction of PE in late
reducing the false-positive rate. pregnancy. Thus, among several potential factors, mean
Combined screening has been the subject of arterial pressure, PlGF and sFlt-1 were the ones associated
81
approximately 400 PubMed articles up to April 2018. Multiple with the prediction of PE between 30–34weeks and 35–37
82
studies have shown that women who go on to develop PE weeks . In contrast, the addition of uterine artery PI and
68
have, on average, higher mean arterial pressure , higher maternal cardiovascular parameters did not improve the
83
concentrations of maternal serum soluble fms-like tyrosine prediction of PE after 35–36 weeks . The sFlt-1/PlGF ratio as a
69, 70 71
kinase-1 (sFlt-1) and alpha-fetoprotein (AFP) , and lower standalone marker can predict more than 75% of cases which
concentrations of pregnancy-associated plasma protein-A will develop PE within 4 weeks, but its sensitivity is significantly
72 73
(PAPP-A) and PlGF70, , along with higher resistance in the higher at 31–34 than at 35–37weeks (false-positive rate, 1.7%
8474
uterine arteries , compared with women who do not. For all vs 9.6%) .
these predictors, the performance was better for early than A common concern with combined screening models is
9,70
for late PE and was better when assessed later in pregnancy that they may perform differently when applied prospectively
than at 11–13 weeks, i.e. closer to the development of in populations different from the ones from which they were71,73–7568– . 85
PE derived . The performance of the combined screening
Data from almost 36000 prospectively followed model used for the ASPRE trial (maternal factors, mean arterial
singleton pregnancies showed that, at a false-positive rate of pressure, mean uterine artery PI, PlGF) was practically identical
10%, maternal factors alone (including age, weight, ethnic when applied to the dataset used for its development and the
9, 76
origin, reproductive and medical history and smoking) could actual clinical trial . In fact, this screening model was found
predict 49% of PE<37 weeks. The addition of PlGF increased to be considerably more efficient for the prediction of early PE
this rate to 60%, and combined screening with maternal than were the history-based screening policies
characteristics, mean uterine artery PI, mean arterial pressure recommended by both the American College of
6

Obstetricians and Gynecologists and the UK National Institute for a 10% false-positive rate, the detection rate was 43.4% for
22, 86
for Health and Care Excellence . all types of PE, 52% for PEwithout a SGA fetus and 23.3% for
94.
gestational hypertension Women who subsequentlyASSESSMENT OF MATERNAL HEMODYNAMICS
develop PE have evidence of left ventricular concentric
Recommendation 97.
remodeling in mid-gestation
• Despite the fact that maternal hemodynamic assessment
Despite the fact that maternal hemodynamics are
may be of value in prediction of PE, there are still too few
promising screening markers of PE, a combined approach
data to support its routine implementation in clinical
taking into account maternal characteristics and biochemical
practice as a standalone test (GOOD PRACTICE POINT).
markers is required to reach a clinically useful prediction
Cardiovascular adaptation plays a critical role in the model. Meanwhile, as assessment of maternal hemodynamics
hemodynamic changes observed in normal pregnancy. Failure is being performed increasingly in PE studies, it is imperative
of this adaptation, and possibly subclinical prepregnancy that relevant devices and techniques are used appropriately in
cardiovascular dysfunction, have been associated with the risk 111.
pregnant populations87–89
of developing PE . Women who develop PE have
MANAGEMENT AFTER SCREENING
prepregnancy cardiovascular risk factors, demonstrating
Recommendationincreased arterial stiffness and impaired cardiac function at the
time of the clinical diagnosis, as well as several weeks before • There is convincing evidence that low-dose aspirin can
clinical onset of the pathology and several months after the decrease significantly the risk for development of early PE,
90–101
when administration commences at the time of first-index pregnancy . The cardiovascular implications of PE
trimester screening (GRADE OF RECOMMENDATION: A).appear to continue long-term, as shown both by increased
frequency of prolonged subclinical impairment of systolic First trimester
102 103
biventricular and endothelial function, and by the Currently, the American College of Obstetricians and104–106.
112,increased risk of cardiovascular morbidity later in life The Gynecologists (ACOG) the UK National Institute for Health
113hazard ratio for developing cardiovascular disease later in life and Care Excellence (NICE) and the Society of Obstetricians105.
114,is as high as 5.4 in women who had severe PE/eclampsia and Gynaecologists of Canada (SOGC) among others,
Moreover, compared to women without recurrent disease, recommend administering low-dose aspirin, commencing
women who develop PE in a subsequent pregnancy tend to before 16weeks, to women at risk for placental insufficiency.
have altered cardiovascular parameters between
Most of the studies on which current recommendations
pregnancies, which may hinder their normal adaptation in the
are based classified women as high risk according to historical107.
next pregnancy
or medical factors rather than using current screeningmethods
The simplest hemodynamic parameter with established (i.e.maternal factors, Doppler and biochemistry). In the ASPRE
value in the context of combined screening is maternal mean study, 1776 women at high risk for PE based on first-trimester9,76,78,108.
arterial pressure Additionally, arterial stiffness can be combined screening were randomized to either aspirin (150
estimated by ultrasound and this parameter has been found to mg daily at bedtime) or placebo, from 11–14weeks to 36
10.
differ significantly between women with PE and those with weeks’ gestation The dose of 150 mg was selected in line
normal pregnancy. In a systematic review of 23 studies with evidence that a significant proportion (10–30%) of
115,
evaluating arterial stiffness in association with hypertensive patients show aspirin resistance at lower doses and in-vitro
90,
disease of pregnancy women with PE had elevated arterial data showing that the optimal dose to improve trophoblast
116
stiffness both during and after pregnancy, and to a greater function is the equivalent of 150 mg in vivo The timing of
extent than those with gestational hypertension. Interestingly, administration was based on data indicating the presence of a
90.
more severe PE was associated with greater arterial stiffness diurnal effect in response to aspirin, with optimal effectiveness
117.
Both pulse-wave velocity analysis and the augmentation index for bedtime administration The ASPRE trial found that aspirin
have also been observed to be higher in the subclinical stage reduced the risk for PE before 37 weeks by 62% (from 4.3%
91,92
(as early as 11 weeks) in women who go on to develop PE . to 1.6%). Aspirin also reduced the risk of PE before 34weeks
Cross-sectional and longitudinal studies have demonstrated by 82%, but this effect did not reach statistical significance
10.
that arterial stiffness indices could be used as a screening test, due to the low absolute rates (0.4% vs 1.8%) The beneficial
effect of aspirin appeared to depend on the degree ofas early as 11weeks’ gestation, to predict subsequent
compliance, with the greatest risk reduction observed indevelopment of early- and late-onset PE, especially when
118
women with compliance > 90% .combined with othermaternal variables, such as central
91,92
systolic blood pressure . Lower flow-mediated dilatation First-trimester screening and intervention with aspirin
has been reported in the first and second trimesters among appears to be cost-effective, combining the prevention of a
109,110.
high-risk women who subsequently developed PE significant proportion of early-onset cases with cost savings
119
for the health system .Cardiac output was significantly higher at 11–13weeks in
women who later developed PE or gestational hypertension, Second trimester
compared with that in women with uncomplicated Second-trimester prediction of PE appears to be at least94
70,78pregnancy . When combined with other maternal variables, as sensitive as prediction in the first trimester, but its value is
7

limited by the lack of effective interventions at this gestational Excluding cases with subsequent twin-to-twin transfusion
stage. While aspirin commenced in the first trimester appears syndrome, first-trimester mean uterine artery PI was 46%
120,121,
to reduce the development of PE the same intervention higher in twin pregnancies that developed early-onset PE and
120.
seems ineffective when started after 20weeks Although it is 22% higher in those devloping late PE, compared with
128.
too late to prevent the development of PE after second- uncomplicated twin pregnancies
trimester prediction, the knowledge can still be useful in In a study of dichorionic twin pregnancies from 17 to 38122,123
guiding follow-up and management of a pregnancy at risk. weeks, the 95th centile for the mean uterine artery PI,
However, the clinical impact of intensified follow-up has yet to measured transabdominally, was 1.21 at 21 weeks, 1.16 at 22
be proven. A Spanish trial randomized 11667 women who weeks, 1.12 at 23 weeks and 1.09 at 24 weeks133. Using the
attended for a routine second-trimester scan to Doppler or transvaginal approach, a cut-off of 1.5 for mean uterine artery
non-Doppler group. It was found that Doppler velocimetry PI at 22–24 weeks had a sensitivity for PE of 33.3%, for a 3.3%
129.identified 60% of the women who went on to develop PE, false-positive rate (monochorionic and dichorionic twins)
but the intensification of their care did not result in better
Chorionicity could theoretically have an impact on the
short-term maternal or perinatal outcome compared with that
extent of uterine hemodynamic adaptation, as monoand
of women who did not have a Doppler examination at the
dichorionic twins have different placental masses and124
second-trimester scan .
architecture. Indeed, a survival-time model analysis calculated
Third trimester that, for a reference population standardized for maternal
Third-trimester testing can identify themajority of women characteristics, the risk for PE<37 weeks’ gestation is 8% for
80,125.
who will develop PE in the subsequent weeks It has been dichorionic twins and 14% for monochorionic twins, as
127.
described as part of a longitudinal risk-assessment scheme compared with 0.6% for singleton pregnancy A study in the
focused mainly on early detection, which involves detailed first trimester reported higher uterine artery resistance in
screening in the first trimester for stratification for all major monochorionic compared with dichorionic twins; in fact,
obstetric complications, and then contingent screening monochorionic twins had similar resistance to that of singleton
125,126 132.
based on the risk reassessment at each visit . The fetuses
validation and audit of this strategy is the subject of ongoing As in singleton pregnancy, combined screening in twin
research. pregnancy performs better than does each of its individual
MULTIPLE PREGNANCY components. A recent study assessed first-trimester
screening with maternal factors, uterine artery PI, mean arterialRecommendations
pressure, PAPP-A and PlGF, and found that the detection rate
• Due to increased placental mass in twin pregnancy,
of PE requiring delivery before 32 and 37 weeks was 100%
resulting in lower mean resistance in the uterine arteries,
and 99%, respectively, at the cost of a screen-positive rate of
twin-specific reference ranges are preferred for Doppler
75%. The use of twin-specific charts resulted in only a minor
examination, if available (GRADE OF RECOMMENDATION 131
increase in the performance of the model
: B).
USE OF ULTRASOUND IN PATIENTS WITH ESTABLISHED• The combined screening (maternal factors, uterine artery
PRE-ECLAMPSIAPI, mean blood pressure, PlGF) algorithm for singletons
Deteriorating fetal status is one of the indications forcan also be used in twins and can identifymore than 95%
delivery in PE; therefore, close fetal surveillance is neededof women with twin pregnancy who will develop PE. ,134 135
until delivery Ultrasound is the cornerstone for fetalHowever, the examiner should be aware that this is
assessment. However, as yet there have been no randomizedachieved at the cost of a 75% screen-positive rate
controlled trials; therefore, the optimal surveillance strategy(GRADE OF RECOMMENDATION: B).
and its impact on outcome need to be determined. The three
Twin pregnancy is a risk factor for obstetric complications,
main components for fetal evaluation in clinical practice are:127.
including PE The increased placental mass in twin pregnancy (1) B-mode ultrasound, (2) Doppler and (3) fetal heart-rate
136results in a lower mean uterine artery resistance compared monitoring .
with that of singleton pregnancy at the same gestational
Recommendations128–131,
age and this can be observed even during the first
128,132. • Given that fetal deterioration is an indication for delivery intrimester Consequently, using reference ranges for
established PE, fetal status should be assessed regularly in
singleton pregnancies, which are higher than those for twins,
these patients (GOOD PRACTICE POINT).
may result in reduced sensitivity of Doppler screening. A study
• The sonographic follow-up in pregnancies affected by PEcomparing the two approaches reported that twin-specific
includes assessment of fetal growth and biophysicalranges resulted in a sensitivity of 36.4%, for a 12% false-
profile, and fetal Doppler studies (GOOD PRACTICEpositive rate; if the standard cut-offs for singleton pregnancy
POINT).
were used, the sensitivity would be 18% for a 1.7% false-
130. • As there have been no randomized controlled trials, thepositive rate
components, frequency and impact of ultrasound
8

surveillance in pregnancies affected by PE have yet to be abruption include retroplacental hematoma (hyperechoic,
determined (GOOD PRACTICE POINT). isoechoic, hypoechoic), preplacental hematoma, increased
placental thickness and echogenicity, subchorionic collection• Examination of fetal biometry, amniotic fluid volume,
and marginal collection of blood. However, the sensitivity ofuterine artery, umbilical artery (UA) and fetal middle
ultrasound in diagnosing placental abruption is poor, ascerebral artery (MCA) PI and cerebroplacental ratio
approximately 50–75% of these cases may be missed by(CPR), as well as placental visualization to exclude 151,152.
ultrasound examination Chronic abruption, which may beabruption, should be considered in women presenting
seen as a retroplacental sonolucent area on ultrasoundwith headache, abdominal pain, bleeding and/or
imaging, and oligohydramnios sequence can develop in PEreduced fetal movements (GOOD PRACTICE POINT). 153
patients .
• The same tests should be considered for women
Doppleradmitted for PE or with suspected PE, as well as for those
with severe PE or HELLP syndrome (GOOD PRACTICE The four Doppler territories commonly examined for fetal
POINT). and maternal evaluation are: (1) UA, (2) fetal MCA, (3) fetal
ductus venosus and (4) uterine arteries.PE is commonly associated with fetal growth restriction,
Briefly, absent or reversed end-diastolic velocity in the UAand these fetuses tend to be delivered earlier and deteriorate
154,155
is strongly associated with perinatal morbidity/ mortality .faster compared with growth-restricted fetuses of
137.
Reduced MCA-PI <10th percentile is a sign of brainnormotensive mothers Therefore, the identification and
vasodilatation and has been associated with emergencyfollow-up of fetal growth restriction is of paramount
Cesarean delivery due to non-reassuring fetal heart rate inimportance for the optimization of perinatal outcome in PE.
156–158
growth-restricted fetuses . CPR<10th percentile isB-mode ultrasound
considered to be a sign of hemodynamic redistribution, can
Biometry. Fetal biometry can be assessed to identify a
be observed even before the UA is affected and is an138
159–161SGA fetus and to predict SGA newborns .
indicator for close fetal surveillance . Reversed a-wave in
Amniotic fluid index. The amount of amniotic fluid can be the ductus venosus is a strong manifestation of fetal cardiac
assessed by the amniotic fluid index (AFI) or by the maximum deterioration and is associated with a high risk of perinatal
162,163
vertical pocket (MVP): MVP<2 cm and/or AFI<5 cm are mortality and severe neonatal morbidity The results of the
considered as cut-off values for the diagnosis of reduced TRUFFLE trial provide insight into the follow-up of growth-
139,140.
amniotic fluid or oligohydramnios Compared with AFI, restricted fetuses in PE, as most of its participants either had PE
measurement of MVP may result in fewer interventions without at enrollment or developed it during their follow-up. It was
141.
increasing adverse perinatal outcome found that optimal long-term outcome for growth-restricted
fetuses with abnormal UA flow is achieved when delivery isFetal movements. As part of the fetal biophysical profile,
postponed until the a-wave in the ductus venosus becomesfetal breathing movements, body/limb movements and
reversed, unless reduced short-term variability on non-stressmuscular tone (e.g. extension and flexion of a fetal extremity or
142.
test is observed meanwhile, prompting immediateopening and closing of the hand) should be observed 137,164,165
delivery . Increased resistance in the uterine arteriesThese three components, plus the assessment of amniotic
indicates defective spiral artery transformation and is notfluid volume and fetal heart rate, constitute the fetal
useful as an indication for delivery.biophysical profile. Positive findings for each component are
assigned a value of 2, with the total biophysical profile score Guidelines for fetal Doppler evaluation have been
16
(BPP score) ranging from 0 to 10. A BPP score≥8 is considered published previously further details of Doppler evaluation
to be normal and a manifestation of fetal wellbeing. A BPP are beyond the scope of these Guidelines.
score of 6 is an inconclusive result, and the test should be Technical advice
repeated. A BPP score≤4 is a non-reassuring fetal test result, • Administration of antihypertensive drugs is not143,144.
and delivery should be considered Biophysical profile associated with significant changes in maternal and fetal
testing is used mostly in the USA, whereas clinical Doppler indices (EVIDENCE LEVEL: 2+).
management in Europe is based mostly on Doppler
• Antenatal corticosteroids are associated with a transient
examination. There are no data for the comparative cost-
decrease in vascular resistance in the UA and ductus
effectiveness of the two methods.
venosus (EVIDENCE LEVEL: 2+).
Placenta. Visualization of the placenta might help to
• Data regarding a potential effect of magnesium sulfate on
exclude signs suggestive of severe PE, such as a thickened
maternal and fetal Doppler indices are inconclusive
placenta with diffuse echogenicity most probably due to
(EVIDENCE LEVEL: 2–).145,146,
edema, a thin placenta with reduced vascularization or
147,148. Use of labetalol, nifedipine or hydralazine has not beencystic regions suggestive of infarctions or hematomas
found to be associated with changes in uterine artery or UAWomen with PE are at risk of partial or total abruption; 166–169. 170
Doppler waveforms However, Grzesiak et al. and Limatherefore, evaluation of the placenta–myometrium interface is 171
149,150. et al. reported a mild reduction in MCA-PI afterimportant Sonographic findings related to placental
9

administration of nifedipine, with no alteration in the other Screening for pre-eclampsia using ultrasound
vascular territories. Methyldopa also has no effect on uterine Which Doppler index to use
artery resistance in patients with gestational hypertensive
• The PI should be used for examination of uterine artery172.
disease resistance in the context of PE screening (GRADE OF
The effect of antenatal corticosteroids in the fetal RECOMMENDATION: B).
circulation has been documented extensively. A transient First trimester
reduction in vascular resistance and in UA-PI and ductus
• Doppler examination of the uterine arteries at 11+0 tovenosus-PI is generally observed. Absent or reversed end-
13+6 weeks can be performed either transabdominallydiastolic or atrial velocities generally improve after the
or transvaginally, according to local preferences andadministration of corticosteroids; this effect generally lasts for
resources (GOOD PRACTICE POINT).48–72 hours, but it can be longer in some fetuses. Some have
also reported a mild reduction in MCA-PI; however, no effect • Standardized methodology, as described in these
of steroids on the uterine artery Doppler waveform has been Guidelines, should be followed for assessment of the
173–176.
reported uterine artery Doppler indices (GOOD PRACTICE POINT).
There is no consensus regarding the effect of magnesium • Mean uterine artery PI should be the Doppler index of
sulfate on fetal hemodynamics. Some studies found a choice for screening in the first trimester (GRADE OF
reduction in PI or in RI of the UA, uterine artery andMCA after RECOMMENDATION: B).177–179,
the administration of magnesium sulfate but others found
• Given that maternal factors can affect uterine artery PI, its180.
no such effect
inclusion in a multifactorial screening model should,
FUTURE RESEARCH whenever feasible, be preferred over its use as a
standalone test with absolute cut-offs (GRADE OFRecommendation
RECOMMENDATION: B).• Doppler studies need to fulfill quality criteria, including
prospective data collection, specific scan for research Second trimester
purposes and examination of consecutive patients (i.e. • Doppler examination of the uterine arteries at the
non-opportunistic recruitment) (GRADE OF second-trimester scan can be performed either
RECOMMENDATION: C). transabdominally or transvaginally, according to local
Doppler examination of maternal and fetal vessels has preferences and resources (GOOD PRACTICE POINT).
been in use for about two decades, with a significant positive
• Mean uterine artery PI should be used for prediction of PE.
impact on maternal and fetal health. However, both older and
In case of a unilateral placenta, a unilaterally increased PI
newer Doppler studies may be biased, for different reasons.
does not appear to increase the risk for PE if the mean PI is
Older studies were performed using ultrasound machines
within normal limits (GRADE OF RECOMMENDATION: B).with lower image resolution than the ones used now, and it is
Third trimesternot certain whether results would be the same if newer
ultrasound technology had been used. Newer Doppler • There are currently no randomized trials on the impact of
studies were performed at a time when the value of Doppler third-trimester screening for PE on maternal, fetal and
was already established and this may have resulted in two neonatal outcomes; consequently, its implementation
forms of bias: intention-to-treat bias, i.e. the Doppler findings into routine practice cannot be recommended at present
may have affected the management, and hence the natural (GOOD PRACTICE POINT).
history, of any condition diagnosed; and expected-value bias,
• Mean uterine artery PI should be used for prediction ofi.e. as normal ranges of Doppler measurements became
PE, if this is offered in the third trimester (GRADE OFavailable, examiners might subconsciously have adjusted their
RECOMMENDATION: B).measurements towards the expected normal range,
Longitudinal changes in Doppler indicespotentially biasing any retrospective study using these data. A
181
recent systematic review showed that the vast majority of • Given that preventive strategies (e.g. low-dose aspirin)
Doppler studies suffer from methodological limitations, and for reducing the risk of PE are effective if started in the first
proposed a set of criteria which should be applied in future trimester, their use should be commenced as soon as
high-quality studies. These criteria involve, among others: possible in women identified as being high-risk, without
prospective data collection, a specific scan for research
waiting to assess the evolution of Doppler in the second
purposes and examination of consecutive patients (i.e. non-
181 trimester (GOOD PRACTICE POINT).
opportunistic recruitment) .
Placental volume
SUMMARY OF RECOMMENDATIONS
• Although placental volume and vascularization indices
Relevant information available to the examiner have been assessed as predictors for PE, they cannot be
• Examiners involved in screening for PE should have up- recommended for screening purposes given that their
to-date knowledge regarding major risk factors for PE reproducibility is limited, they require special equipment
(GOOD PRACTICE POINT). and they are time-consuming (GOODPRACTICE POINT).
10

Combined screening strategies bleeding and/or reduced fetal movements (GOOD
PRACTICE POINT).• A combination of maternal factors, maternal arterial
blood pressure, uterine artery Doppler and PlGF level at • The same tests should be considered for women
11–13 weeks appears to be the most efficient screening admitted for PE or with suspected PE, as well as for those
model for identification of women at risk of PE (GRADE with severe PE or HELLP syndrome (GOOD PRACTICE
OF RECOMMENDATION: B). POINT).
• Given the superiority of combined screening, the use of Future research
Doppler cut-offs as a standalone screening modality • Doppler studies need to fulfill quality criteria, including
should be avoided if combined screening is available prospective data collection, specific scan for research
(GRADE OF RECOMMENDATION: B). purposes and examination of consecutive patients (i.e.
• The transabdominal approach is preferred for calculating non-opportunistic recruitment) (GRADE OF
first-trimester individual patient risk, asmost screening RECOMMENDATION: C).
algorithms were developed using this approach (GOOD
GUIDELINE AUTHORSPRACTICE POINT).
These guidelines were produced by ISUOG CSCAssessment of maternal hemodynamics
Preeclampsia Task Force.• Despite the fact that maternal hemodynamic assessment
A. Sotiriadis, Second Department of Obstetrics andmay be of value in prediction of PE, there are still few data
Gynecology, Faculty of Medicine, Aristotle University ofto support its routine implementation in clinical practice
Thessaloniki, Thessaloniki, Greeceas a standalone test (GOOD PRACTICE POINT).
E.Hernandez-Andrade, Division of Maternal FetalManagement after screening
Medicine, Department of Obstetrics and Gynecology, Hutzel• There is convincing evidence that low-dose aspirin can
Women Hospital, Wayne State University, Detroit, MI, USAdecrease significantly the risk for development of early PE,
F. da Silva Costa, Department of Gynecology andwhen administration commences at the time of first-
Obstetrics, Ribeirao Preto Medical School, University of Saotrimester screening (GRADE OF RECOMMENDATION : A).
Paulo, Ribeirao Preto, Sao Paulo, Brazil; and Department ofMultiple pregnancy
Obstetrics and Gynaecology, Monash University, Melbourne,• Due to increased placental mass in twin pregnancy,
Australiaresulting in lower mean resistance in the uterine arteries,
T. Ghi, Obstetrics and Gynecology Unit, University oftwin-specific reference ranges are preferred for Doppler
Parma, Parma, Italyexamination, if available (GRADE OF RECOMMENDA-
TION: B). P. Glanc, Department of Radiology, University of Toronto,
Toronto, Ontario, Canada• The combined screening (maternal factors, uterine artery
PI, mean blood pressure, PlGF) algorithm for singletons A. Khalil, Fetal Medicine Unit, St George’s University
can also be used in twins and can identify more than 95% Hospitals NHS Foundation Trust, London, UK; and Vascular
of women with twin pregnancy who will develop PE. Biology Research Centre, Molecular and Clinical Sciences
However, the examiner should be aware that this is Research Institute, St George’s University of London, London,
achieved at the cost of a 75% screen-positive rate UK
(GRADE OF RECOMMENDATION: B). W. P. Martins, SEMEAR Fertilidade, Reproductive
Use of ultrasound in patients with established pre-eclampsia Medicine and Ribeirao PretoMedical School, University of Sao
• Given that fetal deterioration is an indication for delivery in Paulo, Ribeirao Preto, Brazil
established PE, fetal status should be assessed regularly in A. O. Odibo, Department of Obstetrics and Gynecology,
these patients (GOOD PRACTICE POINT). Morsani College of Medicine, University of South Florida,
• The sonographic follow-up in pregnancies affected by PE Tampa, FL, USA
includes assessment of fetal growth and biophysical A. T. Papageorghiou, Fetal Medicine Unit, St George’s
profile, and fetal Doppler studies (GOOD PRACTICE University Hospitals NHS Foundation Trust, London, UK;
POINT). and Nuffield Department of Obstetrics and Gynecology,
• As there have been no randomized controlled trials, the University of Oxford, Women’s Center, John Radcliffe Hospital,
components, frequency and impact of ultrasound Oxford, UK
surveillance in pregnancies affected by PE have yet to be L. J. Salomon, Department of Obstetrics and Fetal
determined (GOOD PRACTICE POINT). Medicine, Hopital Necker-Enfants Malades, Assistance
• Examination of fetal biometry, amniotic fluid volume, Publique-Hopitaux de Paris, Paris Descartes University, Paris,
uterine artery, UA and MCA PI and CPR, as well as placental France
visualization to exclude abruption, should be considered B. Thilaganathan, Fetal Medicine Unit, St George’s
in women presenting with headache, abdominal pain, University Hospitals NHS Foundation Trust, London, UK; and
11

14. FalcoML, Sivanathan J, Laoreti A, Thilaganathan B, Khalil A. PlacentalVascular Biology Research Centre, Molecular and Clinical
histopathology associated with pre-eclampsia: systematic review and
Sciences Research Institute, St George’s University of London,
meta-analysis. Ultrasound Obstet Gynecol 2017; 50: 295–301.
London, UK
15. Orabona R, Donzelli CM, Falchetti M, Santoro A, Valcamonico A, Frusca
T. Placental histological patterns and uterine artery Doppler velocimetryCITATION
in pregnancies complicated by early or late pre-eclampsia. Ultrasound
These Guidelines should be cited as: ‘Sotiriadis A, Obstet Gynecol 2016; 47: 580–585.
Hernandez-Andrade E, da Silva Costa F, Ghi T, Glanc P, Khalil A,
16. Bhide A, Acharya G, Bilardo CM, Brezinka C, Cafici D, Hernandez-
Martins WP, Odibo AO, Papageorghiou AT, Salomon LJ, Andrade E, Kalache K, Kingdom J, Kiserud T, Lee W, Lees C, Leung KY,
Thilaganathan B. ISUOG Practice Guidelines: role of ultrasound Malinger G, Mari G, Prefumo F, Sepulveda W, Trudinger B. ISUOG Practice
Guidelines: use of Doppler ultrasonography in obstetrics. Ultrasoundin screening for and follow-up of pre-eclampsia. Ultrasound
Obstet Gynecol 2013; 41: 233–239.
Obstet Gynecol 2018; 53: 7–22’.
17. Papageorghiou AT, Yu CK, Bindra R, Pandis G, Nicolaides KH, Fetal
REFERENCES Medicine Foundation Second-Trimester Screening Group. Multicenter
screening for pre-eclampsia and fetal growth restriction by transvaginal
1. Duley L. The global impact of pre-eclampsia and eclampsia. Semin
uterine artery Doppler at 23 weeks of gestation. Ultrasound Obstet
Perinatol 2009; 33: 130–137.
Gynecol 2001; 18: 441–449.
2. Dolea C, AbouZahr C. Global burden of hypertensive disorders of
18. Brodszki J, Lanne T, Laurini R, Strevens H, Wide-Swensson D, Marsal K.
pregnancy in the year 2000. Evidence and Information for Policy (EIP).
Vascular mechanical properties and endothelial function in pre-
World Health Organization: Geneva, 2003. http://www.who.int/
eclampsia with special reference to bilateral uterine artery notch. Actahealthinfo/statistics/bod_ hypertensivedisordersofpregnancy.pdf
Obstet Gynecol Scand 2008; 87: 154–162.
3. WHO. WHO recommendations for prevention and treatment of pre-
19. Melchiorre K, Leslie K, Prefumo F, Bhide A, Thilaganathan B. First-trimestereclampsia and eclampsia. WHO: Geneva, Switzerland, 2011.
uterine artery Doppler indices in the prediction of small-for-gestationalhttp://www.who.int/ reproductivehealth/publications/
age pregnancy and intrauterine growth restriction. Ultrasound Obstetmaternal_perinatal_health/9789241548335/en/
Gynecol 2009; 33: 524–529.
4. Chaiworapongsa T, Chaemsaithong P, Yeo L, Romero R. Pre-eclampsia
20. Cnossen JS, Morris RK, ter Riet G, Mol BW, van der Post JA, Coomarasamypart 1: current understanding of its pathophysiology. Nat Rev Nephrol
A, Zwinderman AH, Robson SC, Bindels PJ, Kleijnen J, Khan KS. Use of2014; 10: 466–480.
uterine artery Doppler ultrasonography to predict pre-eclampsia and
5. Melchiorre K, Sharma R, Thilaganathan B. Cardiovascular implications in intrauterine growth restriction: a systematic review and bivariable meta-
preeclampsia: an overview. Circulation 2014; 130: 703–714. analysis. CMAJ 2008; 178: 701–711.
6. Mifsud W, Sebire NJ. Placental pathology in early-onset and late-onset 21. Rolnik DL, Wright D, Poon LCY, Syngelaki A, O’Gorman N, de Paco
fetal growth restriction. Fetal Diagn Ther 2014; 36: 117–128. Matallana C, Akolekar R, Cicero S, Janga D, Singh M, Molina FS, Persico N,
Jani JC, Plasencia W, Papaioannou G, Tenenbaum-Gavish K, Nicolaides7. Llurba E, Carreras E, Gratacos E, Juan M, Astor J, Vives A, Hermosilla E,
KH. ASPRE trial: performance of screening for preterm pre-eclampsia.Calero I, Millan P, Garcia-Valdecasas B, Cabero L. Maternal history and
Ultrasound Obstet Gynecol 2017; 50: 492–495.uterine artery Doppler in the assessment of risk for development of
early- and late-onset preeclampsia and intrauterine growth restriction.
22. TanMY, Wright D, Syngelaki A, Akolekar R, Cicero S, Janga D, SinghM,
Obstet Gynecol Int 2009; 2009: 275613.
Greco E, Wright A, Maclagan K, Poon LC, Nicolaides KH. Comparison of
diagnostic accuracy of early screening for pre-eclampsia by NICE8. Stergiotou I, Crispi F, Valenzuela-Alcaraz B, Bijnens B, Gratacos E. Patterns
of maternal vascular remodeling and responsiveness in early- versus guidelines and a method combining maternal factors and biomarkers:
late-onset preeclampsia. Am J Obstet Gynecol 2013; 209: 558.e1–14. results of SPREE. Ultrasound Obstet Gynecol 2018; 51: 743–750.
9. O’Gorman N, Wright D, Syngelaki A, Akolekar R, Wright A, Poon LC, 23. Tan MY, Poon LC, Rolnik DL, Syngelaki A, de Paco Matallana C, Akolekar R,
Nicolaides KH. Competing risks model in screening for preeclampsia by Cicero S, Janga D, Singh M, Molina FS, Persico N, Jani JC, Plasencia W,
maternal factors and biomarkers at 11–13 weeks gestation. Am JObstet Greco E, Papaioannou G, Wright D, Nicolaides KH. Prediction and
Gynecol 2016; 214: 103.e1–12. prevention of small-for-gestational-age neonates: evidence from SPREE
and ASPRE. Ultrasound Obstet Gynecol 2018; 52: 52–59.10. Rolnik DL, Wright D, Poon LC, O’Gorman N, Syngelaki A, de Paco
Matallana C, Akolekar R, Cicero S, Janga D, Singh M, Molina FS, Persico N, 24. Tayyar A, Guerra L, Wright A, Wright D, Nicolaides KH. Uterine artery
Jani JC, PlasenciaW, Papaioannou G, Tenenbaum-Gavish K, Meiri H, pulsatility index in the three trimesters of pregnancy: effects of maternal
Gizurarson S,Maclagan K, Nicolaides KH. Aspirin versus placebo in characteristics and medical history. Ultrasound Obstet Gynecol 2015;
pregnancies at high risk for preterm preeclampsia. N Engl J Med 2017; 45: 689–697.
377: 613–622.
25. Martin AM, Bindra R, Curcio P, Cicero S, Nicolaides KH. Screening for pre-
11. Baschat AA. First-trimester screening for pre-eclampsia: moving from eclampsia and fetal growth restriction by uterine artery Doppler at
personalized risk prediction to prevention. Ultrasound Obstet Gynecol 11–14 weeks of gestation. Ultrasound Obstet Gynecol 2001; 18:
2015; 45: 119–129. 583–586.
12. World Health Organization. Screening for various cancers. Secondary 26. Plasencia W, Maiz N, Bonino S, Kaihura C, Nicolaides KH. Uterine artery
screening for various cancers 2018. http: //www.who.int/ Doppler at 11 + 0 to 13 + 6 weeks in the prediction of pre-eclampsia.
cancer/detection/variouscancer/en/. Ultrasound Obstet Gynecol 2007; 30: 742–749.
13. Public Health England. Guidance: Criteria for appraising the viability, 27. Khalil A, Nicolaides KH. How to record uterine artery Doppler in the first
effectiveness and appropriateness of a screening programme.
trimester. Ultrasound Obstet Gynecol 2013; 42: 478–479.
Secondary guidance: criteria for appraising the viability, effectiveness
28. Gomez O, Martinez JM, Figueras F, Del Rio M, Borobio V, Puerto B, Coll O,and appropriateness of a screening programme 2015. https:
//www.gov.uk/government/publications/evidence-review- Cararach V, Vanrell JA. Uterine artery Doppler at 11–14 weeks of
criterianational- screening-programmes/criteria-for-appraising-the- gestation to screen for hypertensive disorders and associated
viability-effectivenessand- appropriateness-of-a-screening- complications in an unselected population. Ultrasound Obstet Gynecol
programme. 2005; 26: 490–494.
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