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  1. 1. HAND BOOK OF INSUOG Design & Printed by : Dinkar - 08057108836
  2. 2. INSUOG 2019 HAND BOOK OF INSUOG 3rd - 5th May Radission Blu, Agra
  3. 3. 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 2
  5. 5. 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 4
  6. 6. 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 5
  7. 7. 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 6
  8. 8. 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 7
  9. 9. 9 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 18:05-18:10 Audience Interaction 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)
  10. 10. 10 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 10:20-10:35 Audience Interaction 10:35-11:00 Tea/Coffee Break 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 13:00-13:20 Audience Interaction 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 11:00-11:30 Tea/Coffee Break 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 13:00-13:15 Audience Interaction 13:15-14:15 Lunch
  11. 11. 11 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 16:30-16:45 Audience Interaction 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 11:15-11:25 Audience Interaction 11:25-11:45 Tea/Coffee Break 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 13:45-14:00 Audience Interaction 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 17:20-17:30 Audience Interaction 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)
  12. 12. 12 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 12:40-13:00 Audience Interaction 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 14:45-15:00 Audience Interaction 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 11:20-11:25 Audience Interaction 11:25-11:45 Tea/Coffee Break 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
  13. 13. 13 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 15:45-16:00 Audience Interaction 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 10:50-11:00 Audience Interaction 11:00-11:30 Tea/Coffee Break 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)
  14. 14. 14 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 11:30-12:00 Tea/Coffee Break 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
  15. 15. 15 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 15
  16. 16. 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
  17. 17. 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
  18. 18. 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.
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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. 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