Prenatal Evaluation of High Risk Pregnancies

following Invitro-Fertilization:

“Reduce Mother and Fetus Mortality Rates!”

Irani Sh.* (B.Sc.&PHD), Javam M. (B.Sc), Ahmadi F. (MD)

Department of Reproductive Imaging at Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran

What’s the issue ?

The use of assisted-reproduction technologies has increased

over the past decade!

Pregnancies following IVF are associated with higher risk of obstetric morbidities and perinatal mortality and several studies have demonstrated that the rate of prenatal complications is significantly more frequent in IVF-conceived pregnancies compared to spontaneous pregnancies.

Results Population Country Author (year)Ante-partum hemorrhage congenital anomalies hypertensive disorders of pregnancy (HTN)preterm rupture of membranes (PROM)cesarean section (CS)low birth weight (LBW)perinatal mortality (P.M)preterm delivery (PTD)gestational diabetes small for gestational age

Metha analysis(20 Studies) UK Shilpi pandy

2012

Multiple pregnancy P.MPTDLBWCSplacenta previa (P.P)congenital abnormalitiesReduction

Review article canada Vicoriam(2006)

Overall failure of pregnancy: 21,7% Twins: (%17/1)Death after positive FHR : 12,2%Twins: 7,3%

1597single 1200

Twin 397belgium Philippe Tummers (2003)

CSPTDLess average birth weight

283 croatia Du valtka (2005)

Bleeding ovarian torsion preeclampsia placental abruptionPROM P.P

- sweden Bengt kallen (1981- 2001)

Single : HTN / bleeding / maternal complication Twins : CS / bleeding / preterm labor / LBW

Single : 322Twin : 78

Germany Odsenkuhn.R

(1991-1996)

Thus, a proper prenatal evaluation is required in this group to

protect mother and fetus health!

Sonographic examination during pregnancy is a helping method to detect

pregnancy complications and to organize a proper “prenatal care” for IVF-

conceived women.

We provide a clinical instruction for sonographic assessment of

pregnancies following IVF and management of patients based on reports:

1st trimester :

Goals of first ultrasound scan of IVF-resulted pregnancies:

To assure a normal “intrauterine” pregnancy!

To rule out emergency conditions that are a threat to mother’s health:

* Ectopic or Heterotopic Pregnancy is shown to be 5-10 times more prevalent

than general population!

* Molar pregnancy & threatened abortion are also more frequent in this group

To establish gestational age “accurately” and to confirm fetus viability

To determine the number of fetuses and chorionicity-amnionicity in multiple pregnancies based on:

the number of gestational sacs, amnions, and yolk sacs

D-D twins

(DZ)

M-D twins

(MZ)

M-M twins

(MZ)

1st trimester complications:

1. Bleeding

with IUP:

• Failed pregnancy (missed AB FHR -) • Hemorrhage • Partial mole (less common) • An embryonic• Heterotopic pregnancy (rare)• Interestitial / cervical EP (rare)• Twin demise

without IUP:

• Complete Abortion• Very early pregnancy • Retained product of P.• Tubal ectopic • Complete hydatyform Mole

(less common)• Abdominal ectopic (rare)

2. Pain:

• Hemorrhagic cyst

• Corpus Luteum cyst

• EP

• OHSS

• Adnexal torsion

• Appendicitis (less common)

3. Discrepancy between GA and ET-date:

GS without fetal pole

Fetal pole without FHR

Fetal pole with FHR

Multiple fetuses

blighted ovum or not ?

(GS diameter <20mm or >20mm?)

monitor sonography recommended

(based on previous exams)

follow-up within weeks 11-14

follow-up studies based on chorionicity

1st trimester Anomaly Screening

Some embriologists believe that the risk of fetal anomalies in IVF-resulted embryos is a bit higher!

Thus, a careful examination needs to be done for anomaly screening in this group.

First anomaly scan contains “Nuchal Translucency” measurement and look for structural abnormalities within 11th-14th weeks.

Further investigations are recommended in case of increased risk.

First TrimesterAnomaly

Screening

2nd & 3rd trimesters :

Second and third trimester have are vital periods of fetal growth.

There are several complications which have adverse affects on this

event.

Sonography is helpful for early detection of risks for most of these

complications such as vaginal bleeding, IUGR, preterm birth, etc.

1. Cervical Insufficiency:

A prevalent cause of preterm birth

among these women

Early diagnosis & decision for cerclage

placement can reduce PTB rate.

Screening method:

- Serial cervical length measurement by means of TAS or TVS (preferred)

- At least twice during 2nd trimester (before 20th week)

2. Bleeding:

Common reasons:

• Placenta previa • Marginal sinus previa • Placenta accreta spectrum

Less common:

• Succenturiate lobe • Placenta accreta • Placenta abruption• Cesarean section rupture

Marginal previa

3. PROM & oligohydroamnios:

Maximum Vertical pocket<2cm , AFI < 5cm

Early oligohydroamnios: <25 week

Prolonged oligohydroamnios : >14 days

D.D: PROM / IUGR /Renal agenesis /bladder outlet obstruction / TTTS in multiples

Serial monitoring sonographies are essential

4. Growth Restriction:

Fetal weight < %10 percentile

IUGR differential diagnosis approach:

Rule out fetal anomaly as cause for IUGR

Amniocentesis if fetal anomaly suspected

Consider maternal medical history

Assess amniotic fluid

Assess fetal / placental circulation

Differentiate between symmetric vs. asymmetric IUGR

Doppler Examination

Biophysical profile (BPP) if needed

5. Gestational Diabetes and Pre-eclampsia:

- Consider fetal growth and probable discrepancy

- Mention to placenta size and shape

- Assess A.F.I

- Use Color Doppler to check blood circulation if needed

- BPP if prescribed

6. Multiple Gestations:

Discrepancy between multiples:

“Consider Chorionicity!”

Follow up sonography every 2 weeks

TTTS:

Recommendation for US exams:

1. Early first trimester ( to week of gestation): To confirm intra uterine pregnancy (IUP) and to rule out ectopic pregnancy (EP), to ensure fetal heart activity, diagnosis of multiple pregnancy and estimation of gestational age.

2. Late first trimester (to week): To evaluation fetal growth, to assess fetal structural malformations (like Anencephaly, etc.) and detection of anomaly markers (measuring nuchal translucency) to find out high risk patients.

3. Second trimester ( to week): Evaluation of fetal growth, to assess fetal structural malformations and anomaly markers (measuring nuchal fold & nasal bone) to detect high risk patients, diagnosis of cervical insufficiency and need to “cerclage placement”.

4. Third trimester ( to week): Evaluation of fetal growth and weight, measuring amniotic fluid index (AFI), assessment of fetal structural abnormalities (such as hydrocephaly, etc.) and Biophysical Profile (if needed).

Conclusion:

Prenatal sonography is an accurate, non-invasive, and cost-effective tool that helps midwives and obstetricians to evaluate mother and fetus health and detection of pregnancy complications to give better prenatal care for pregnant women, especially for those who became pregnant after IVF treatment.

A proper “prenatal care” can be organized based on sonography reports.

THANKSFOR

YOUR

ATTENTION!