Rationale of Treatment

*1.Ultrasound Guided Amnioinfusion* :

*a)* Obviously would immediately increase AFI.

*b)* The immediate expansion of amniotic cavity would plaster the broken hole of amnion-chorion to the uterine wall, thereby blocking the potential leak.

*c)* Apt Fluid hence would let fetus to move freely leading to decrease chances of potential strictures, Hypoplasia, Deformities etc

*d)* A good AFI is must for an Ultrasound for anatomical surveillance (Level- II), Especially for Foetal urogenital area

 *2 *.Fibrin Sealents/Amniopatch* ( Esp in PPROM)

It is supported by the fact that the infusion of platelets followed by cryoprecipitate provides fibrinogen, fibronectin, platelet derived growth factors, TGF-beta, von Willebarnd factor, factor VIII and factor XIII in high concentrations, which adhere to the area of leak in amnion and chorion forming a platelet plugs which is subsequently stabilized by cryoprecipitate

Other Treatments offered In cases with *Idiopathic Oligohydraminos* are:

*1. Maternal Hydration (Oral/Intravenous* )

 *Rationale* : Maternal osmotic change and/or maternal volume expansion would probably bring a positive osmotic gradient towards the amniotic cavity thereby increasing AFI.

*2. Amino acids (Arginine) (Oral /Intravenous)*

 *Rationale:* l-arginine is the sole endogenous precursor of nitric oxide (NO) which is involved in the regulation of blood flow in vascular beds ,causes vasodilatation and shows aggregative effect on platelets which  increases the volume and viscosity of blood  in the fetomaternal circulation


*Rationale*: These all would improve the compromised uteroplacental circulation and hypoperfusion in one way or the other and hence improve AFI




*Ever Wondered*

*Why Nuchal Translucency scan is offered between 11 to 13+6 weeks of Gestation and not Before or After*


There are *two reasons* for selecting 11 weeks as the earliest gestation for measurements of NT.

1. As the Fetus is growing, *Many major fetal areas appear clealy only after 11 weeks* (For Example)

*a)  Ossification of the fetal skull is not reliable before this gestation* and hence one can miss Diagnosis or exclusion of *acrania* and therefore *anencephaly* If done before 11 weeks.

*b)* Examination of the *four-chamber view of the heart* and main arteries is possible only after 10 weeks.

*c)* There is a *normal herniation of the midgut* that is visualized as a hyperechogenic mass in the base of the umbilical cord before 10 weeks  and it is therefore unsafe to diagnose or exclude *exomphalos* at this gestation.

*d)* The *fetal bladder* can be visualized in only 50% of fetuses at 10 weeks, in 80% at 11 weeks and in all cases by 12 weeks.

*2.*  In cases which come positive and further need a diagnostic Invasive procedures , *chorionic villous sampling before this gestation is not recommended as it is associated with transverse limb reduction defects.*

The reasons for selecting *13 weeks and 6 days* as the upper limit is to:

1. Provide women with affected fetuses the option of *first rather than second trimester termination.*

*2* . The incidence of abnormal accumulation of nuchal fluid in chromosomally abnormal fetuses is *lower at 14–18 weeks than before 14 weeks*

*3* . The fetus *becomes vertical after 14 weeks* making it more difficult to obtain the appropriate image.





*Dr Jyotsna* of _PROMISE ULTRASOUND AND FETAL MEDICINE CENTRE_ is *specially trained in 4D Fetal echocardiography* and Fetal Invasive procedures.

Lets discuss in brief about Fetal Echocardiography and it’s indications *(especially where we miss to offer it to our patients)*

Fetal echocardiography is a  specialized

diagnostic procedure which basically is  an *extension of The classic Four chamber view and outflow tracts* seen in routine Level II scan.Congenital heart disease is a *leading cause of infant morbidity and mortality* from birth defects with an estimated incidence of 6 per 1000 live births for moderate to severe forms Although there are specific indications, *we usually  miss to offer Fetal echocardiography in following situations*

 *1.* *IVF pregnancy*  Always offer a separate Fetal echo in IVF cases according to AIUM guidelines.This probably is because gametes are externally manipulated with exposure to so much media or because IVF itself is a high risk pregnancy.

*2.Diabetes stuck pregnancy*as diabetes has a strong known association with VSD,truncus arteriosus,TOF,TGA etc

*3.Abnormal Nuchal translucency scan or  prenatal screening/markers* ….Although in all cases with increased NT, Fetal Echo should be done according to AIUM guidelines,We at _PROMISE ULTRASOUND AND FETAL MEDICINE CENTRE_ recommend the same for other positive prenatal Screening tests as well

*4.Any Accidental clinical Finding of Fetal bradycardia or dysthymia on auscultation*

*5.Suspected Unknown teratogenic exposure in first trimester*

Other  Indications are:

• Autoimmune antibodies, anti-Ro (SSA)/anti-La (SSB);

• Familial inherited disorders (eg, 22q11.2 deletion syndrome)

• Abnormal cardiac screening examination

• First-degree relative of a fetus with congenital heart disease

• Fetal chromosomal anomaly

• Extracardiac anomaly

• Hydrops

• Monochorionic twins

Dear Doctor,

You must have noticed that while doing *First Trimester Ultrasonography* for various reasons, _PROMISE ULTRASOUND AND FETAL MEDICINE CENTRE_ always report *Uterine Artery Doppler Parameters* . Let’s briefly discuss the Importance of the same in First Trimester.

Doppler in second and third trimester is not new to anyone. There is a growing evidence that first-trimester uterine artery Doppler has better predictive accuracy in detecting *early-onset preeclampsia and Fetal Growth Restriction* than late-onset disease. Although The sensitivities and specificities of uterine artery Doppler is moderate (40%) which limits its utility as a disease marker in isolation but associating Doppler with other multiparametric models like *maternal characteristics  and biochemical markers*  have the potential to improve detection rates for preeclampsia and other adverse pregnancy outcomes to *over 90%.*

The biochemical markers used in First trimester  screening for Preeclampsia and FGR are *PAPP-A, PlGF, sFLT-1, Inhibin-A, Activin-A, sEng, PP13, ADAM12* etc. Maternal characteristics that associate the most are *BMI, Ethnicity, parity, previous PE, age, HTN, DM, Renal Disease, thrombophilia and smoking .* So in conclusion, A Well Studied Ultrasound in first trimester  can tell you a lot of things other than Fetal well being ,Chorionicity and Multiplicity….

1. *As an aneuploidy scan* , Nuchal translucency with Nasal bone, tricuspid flow, ductus venosus flow ,maternal age and PAPP-A and HCG, it can Detect for Down’s Syndrome with an accuracy *of 95%*

2. *As a chance to screen for Preeclampsia and IUGR* ,As mentioned above with an accuracy *of 95%*

3. *As a Anomaly scan* with Detection rate of *100 %* for some abnormalities like Anencephaly,Holoprosencephaly etc and *50%* in some others.


Two most frequently encountered dilemmas in routine

*First trimester* 

In cases with *enlarged* *nuchal* *translucency* , not only Aneuploidy risk increases but it can also be associated with *Noonan syndrome, multiple pterygium syndrome, skeletal dysplasias, congenital heart disease, and other anomalies.*


For patients with increased NT, We at Promise Ultrasound and fetal medicine centre do an *early Detailed anatomical/Structural Surveillance* . If No Structural abnormality is seen, we offer Cell Free DNA (cfDNA/NIPT), *But in cases where structural Anomaly is found, we prefer to do Amniocentesis with Micro array rather than a just Karyotype* .

*Second trimester*:

Any isolated finding Like:

*a)  Pyelectasis* ( Renal pelvis measuring ≥ 4 mm in anteroposterior diameter up to 20 weeks of gestation)

*b) Echogenic intracardiac foci* ( Echogenic tissue in one or both ventricles of the heart seen on standard four-chamber view )

*c) Echogenic bowel* (Fetal small bowel as echogenic as bone )

*d) Thickened 2nd Trimester nuchal fold* ( ≥ 6 mm from outer edge of the occipital bone to outer skin in the midline )

*e) Mild ventriculomegaly* ( Lateral ventricular atrial measurement between 10–15 mm )

*f) Choroid plexus cysts* (Discrete cyst(s) in one or both choroid plexus(es)

*g) *Short femur length** (Measurement < 2.5 percentile for gestational age)


*A proper Genetic Counselling* with *Aneuploidy sceening*( If missed early) along with Second-trimester *detailed anatomic survey* is a must. *Fetal echocardiography* too is indicated in most of these cases.Testing for *Cytomegalovirus* is indicated in echogenic bowel and ventriculomegaly.A *repeat ultrasonography* for potential IUGR and Urinary Obstruction might also be needed in some.