The Role of Ultrasound in Post Term Pregnancy Management JJE 20101122

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The Role of Ultrasound in theManagement of Post Term

Pregnancy

National Symposium: The role of ultrasound in reducingmaternal and perinatal morbidity & mortality

Judi Januadi Endjun*

, Sanny Santana*, Amanda Rumondang,Devi Marischa Malik, Sarah Kusumawati, Dewi Friska

Gatot Soebroto Army Central & Teaching Hospital*Department of Obstetrics and GynecologyMedical Faculty, University of Indonesia Jakarta

Gumaya Tower Hotel, Semarang, 22 24 November 2010


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MATERI AJAR INI HANYAUNTUK DIPERGUNAKAN PADAKEGIATAN PENDIDIKAN DAN

KESEHATAN

JJE-2010/11/22Hanya untuk Pendidikan & Kesehatan

RSPAD GATOT SOEBROTO


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Judi Januadi Endjun, dr. SpOG


Bandung, 7-1-1959

1985: FK UNPAD, S1

1991: Postgraduate ultrasoundUniversity of Zagreb

1993: FKUI, S2 SpOG

1993: RSPAD, Divisi Fetomaternal

1993: Dosen FKUI, PPDS OBGIN

1993: Pengajar di PUSKI dan AKBID

RSPAD1995: Dosen FK UPN Veteran

2009: Ketua PERISTI RSPAD

2009: Ketua Komite Medik KMC

2010: Anggota Komite Medik RSPAD

2010: Manajer Medik Yanmasum

Paviliun RSPAD2010: Anggota pokja akreditasi JCI

(Internasional) RSPAD

Organisasi: IDI, POGI, ISUOG, PUSKI


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BAHAN RENUNGAN

UNTUK APA KITA ADADISINI ?

POS TERM jangan dilupakan IBADAH ? EDUKASI !! HARI INI

BERHENTIMENGELUH, JANGANBERHENTI BERBUAT BAIK !

BERSAMA KITA DAPAT LEBIH

BAIK !!

JJE-2010/11/22

Hanya untuk Pendidikan & Kesehatan http://assets.aarp.org/www.aarp.org_/articles/GRA/Singleton_graphic.jpg


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Barang siapa mengamalkan apa-apa yang ia ketahui, maka Allah SWT akan mewariskankepadanya ilmu yang belum diketahuinya, dan Allah SWT akan menolong dia dalam amalannyasehingga ia mendapatkan surga. Dan barang siapa yang tidak mengamalkan ilmunya, maka ia

tersesat oleh ilmunya itu, dan Allah SWT tidak menolong dia dalam amalannya sehingga ia akanmendapatkan neraka (sabda Rasulullah Muhammad SAW)

Ilmu lebih utama dari harta, ilmu adalah pusaka para Nabi, sedangkan harta adalah pusakaKarun atau Firaun.

Ilmu lebih utama dari harta, karena ilmu akan menjagamu sementara harta malah engkau yangharus menjaganya.

Ilmu lebih utama dari harta karena di akherat nanti pemilik harta akan dihisab, sedangkanorang berilmu akan memperoleh syafaat.

Ilmu lebih utama dari harta karena pemilik harta bisa mengaku menjadi Tuhan akibat hartayang dimilikinya, sedangkan orang berilmu justru mengaku sebagai hamba Tuhan karena

nyilmunya.Harta itu jika engkau berikan menjadi berkurang, sebaliknya ilmu jika engkau berikan malahan

semakin bertambah.

Pemilik harta disebut dengan nama kikir dan buruk, tetapi pemilik ilmu disebut dengan namakeagungan dan kemuliaan.

Pemilik harta itu musuhnya banyak, sedangkan pemilik ilmu temannya banyak.Harta akan hancur berantakan karena lama ditimbun zaman, tetapi ilmu tidak akan rusak dan

musnah walau ditimbun zaman.

Harta membuat hati seseorang menjadi keras, sedangkan ilmu malah membuat hati menjadibercahaya.

(hamba Allah)JJE-2010/11/22

Hanya untuk Pendidikan & Kesehatan


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Motto :

Jalani hidup ini dengan sabar, jujur dan ikhlas, Mau mengerti dan melaksanakan tatacara (adab) yangbenar, dan Mempunyai kemauan untuk selalu berbuat baikmemperbaiki diri dan lingkungan, serta membuat orang lainlebih baik



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Ingatlah ketika Tuhanmu berfirman kepada para Malaikat: "Sesungguhnya Akuhendak menjadikan seorang khalifah di muka bumi." Mereka berkata: "Mengapa

Engkau hendak menjadikan (khalifah) di bumi itu orang yang akan membuatkerusakan padanya dan menumpahkan darah, padahal kami senantiasa bertasbih

dengan memuji Engkau dan mensucikan Engkau? Tuhan berfirman:"Sesungguhnya Aku mengetahui apa yang tidak kamu ketahui." (Al Baqarah :30)



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AGENDA

Introduction

Etiology

Problems The role of ultrasound

Conclusions

Take home messages

Bibliography



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INTRODUCTION Post term pregnancy is 42 week pregnancy

counted from the first day ofLMP in normalmenstruation cycle or based on CRL examination.

It is a recommendation to do CRL examination at 1st

trimester pregnancy (6-10 weeks) There is a high risk in morbidity and mortality

towards mother and fetus in post term pregnancy.

The accurate and efficient management in post

term pregnancy not only can decrease maternaldeath and perinatal death cases, but also motherand child morbidity cases.



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43 Weeks Pregnancy ?

Electronic FHR monitoringis a modality difficult tolearn, difficult to interpret,and probably results in

many inappropriateoperative interventions

Major factor in obstetric

malpractice litigation, inwhich its inexact natureconfuses attorneys and lay

juriesFreeman RK et al, 2003 JJE-2010/11/22Hanya untuk Pendidikan & Kesehatan


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ETIOLOGY

The exact etiology of post termpregnancy remain unknown

Several factors that cause post termpregnancy are history of post termpregnancy, anencephalus, 1st

pregnancy (primipara), geneticfactor and male fetus.



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PROBLEMS USA : 10% (Norwitz ER et al, 2007) and 3-12% (Aaron et

al, 2008), while in Indonesia the incidence of postterm pregnancy cannot be determined withcertainty.

Post term pregnancy increasing morbidity andmortality towards mother or fetus.

Some problems in mother related to post term

pregnancy are missed diagnosed(estimated as postterm, but delivered as term or preterm),Inductionfailure, prolonged labor and increasing cases of

section cesarean delivery.JJE-2010/11/22Hanya untuk Pendidikan & Kesehatan


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PROBLEMS Some problems in fetus and neonates

related to post term pregnancy are

intrauterine and intrapartum hypoxia,

macrosomia, fetal death, fetal injury andperinatal death.

Examine the CRL at 6-10 weeks pregnancy

can reduce the missed diagnose in

determining gestational age.



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DIFFERENTIAL DIAGNOSIS

Wrong dates and normal fetus

Normal big fetus


Semarang, 2010


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http://emedicine.medscape.com/article/262679-print


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THE ROLE OF ULTRASOUND

Ultrasound takes an important role inpost term pregnancy management:

Gestational Age

Fetal biometry and anomaly

Placenta & Amniotic Fluid Volume

Fetal well-being evaluation (BPP,Doppler) + CTG

Timing and mode of delivery



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Gestational Age

CRL at 1st trimester: 3 5 day

BPD, HC and Cerebellum before 24weeks: 1 2 weeks

> 24 weeks : HC and Cerebellum

>2 - 3 weeks



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JJE-2010/03/01

Hanya untuk Pendidikan dan Kesehatan


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Fetal Biometry & Anomaly

IUGR ?

CPD: BPD > 96 mm

Macrosomia: BPD 10 cm

Anomaly:Anencephalus



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< 5 weeks 5 weeks 6-10weeks

10-12weeks

GS GS

(Yolksac)

CRL CRLBPD

> 12weeks

BPD

FL

etc

BIOMETRICS PARAMETER

Bambang Karsono

JJE-2010/03/01Hanya untuk Pendidikan dan Kesehatan


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Anencephaly

TVS can be usedto detect

anencephaly asearly as 7-8 W(Arthur C. Fleischer, 2004)

TAS : 12 14 WArthur C. Fleischer, 2004

JJE-2010/03/01Hanya untuk Pendidikan dan Kesehatan


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Placenta & Amniotic Fluid Volume

Placenta location

Placenta grading

Placenta pathology

4 Quadrant evaluation (Phelan):AFI < 5 cm

Single Pocket: < 1 cm



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Fetal Wellbeing Evaluation

Fundal height

Fetal movement

CTG: NST, OCT, CNS dysfunction?

US & Doppler: anomaly, brain sparringeffect, AEDF, Reverse Flow

AFI: < 5 cm

BPP:


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Fundal-symphiseal Height

http://www.pamf.org/pregnancy/second/

https://reader009.{domain}/reader009/html5/0526/5b08c8894f81a/5b08c8984ed34.jpghttp://www.pregnancyetc.com/bringingupbaby/Icons/bir_a.jpg

http://findlaw.doereport.com/imagescooked/1274W.jpg

http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/Pregnancy/FundalHeight3.jpg



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http://www.gestation.net/fetal_growth/examples.htm



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US screening also an important criteria inpost term pregnancy management.

Fetal abnormalities will interfere the CTG

interpretation for example : a CNSabnormality : anencephalus, hydrancephalus orholo procencephalus).

Presence of severe abnormalities will be a

consideration to perform a vaginal orsection cesarean delivery.



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FHR Patterns Associated withFetal CNS Dysfunction !!

1. Flat FHR

2. Blunted patterns3. Unstable baseline

4. Overshoot

5. Sinusoidal patterns

6. Checkmark pattern

Freeman RK et al, 200


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Contemporary Obgyn, 2005


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Doppler Screening: Ut, Umb,MCA, DV

Umbilical artery : insufficient data to showvalue; but studies of insufficient powerand largely looking at one Dopplermeasurement in late pregnancy(EBM : Ia/A,Bricker, Cochrane, 2001)



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Timing & Mode of Delivery

Fetal presentation & Position

Cervical evaluation

CPD AFI & Doppler: early sign of fetal

hypoxia

BPP Perinatology Unit



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A meta-analysis by Neilson JPin 2000(Cochrane Database Syst Rev 2000;2:CD000182)

conclude that gestational age

determination based on ultrasoundexamination before 24 weeks ofpregnancy proved to be decreasing theincidence of induction of labor with postterm pregnancy indication (OR 0,68;95% CI,0,57-0,82).



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CONCLUSIONS The risk ofmorbidity and mortalityfor mother and

fetus are rising in post term pregnancy.

CRL examination takes an important role indetermining gestational age.

Accuracy in determining gestational age can decrease

post term pregnancy and post term labor. Ultrasound examination takes an important role in

post term pregnancy management.

This including fetal abnormalities screening, fetalbiometry, AFI and Doppler.

These are important parameter in ultrasoundexamination that must be performed byevery doctorin managing post term pregnancy.



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TAKE HOME MESSAGES

The failure of basic training to keep up with diagnosticand technical developments opens the door tomisinterpretation, mistakes and poor reproducibilityin using the equipment.

At the same time, throughout the specialty evergreater reliance is placed on ultrasound diagnoses inmanagement for both obstetrics and gynecology.

Diagnostic error can only be overcome by proper

trainingunderstanding both the limitations and thepotential of ultrasound equipment.


Basic European ultrasound training in obstetrics and gynecology: where are we and where do we gofrom here?K. . Salvesen1,*, C. Lees2,*, B. Tutschek3,*Article first published online: 27 OCT 2010
http://onlinelibrary.wiley.com/doi/10.1002/uog.8851/fullhttp://onlinelibrary.wiley.com/doi/10.1002/uog.8851/full


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CPD : RSPAD Basic US Course

Pelatihan USG OBGIN Angkatan ke 6, 14 17 November 2007,saat pertama kali pelatihan ini di approved oleh ISUOGdengan pengajar utama Prof. J. Wladimiroff, MD, PhD, FRCOG



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BERSAMA KITA BISA, MARIKITA MULAI BERBUAT

BAIK!!


http://www.youtube.com/watch?v=YBanSSETE78

STOP ! JANGAN BERKELAHI

http://www.youtube.com/watch?v=tQSedpzA-iQ


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BIBLIOGRAPHY1. Endjun, JJ. USG Dasar Obstetri dan Ginekologi. Edisi 1, Balai Penerbit

FKUI, 2009.

2. Departemen Obstetri Ginekologi RSPAD Gatot Soebroto. InduksiPersalinan. Dalam Panduan Pelayanan Medik, Jakarta, 2008

3. Norwitz ER, Snegovskikh V. Prolonged pregnancy. Dalam :Management of High-Risk Pregnancy, Ed: John T. Queenan dkk, Edisikelima, 2007:373-381.

4. BC Aaron, RB Jennifer. Postterm pregnancy, 2008. Downloaded atSeptember 5 2010 fromhttp://emedicine.medscape.com/article/261369-overview

5. Salvesen KA, Lees C, Tutscheck B. Basic European ultrasound trainingin obstetrics and gynecology: where are we and where do we go from

here?Article first published online: 27 OCT 2010

http://emedicine.medscape.com/article/261369-overviewhttp://onlinelibrary.wiley.com/doi/10.1002/uog.8851/fullhttp://onlinelibrary.wiley.com/doi/10.1002/uog.8851/fullhttp://emedicine.medscape.com/article/261369-overviewhttp://emedicine.medscape.com/article/261369-overviewhttp://emedicine.medscape.com/article/261369-overview


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THANK YOU

The Role of Ultrasound in Post Term Pregnancy Management JJE 20101122

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