Evaluation of the Placenta Disclaimer and Cervix • I have no relevant financial relationships Judy A. Estroff, MD with the manufacturer(s) of any commercial product(s) and/or provider(s) of any commercial services discussed in this CME activity. • I do not intend to discuss unapproved or Boston Children’s Hospital investigative use of a commercial Harvard Medical School product/device in my presentation. Boston, MA

Overview Everything you need to know in • 15 minutes! • Placenta • Umblical cord • Cervix • Membranes

Amniotic fluid volume Amniotic Fluid • Increases logarithmically first ½ • Definitions • < 10 mL @ 8 weeks gestation • Classification • 630 mL @ 22 weeks gestation • 770 mL @ 28 weeks gestation • 30-36 weeks: volume stable or slowly inc • > 36 weeks: volume decreases • 41 weeks: 515 mL • Decreases 33% each week after 41 weeks

Creasy & Resnik: Maternal Fetal Medicine 6th Edition, 2009

1 Measurement of amniotic fluid

• AFI= • Subjective assessment • Deepest vertical pocket

AFI: Amniotic Fluid Index x

• Definition: Summation of the deepest vertical pocket (DVP) in 4 cord and extremity- free quadrants of the gravid • : < 5 cm • Polyhydramnios: > 24 cm

27w DVP=13.3 cm

Oligohydramnios Oligohydramnios • Definition: Condition in which the amniotic fluid volume (AFV) is • Almost always associated with an decreased relative to gestational age. increased risk of fetal morbidity and mortality • Or: AFI < 300-500 mL in 2nd trimester • MVP < 1-2 cm •AFI < 5 cm • AFI < 5% of expected

2 Oligohydramnios: Causes Oligohydramnios

• Renal: agenesis, obstruction • Associated with guarded outcome • Uteroplacental insufficiency/ IUGR • Highly associated with anomalies • Ruptured membranes • Not universally fatal, depends upon • Post term pregnancy gestational age at onset (after 26 • Unknown weeks, may have enough pulmonary development to survive)

Branchio-Oto-Renal Syndrome: History BOR; Melnick-Fraser Syndrome

• 19 weeks 2 days gestation • Autosomal dominant • Referring dx: bilateral , oligohydramnios • Variable expression and penetrance • Family hx: Branchio-oto-renal syndrome • Chromosome 8q13.3; EYA1 gene • Renal: dysplasia, aplasia, polycystic kidney, reflux

UAs: no fluid in bladder

19w2d 19w2d

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• Definition: Excessive accumulation of amniotic fluid at some time during pregnancy • Greater than 1500-2000 mL • Deepest vertical pocket > 8 cm

19w2d: kidneys not seen

Polyhydramnios Polyhydramnios: Causes

• Often associated with an increased • Idiopathic risk of fetal morbidity and mortality • LGA fetus • Impaired swallowing (neck mass, EA/TEF, DA, CPAM • Chromosomal • Neurologic

Polyhydramnios: Causes Placenta • CNS: ie, • GI: • Respiratory: CCAM • GU: • CV: Ebstein anomaly • MSK: Fetal akinesia/hypokinesia syndrome

4 Placenta Placenta: normal appearance • Normal sonographic appearance • Thickness: less than 5 cm • Normal thickness • Attachment site: anywhere • Previa types • “Matures” during gestation (Type 0-3) • Accreta types • Placental lakes • Cysts, masses, molar change • Accessory lobes • Chorioamniotic separation • Amniotic bands, senechiae

Position of placenta in relation to Placental cord insertion site internal os of cervix • Central • Low-lying • Eccentric • Marginal previa • Velamentous • Central previa • Vasa previa

Invasive placenta Invasive placenta

• Increased with previous C-section • Accreta (80%):superficial invasion • Previous uterine surgery chorionic villi • Difficult to diagnose • Increta (15%): deep myometrial • Treatment options: methotrexate, invasion uterine artery embolization, • Percreta (5%): full thickness invasion hysteroscopy, gravid hysterectomy of myometrium, often into adjacent bladder

5 Abnormal placenta

• Trophoblastic disease • Masses: cystic and solid • Hydropic change

Umbilical cord cysts Cord Issues

• Number of vessels • Usually benign, but not always • Cord length • Most often on the fetal end • Coiling index • Represent remnants of allantoic • Cord insertion sites: fetus, placenta duct (urachus) or vitelline duct • Cord position in relation to fetus • Cord masses: fetal end, placental end, free-floating cord

Importance of cord insertion site Case of urachal remnant • Into fetal abdomen • Into placenta

6 Abnormal cord insertion sites Cord

• Eccentric • 2 vessel, 3 vessel, more • Marginal • Umbilical cord cysts • Velamentous • Umbilical cord varix • Short cord • Coiled, uncoiled •

Nuchal cord Nuchal cord

• ~ 25% of have a “single” nuchal cord • ~2% have “double” nuchal cord • 0.3% have a triple nuchal cord • <0.1% have a quadruple cord

22w

Cervix

• Incidence: 1% live births • Association with anomalies

7 Cervix x • Normal anatomy • Expected changes during pregnancy • Normal length • Short cervix • Open cervix • Imaging of the cervix: TA US, TV US, MRI Normal cervix= 3 cm or longer

x

Note: central cord insertion

Cervix length can change! 22w Cervix: long and closed, no funneling 23w6d

Warning! • Evaluation of placenta, cervix and amniotic fluid is not just for coding 1.8 cm purposes • Critical to good outcome for the pregnancy • Treat woman carrying an anomalous fetus like any other pregnant woman: maternal and fetal well-being first and Gold standard=transvaginal sonography foremost, before anomaly evaluation 23w6d

8 Report of major impact: Universal cervical length screening Asymptomatic short cervix and vaginal progesterone Vaginal progesterone in women with an asymptomatic sonographic short • Prevents preterm births cervix in the midtrimester decreases • Reduces neonatal morbidity preterm delivery and neonatal • Reduces health care costs morbidity: a systematic review and metaanalysis of individual patient data • “Doing nothing is no longer an Roberto Romero, MD, Kypros Nicolaides, MD, Agustin Conde- option.” Agudelo, MD, MPH, et al. American Journal of and Gynecology 206(2):124.e1–124.e19, February 2012 -Stuart Campbell

Membranes Amniotic bands

• Chorioamniotic separation • “Sticky” side of attaches • Amniotic bands to fetus • Unusual clefts, defects

Significance of chorioamniotic separation Review • Amniotic fluid • Guarded outcome • Placenta • Depends upon whether it is spontaneous (worse) or after an • Umblical cord intervention (better) • Cervix • Can re-seal • Membranes

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