Study of Placenta Location in Sudanese Pregnant Women Using Ultrasonography
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Sudan University of Science and Technology Collage of Graduate Studies Study of Placenta Location in Sudanese Pregnant Women Using Ultrasonography دراسة موقع المشيمة للحوامل السودانيات بإستخدام الموجات فوق الصوتيه A thesis Submitted for Partial Requirements of M.Sc. Degree in Medical Diagnostic Ultrasound By: Hafiz Osman Bahar Hafiz Supervisor: Dr. Mohammed Elfadil Mohamed Garelnabi Associate professor 2016 اﻻية قال تعالي: ﴿ َوا ذ َِّلي َن َجا ُءوا ِم ْن بَ ْع ِد ِ ِْه يَ ُقولُو َن َربذنَا ا ْغ ِف ْر لَنَا وِِل ْخواِننَا ا ذ َِّلي َن َس ب ُقوََن ِِبِْلميَا ِن وَِل َ ْت َع ْف ِ َ ِ َ َ ِ َ ُقلُوِبنَا ِغ ا ًّل ِل ذ َِّلي َن َآ َمنُوا ربذنَا انذ َك رءو ف ر ِِ م﴾ َ ِ َ ُ َ صدق اهلل العظيم )سورة الحشر اﻵية : 01( I Dedication To; My parents… My brothers and all friends… II Acknowledgment First of all, I thank Allah the Almighty for helping me complete this project. I thank Dr. Mohamed Elfadil Mohamed, my supervisor, for her help and guidance. I would like to express my gratitude to Dr. Ahmed Elmostfa abo- Konna, and the whole staff of the diagnostic radiology department, for their great help and support. I am greatly indebted to my college bearing with me during the past several months. Finally I would like to thank everybody especially my brothers in college of medical radiological science who helped me prepare and finish this study. III Tables of Contents Topic Page number I اﻻيه Dedication II Acknowledgement III Table of contents V English Abstract VI Arabic Abstract VII List of abbreviation VIII List of figures X List of tables Chapter One Introduction 1-1 Introduction 1 1-2- problem of the study 3 1-3 Objectives 3 1-4- significant of the study 4 1-5 Overview of study 4 Chapter Two Literature Review Theoretical background 2-1 Anatomy placenta 5 2-2 physiology of placenta 10 2-3 pathology of Placenta 12 2-4 Ultrasound of placenta 22 2-5 previous study 33 Chapter Three Material & Methodology 3-1 Material 37 3-2 Methodology 37 IV Chapter Four Results Results and Analysis 40 Chapter Five Discussion, Conclusions and Recommendations 5-1 Discussion 50 5-2Conclusion 52 5-3 Recommendations 53 References 54 Appendices 45 V Abstract Doppler ultrasound of the placenta is one of the method of determinations of fetoplacental locations and related abnormalities. A descriptive study aimed to determine and study of the placental location in normal Sudanese pregnant women in order to assess the common placental location related to the normal pregnancy. The data collected in Omdurman Maternity Hospital (Omdurman) from November 2015 to October 2016; one hundred pregnant women in first, second and third trimesters were scanned by ultrasound machine Toshiba-power vision-6000. Placental location was identified in a longitudinal section at the point of insertion of the umbilical cord. The variables used to establish this study was mother age, BPD, fetalAge, number of pregnancy, trimester, type of delivery, placental location, and liquor, where the result showed that mean age equal to (27.04±6.045) yrs., liquor equal to (5.527±0.4546cm). A significant correlation noted between the GA and liquor, while common placental location found to be posterior most commonly in age group of 27.2-30.5 yrs. Most fetal presentation appear to be in cephalic direction rather than the others most commonly in age group of (17- 20.3yrs.).In Conclusions: US has an excellent presentation of placental location and therefore assessing the related abnormalities. VI ملخص الدراسة فحص المشيمة باستخدام الموجات فوق الصوتية واحدة من اهم الوسائل لتحديد موقع المشيمة بالنسبة للجنين ومايتعلق بها من مشاكل صحية. هذه الدراسة وصفية تهدف لتحديد ودراسة مواقع المشيمة الطبيعية للحوامل السودانيات من اجل تحديد الوضع اﻻكثر شيوعا المتعلق بالحمل الطبيعي. حيث جمعت البيانات من داخل مستشفي امدرمان لﻻمومة )ام درمان( خﻻل الفترة من نوفمبر للعام خمسة عشر والفين الي اكتوبر للعام ستة عشر والفين, حيث ان عدد مائة من الحوامل في الثالوث الثاني والثالث تم فحصهم بالموجات فوق الصوتية باستخدام جهاز توشيبا – 0666. وحدد موقع المشيمة في الوضع الطولي عند نفطة انقراز الحبل السري, غير ان المتغيرات التي جمعت لتحقيق هذه الدراسة كانت كل من عمر اﻻم, القطر العرضي للراس, عمر الجنين, عدد مرات الحمل, الثالوث, نوع الوﻻدة, موقع المشيمة والسائل اﻻمنيوني. فوجد متوسط العمر )40.62±0.626( سنوات ومتوسط قياس السائل )6.640±6.2620(سم. حيث لوحظ وجود عﻻقة قوية بين عمر الجنين والسائل بينما وجد الوضع اﻻكثرشيوعا للمشيمة هو الخلفي شائعا بين اﻻعمار من )40.4 – 56.6(سنوات. كما وجد ان الوضع اﻻكثر شيوعا للجنين هو باتجاه الراس شائعا في اﻻعمار بين )70- 46.5(سنوات. ختاما الموجات فوق الصوتية تعتبروسيلة فعالة في تحديد موقع المشيمة ومايتعلق بها من اوضاع غير طبيعية. VII List of abbreviations D Diastole DM Diabetes Mellitus FVW Flow Velocity Waveform GA Gestational Age GDM Gestational Diabetes Mellitus HCG Human Chorionic Gonadotropin IDDM Insulin Dependent Diabetes Mellitus IUGR Intra Uterine Growth Retardation NIDDM Non InsulinDependent Diabetes Mellitus PEDM Pre Existing Diabetes Mellitus SPSS Statistical Package for Social Sciences SYS Systole TNF Tumour Necrosis Factor US Ultrasound WKS Weeks VIII List of figures Figure Title Page Figure 2-1 Relationship of the Gestational sac and surrounding deciduas. 6 Figure 2-2 Fetal and maternal circulation 7 Figure2-3 Normal Early Placenta Longitudinal TAS image of the uterus 9 (bladder is empty) shows a normal anterior placenta (1) and a retro-placental FMC (2) Figure 2-4 Normal Cord, Insertion Sonogram of the uterus shows a posterior 10 placenta with a centralumbilical cord insertion. Figure 2-5 Placental Thickness Measurement 16 Figure 2-6 Succenturiate Lobe 17 Figure 2-7 Placenta Membranacea 19 Figure 2-8 Abnormal placental attachments. 20 Figure 2-9 Central Complete Placenta Previa (A)Midline EVS image at 14 20 weeks. B) Midline B) TAS image at 22 weeks Figure 2-10 Posterior Marginal Placenta Previa 22 Figure 2-11 Low-lying posterior placenta 23 Figure 2-12 Focal Myometrial Contraction 25 Figure 2-13 Migration, Midline image of the uterus at 15 and 25 weeks 28 gestation shows an upward change in the cervical edge of the placenta. Figure 2-14 Posterior Placenta, Transverse TAS image of a posterior placenta 29 shows the normal hypo echoic uterine wall behind the placenta. Figure 2-15 Retro placental Complex, Sagittal TAS image of a posterior 31 placenta (1) shows a prominent retro-placental complex and the "end" of a FMC (3). Figure 2-16 Grade 0 Placenta, Linear array image of an anterior placenta at 32 31 weeks gestation shows no evidence of placental calcification. Figure 2-17 Grade 1 Placenta, Axial section of the uterus shows an anterior 31 placenta at 32 weeks gestation with evidence of parenchymal calcification but no evidence of basal calcification (maternal surface of the placenta). Figure 2-18 Grade 2 Placenta, Anterior placenta at 38 weeks gestation shows 31 calcification of the basal surface of the placenta consistent with a grade 2 classification. Figure 2-19 Grade 3 Placenta, TAS image of an anterior placenta shows 32 calcification of the placenta extending from the maternal to fetal IX surface, (arrows). Figure 2-20 Grade 3 Placenta, Representative TAS image of the placenta at 39 32 weeks gestation shows calcification of the placenta extending from the maternal to fetal surface and defining the cotyledon. Figure 4-1 a bar graph show age frequency distribution. 40 Figure 4-2 scatter plot show a direct linear relationship between liquor 41 amount and gestational age Figure 4-3 a bar show the relationship between pregnant women age group 42 and trimester Figure 4-4 a bar graphs between age group and type of delivery 43 Figure 4-5 a bar graph between age group and placenta location 44 Figure 4-6 bar graph shows age group and placenta location 45 Figure 4-7 a bar graph between number of pregnancy and trimester 46 X LIST OF TABLES Table Title Page Table 4-1 The mean, max and min of age, liquor and No. of pregnancy 29 Table 4-2 Frequency distribution of age for pregnant women 30 Table 4-3 cross-tabulation table show the relationship of pregnant age 31 groups and trimester Table 4-4 cross-tabulation table between age group and type of delivery 32 Table 4-5 cross-tabulation table between age group and placenta 32 location Table 4-6 cross-tabulation table between age group and Fetal 33 presentation Table 4-7 cross-tabulation table between number of pregnancy and 34 trimester Table 4-8 cross-tabulation table between number of pregnancy and 35 types of delivery Table4-9 Cross-tabulation table between number of pregnancy and 36 placenta location XI Chapter One Introduction Chapter One 1-1: Introduction The placenta is an organ that develops in the uterus during pregnancy. It is a unique characteristic of the higher mammals. In humans it is a thick mass about 7 in. (18 cm) in diameter, liberally supplied with blood vessels. It usually weighs about 1 to 2 pounds (about 1/6 of the weight of the baby). The placenta is attached to the uterus, and the fetus is connected to the placenta by the umbilical cord (http// Wikipedia.com). The placenta develops from the chorionic villi at the implantation site at about the fifth weeks of gestation and by the ninth or tenth week of diffuse granular echo texture of the placenta is clearly apparent at sonography (callen, 2007). Placental location is described with respect to its relative position on the uterine wall and its relationship to the internal OS. The placenta may be described as predominantly anterior, posterior, fundal, right or left lateral.