11-14 September ABSTRACT BOOK www.wcpm2019.org 11-14 September ABSTRACT BOOK SPEAKERS Abstracts 11-14 September S1 - PITFALLS IN DIAGNOSIS AND TREATMENT FOR ADHERENT PLACENTA Yalinkaya A. Dicle University Medical Faculty Department of Obstetrics and Gynecology, Diyarbakir Definition Patients with adherent placenta (AP) have many pitfalls in obstetrics. Adherent Placenta, including placenta accreta, placenta increta and percreta, occurs as a result of placental villi penetrating the myometrium through a defect in the decidua basalis. Adherent placenta cases consist of placenta accreta ~75-78%, placenta accreta ~15-18% and placentae percreta ~5-7%. The incidence of Adherent Placenta (AP) was found 1 in 172 in 2016 and tends to increase continuously in parallel to cesarean section. Pitfalls in Adherent Placenta The patients with adherent placenta carry many life-threatening risks. Sudden massive hemorrhage, patient neglect, patient being away from the operation center or transferred in the critical situation, difficulty in transport, inadequate surgical team and medical facilities, inadequate blood and blood products support and undiagnosed cases are the main traps in the adherent placenta. Diagnosis The accurate diagnosis of adherent placenta depends on the following conditions: Determination of risk factors, the experience of the sonographer who examined the patient and the quality of the device used, such as 2D, 3D or real time 3D (4D) sonography. In addition, examination methods such as TVS, TAS or Color Doppler sonography are important in the diagnosis. The diagnosis of adherent placenta can be made by transvaginal sonography after detection of gestational sac at the beginning of pregnancy and definitive diagnosis can be made until 12 week of gestation. Recurrent cesarean section, myomectomy, endometrial damage, uterine artery embolization, maternal age, multiparity and uterine surgery are major risk factors for adherent placenta. What to do in case of emergency? Great vessel access, fluid replacement should be started, blood and blood products must be provided. If there is massive vaginal bleeding, balloon tamponade should be applied. If the facilities are insufficient, surgery should not be performed and patient should be transferred under optimal conditions possible. If AP is not diagnosed before cesarean section, the surgeon should request help from an experienced surgeon immediately. Relaparotomy should not be performed by the same surgeon without the help of an experienced surgeon. Treatment (Surgical Approach) AP is a potentially life-threatening obstetric condition that requires a multidisciplinary approach to be managed. If the patients with AP are followed and treated by experienced surgeons in multidisciplinary tertiary centers, the maternal morbidity and mortality can be reduced. AP surgery is performed in two ways such as radical and conservative (complete and partial). These patients should be operated by an experienced team in appropriate centers. 4 11-14 September Our Recommendations: • Adherent placenta should be diagnosed in the first trimester. • All patients who have undergone uterine surgery should be evaluated for adherent placenta. • AP patients should be examined at least once by an experienced specialist. • AP patients should not be away from the operation center. • Operations should be done in appropriate centers. • Operations should be performed by an experienced team. • Complete conservative surgery should be the first option in all patients. S2 - PRENATAL AND POSTNATAL CONSEQUENCES OF FETAL STRESS Salihagic Kadic A. University of Zagreb Medical School, Department of Physiology, Zagreb, Croatia Fetal development and growth are influenced by the intrauterine environment. A large number of factors can alter the intrauterine environment and lead to fetal stress. Maternal undernutrition or placental insufficiency and intrauterine growth restriction, maternal emotional stress or stressful life events, as well as fetal pain may trigger the stress response of the fetus. The neuroendocrine stress axis operates in the fetus from midgestation and includes the production and secretion of the corticotropin releasing hormone, adrenocorticotropic hormone and cortisol. Fetal glucocorticoid overexposure affects neurodevelopment, as well as the development of many organs and organ systems, and has lifelong consequences. In response to an adverse intrauterine conditions and prenatal stress, the fetus is able to adapt its physiology to promote survival. However, this adaptation can result in permanent changes in tissue and organ structure and function as well as metabolic changes. It has been shown that the underlying etiology of some of the most common diseases of the modern society, such as hypertension, obesity, diabetes and coronary heart disease, has been traced in intrauterine environment. Further, there is experimental evidence that increased maternal care and environmental enrichment can compensate for prenatal stress-induced effects. Recent data have also indicated gender differences in vulnerability to prenatal stress. Finally, stress-free intrauterine environment is crucial for normal prenatal and postnatal growth and development, as well as good health later in life. 5 11-14 September S3 - FETAL CRANIUM AND FACE AT 13 WEEKS SCAN Ebrashy A. Cairo Egypt Designates the description of the embryonic anatomy, the normal anatomic relations and the development of abnormalities as visualized by ultrasound To confirm the presence of normal anatomy or to make the diagnosis of an anomaly, we need knowledge of the normal embryonic development, including the appearance of the normal embryo. Embryo = to grow (Greek) up to 9 weeks Fetus =off spring in Latin from 9 weeks there after The anterior part of the neural tube expands to form the brain The neural tube goes on to form all parts of the brain The structural organization of the brain: the barin begins as a hollow tube and remains hollow 5 regions of the brain are formed during development The cavities of the brain are the ventricles At the Eighth week (7weeks0d-7wks-6d ) Embryo external form : The embryonic body appears as a triangle in the sagittal section. The embryonic body is slender in the coronal plane. The limbs are short, paddle-shaped outgrowths CNS: The relatively broad and shallow rhombencephalic cavity is always visible from 7 weeks onwards. It then has a well-defined rhombic shape in the cranial pole of the embryo. At the Ninth week (8wks0d-8wks6d) CRL=15-22mm CNS:The brain cavities are easily seen as large ‘holes’ in the embryonic head. No falx cerebri or choriod plexus at least in the first half In sagittal planes the forebrain vesicles ( telencephalic ,diencephalic, metencephalic) are seen. Limbs: both upper and lower buds are clearly seen at this stage At the Tenth week (9wks0d-9wks6d) Brain: CNS The hall mark of the 10th week is the Falx and the echogenic choroid plexus Mid sagittal plane depicts tortous ventricular system Telencephalic vesicle leading to Diencephalon followed by the cephalic flexure between the Diencephalon and the meten cephalon (cerebellum) then the myelencephalon (medulla oblongata and finally the rhombencephalon (hindbrain At the 12th week (11wk0d-11wk-6d)on words till the 14th week (13wk0d-13wk-6d ) CRL= 54-87mm .The ventricular system is obvious, cerebellum, cisterna magna (the posterior fossa) are seen. At this time the vermis is not completely closed. The complete development of the cerebellum will be completed at 17 weeks gestation What is the clinical application? Cavities appearing in the brain are mirror image to the embryological development of the CNS and allowed us to better understand sequential stages in development We can jude on cranium intactness, proper cleavage cleavage of the forebrain with the appearance of the falx as well as looking at the development of the posterior fossa to diagnose open spina bifida Check list for the cranium should include: 6 11-14 September Intact cranium Falx cerebrai Choroid plexus filling the ventricles: butterfly appearance How comment on the posterior fossa Double line in tilted axial plane Intracranial translucency in mid sagittal view What are the cranial anomalies that coud be diagnosed at this age Anencephaly Holoprosencephaly What are the potentials for the diagnosis of open spina bifida based on the cranial sequel of open spina bifuda In all cases of OSB 1-a thickening of the brain stem, a shortening of the distance between brain stem and occipital bone, and an increase in the ratio of brain stem diameter to BSOB distance to greater than 1 are observed. 2-When the tilted axial plane is used and the “single line” sign is observed, this represents the sonographic cluster of early first trimester diagnosis of OSB face at 13 week scan 1- Retronasal traiangle 2- Mandibular gap 3- Maxillary gap Conclusion Sonoembryology paved the way for more understanding of the embryological stages of the fetal organs including the CNS.Brain vesicles and ventricles embryological stages of development can be appreciated like mirror images in early TVS.It helped a lot in better understanding and following up this important stage of evolution to the full sized brain By 11-13 weeks we are able now to document integrity of the cranium as well as proper cleavage of the fore brain .This enabled us to diagnosis anomalies involving these parts e.g. anencephaly and holoprosencephaly The dynamic growth of the brain limits the full diagnosis of abnormalities involving these areas specially the