usg intensif 10 amniotic fluid, cord vessels, placental location jje 20080813

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SONOGRAPHY OF AMNIOTIC FLUID, SONOGRAPHY OF AMNIOTIC FLUID, PLACENTA, AND UMBILICAL CORD PLACENTA, AND UMBILICAL CORD Judi Januadi Endjun Intensive Ultrasound Course DIVISION OF MATERNAL AND FETAL MEDICINE Department of Obstetrics and Gynecology Gatot Soebroto Army Central Hospital School of Medicine Veteran University - Jakarta 2009

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Dengan nama Allah Yang Maha Pengasih dan Penyayang. Semoga materi ajar ini berguna bagi kita semua, dunia akherat serta dapat ikut menyerdaskan dan menyehatkan anak bangsa. Amiin

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Page 1: USG Intensif 10 Amniotic Fluid, Cord Vessels, Placental Location JJE 20080813

SONOGRAPHY OF AMNIOTIC FLUID, SONOGRAPHY OF AMNIOTIC FLUID, PLACENTA, AND UMBILICAL CORDPLACENTA, AND UMBILICAL CORD

Judi Januadi Endjun

Intensive Ultrasound Course

DIVISION OF MATERNAL AND FETAL MEDICINEDepartment of Obstetrics and Gynecology

Gatot Soebroto Army Central HospitalSchool of Medicine Veteran University - Jakarta

2009

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MATERI AJAR INI HANYA MATERI AJAR INI HANYA UNTUK DIPERGUNAKAN UNTUK DIPERGUNAKAN

DALAM KEGIATAN DALAM KEGIATAN PENDIDIKAN DAN PENDIDIKAN DAN

KESEHATANKESEHATAN

JJE-13/07/2009JJE-13/07/2009 Hanya untuk Pendidikan dan KesehatanHanya untuk Pendidikan dan Kesehatan

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JJE-13/07/2009JJE-13/07/2009 Hanya untuk Pendidikan dan KesehatanHanya untuk Pendidikan dan Kesehatan

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Motto :

• Jalani hidup ini dengan sabar, jujur dan ikhlas,

• Mau mengerti dan melaksanakan tatacara (adab) yang benar, dan

• Mempunyai kemauan untuk selalu berbuat baik memperbaiki diri dan

lingkungan, serta membuat orang lain lebih baikJJE-13/07/2009JJE-13/07/2009 Hanya untuk Pendidikan dan KesehatanHanya untuk Pendidikan dan Kesehatan

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KEUTAMAAN ILMU

Barang siapa mengamalkan apa-apa yang ia ketahui, maka Allah SWT akan mewariskan kepadanya ilmu yang belum diketahuinya, dan Allah SWT akan menolong dia dalam amalannya sehingga 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 akan mendapatkan neraka (sabda Rasulullah Muhammad SAW)

Ilmu lebih utama dari harta, ilmu adalah pusaka para Nabi, sedangkan harta adalah pusaka Karun atau Fir’aun.

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

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

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

ilmunya.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 nama keagungan 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 menjadi bercahaya.

(hamba Allah)

JJE-20080810

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INTRODUCTIONINTRODUCTION

The detection of AFV abnormalities in the 2nd trimester may suggest fetal abnormalities, occult diabetes, or placental insufficiency.

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AF RegulationsAF Regulations

Di down-load dari http://neoreviews.aappublications.org/cgi/content/full/neoreviews;7/6/e292/F5 pada tanggal 28 Januari 2007).

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Amniotic Fluid VolumeAmniotic Fluid Volume

Physiologic variation with stage of pregnancy should be considered in assessing the

appropriateness of AF volume

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Tabel 10.1. Pengukuran semikuantitatif (satu kantong) volume cairan amnion

HASIL PENGUKURAN INTERPRETASI

> 2 cm, < 8 cm Volume cairan amnion normal

> 8 cm8 – 12 cm12 – 16 cm> 16 cm

PolihidramnionPolihidramnion ringanPolihidramnion sedangPolihidramnion berat

≥ 1 cm, ≤ 2 cm Volume cairan amnion meragukan normal (borderline)

< 1 cm Oligohidramnion

Sumber : Weber G, Merz E. Amniotic Fluid. Dalam : Ultrasound in Obstetrics and Gynecology. Editor Eberhard Merz, Thieme, 2005:409-414JJE-13/07/2009JJE-13/07/2009 Hanya untuk Pendidikan dan KesehatanHanya untuk Pendidikan dan Kesehatan

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Amniotic Fluid Index (AFI)Amniotic Fluid Index (AFI)

JJE-20071027JJE-13/07/2009JJE-13/07/2009 Hanya untuk Pendidikan dan KesehatanHanya untuk Pendidikan dan Kesehatan

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POLYHIDRAMNIOSPOLYHIDRAMNIOS

> 2,000 ml at birth 0.4 – 1.5% of pregnancies The etiology of

polyhydramnios is poorly understood

Maternal DM : glucose in the fetus (fetal hyperglycemia) → osmolality of the AF and fetal polyuria → AFV

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POLYHYDRAMNIOSPOLYHYDRAMNIOS

CNS malformations : impaired fetal swallowing, polyuria due to lack of antidiuretic hormone, and transudation of fluid across the meninges

GIT abnormalities : diminished fetal swallowing or obstruction

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POLYHYDRAMNIOS POLYHYDRAMNIOS : etiology: etiology1. Idiophatic : 34 – 66.7%2. DM : 7.8 – 24.6%3. Congenital anomalies : 12.7 – 26.9%4. Erythroblastosis fetalis : 11.5%5. Acute polyhydramnios : 1.5%6. CNS : 45% → anencephaly (80%), meningocele,

encephalocele, cebocephaly, hydrocephaly, and hydrancephaly

7. CVS : 7% coarctation of aorta, fetal hyrops8. Other anomalies

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OLIGOHYDRAMNIOSOLIGOHYDRAMNIOS

4% of pregnancies

Associated with fetal growth

Marker to predict altered fetal growth

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OLIGOHYDRAMNIOSOLIGOHYDRAMNIOS

Prenatal Diagnosis :1. Measurement of

total AFV2. Measurement of a

1-cm pocket3. 4-quadrant AFV4. Subjective

evaluation of AFV

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THE PLACENTATHE PLACENTA

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SONOANATOMYSONOANATOMY

Early 2nd trimester : fine granular echogenic pattern with a smooth well-defined chorionic plate

16 – 18 W : small intraplacental arteries

After 20 W gradual changes may occur

3rd trimester : placenta is very vascular organ

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SONOANATOMYSONOANATOMY

The retroplacental The retroplacental areas : frequently not areas : frequently not echogenic, probably echogenic, probably as a result of the as a result of the presence large mural presence large mural veins, can be veins, can be mistaken for abruptio mistaken for abruptio placenta.placenta.

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Grannum’s ClassificationGrannum’s Classification

Grade : 0

Grade : I

Grade : II

Grade : III

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PLACENTA Grade 0 :PLACENTA Grade 0 :

All placentas start with this All placentas start with this morphologic configuration. morphologic configuration.

The chorionic plate is The chorionic plate is smooth. smooth.

The placenta substance is The placenta substance is completely homogenous. completely homogenous.

The basal layer is devoid of The basal layer is devoid of echogenic densities echogenic densities

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PLACENTA Grade I :PLACENTA Grade I :

The chorionic plate assumes The chorionic plate assumes subtle undulations. subtle undulations.

The placental substance shows The placental substance shows randomly dispersed echogenic randomly dispersed echogenic densities, which are linear, densities, which are linear, measure 2 – 4 mm in length, measure 2 – 4 mm in length, and have their long axis parallel and have their long axis parallel to the long axis of the placenta. to the long axis of the placenta.

The basal layer remains devoid The basal layer remains devoid of densitiesof densities

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PLACENTA Grade II :PLACENTA Grade II :

The chorionic plate becomes more The chorionic plate becomes more markedly indented. markedly indented.

There may be extensions, commalike There may be extensions, commalike densities, from the chorionic chorionic densities, from the chorionic chorionic plate into the placental substance, but plate into the placental substance, but not extending all the way to the basal not extending all the way to the basal layer. layer.

The placental substance maintains the The placental substance maintains the randomly dispersed echogenic randomly dispersed echogenic densities, although the latter may densities, although the latter may become more prominent. become more prominent.

The basal layer shows basal echogenic The basal layer shows basal echogenic densities that represent the hallmark densities that represent the hallmark of the grade II placenta. These ere of the grade II placenta. These ere linear, and their long axis is parallel to linear, and their long axis is parallel to the long axis of the placenta. the long axis of the placenta.

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KesehatanKesehatan

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PLACENTA Grade III :PLACENTA Grade III : The chorionic plate maybe markedly The chorionic plate maybe markedly

indented. indented.

The extensions from the chorionic plate The extensions from the chorionic plate reach all the way to the basal layer, reach all the way to the basal layer, dividing the placenta into compartments, dividing the placenta into compartments, the fetal cotyledons. the fetal cotyledons.

At least two complete extensions from At least two complete extensions from the chorionic plate to the basal layer. the chorionic plate to the basal layer.

The substance of the placenta can have The substance of the placenta can have sonolucent “fallout” areas, which sonolucent “fallout” areas, which probably represent the central portions of probably represent the central portions of the cotyledons devoid of villi. the cotyledons devoid of villi.

The basal echogenic densities may The basal echogenic densities may become more confluent and dense become more confluent and dense enough to cast their own shadows.enough to cast their own shadows.

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CLINICAL APPLICATIONSCLINICAL APPLICATIONS

Placental Growth / size / shapePlacental Growth / size / shape Placental LocationPlacental Location Placental Separation / AbruptionPlacental Separation / Abruption Placental CalcificationsPlacental Calcifications Focal Cystic/Hypoechoic LesionsFocal Cystic/Hypoechoic Lesions Vasa PreviaVasa Previa Placenta AccretaPlacenta Accreta Nontrophoblastic Placental TumorsNontrophoblastic Placental Tumors Placental DopplerPlacental Doppler OthersOthers

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PLACENTAL GROWTH / SIZEPLACENTAL GROWTH / SIZE Rule of thumb : the size should be approximately

equal in thickness (in millimeters) to the GA in weeks

Placental volume : placental tissue and the amount of fetal and maternal blood.

Volumetric growth : maximum at late gestation and in volume and size toward the end of gestation.

The thickness gradually > 32 W. The term placenta should generally not be thicker than 40 mm

Grade I : 38 mm, Grade III : 35 mm

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Plasenta pada kehamilan Plasenta pada kehamilan 20 dan 36 minggu20 dan 36 minggu

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PLACENTAL LOCATIONPLACENTAL LOCATION Correlation between the

margin of the placenta and internal cervical os (OUI)

Placenta previa in the 2nd trimester (5%) and only < 1% at term (placental migration).

Repeat scan at 36 W must confirm the diagnosis of placenta previa

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PLACENTA PREVIAPLACENTA PREVIA The placenta is in front of or

previous to the fetus relative to the birth canal

It remains the primary cause of 3rd trimester bleeding and eminently detectable with US (translabial or transvaginal).

No contraindication

Term : 0.5 – 1% all pregnancies. (older, multiparas, prior CS, and prior abortions)

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VASA PREVIAVASA PREVIA Umbilical cord crossing the internal os in front of

the precenting part, usually the fetal head

Very rare, but Life-threatening to the fetus

Two settings : a velamentous cord insertion or in a succenturiate lobe on the opposite side of the internal os from the main placental structure.

The overall sensitivity for US is generally low. Using color or power Doppler.

Typical umbilical artery waveforms may be seen when interrogating a blood vessel near the internal os and confirm the diagnosis

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PLACENTAL SEPARATIONPLACENTAL SEPARATION Sensitivity : 2 – 20% Wide variety of sonographic findings :

overlooked or misdiagnosed The diagnosis of abruptio placenta is best

made clinically Ultrasound can assist in the conservative

management Retroplacental and retromembranous

clot : sonolucent areas between the uterine wall and the placenta or the membranes and the placenta

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PLACENTAL SEPARATIONPLACENTAL SEPARATION

“Tenting up” of the membranes by a retromembranous clot in close proximity to the placental margin.

The dimensions of the clots should be quantified and serial scans will determine whether the clot is regressing or increasing in size.

As the clot becomes more organized, it may appear more echogenic.

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PLACENTAL SEPARATIONPLACENTAL SEPARATION

Kurjak et al (1996) : location Kurjak et al (1996) : location rather than volume was of rather than volume was of predictive value (study of 1predictive value (study of 1stst trimester subchorionic trimester subchorionic hematomas)hematomas)

Fundal or corpus hematomas Fundal or corpus hematomas had a worse prognosis than had a worse prognosis than supracervical hematomas.supracervical hematomas.

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PLACENTA ACCRETAPLACENTA ACCRETA Abnormal adherence of the Abnormal adherence of the

placenta to the uterus with placenta to the uterus with subsequent failure to separate subsequent failure to separate after delivery of the fetus.after delivery of the fetus.

Subdivided : placenta accreta Subdivided : placenta accreta vera, placenta increta, and vera, placenta increta, and placenta percretaplacenta percreta

1 : 2500 pregnancies, but 1 : 2500 pregnancies, but nearly 10% with placenta previanearly 10% with placenta previa

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PLACENTA ACCRETAPLACENTA ACCRETA Independent risk factors : Independent risk factors :

advanced maternal age advanced maternal age and previous CS.and previous CS.

Placenta accreta : Placenta accreta : the the normally hypoechoic, 1 – 2 cm normally hypoechoic, 1 – 2 cm band is absent or markedly band is absent or markedly thinned (thinned (≤ 2 mm), and there is ≤ 2 mm), and there is loss of the normal decidual loss of the normal decidual interface between the placenta interface between the placenta and myometriumand myometrium..( Cox S et al, Obstet ( Cox S et al, Obstet Gynecol, 1988; Levine D et al, Radiology, Gynecol, 1988; Levine D et al, Radiology,

1997)1997) JJE-13/07/2009JJE-13/07/2009 Hanya untuk Pendidikan dan KesehatanHanya untuk Pendidikan dan Kesehatan

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PLACENTA ACCRETAPLACENTA ACCRETA

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PLACENTAL ANOMALIESPLACENTAL ANOMALIES

Bilobata

Circumvallata

SuccenturiateCircum-marginalis

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PLACENTAL CALCIFICATIONPLACENTAL CALCIFICATION

No significant relationship was demonstrated between the sonographic findings and the vitally important pulmonary maturation

Maternal cigarette smoking

Thrombotic disorders who have been placed on heparin or aspirin prophylacties

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FOCAL CYSTIC /HYPOECHOIC FOCAL CYSTIC /HYPOECHOIC LESIONSLESIONS

Resulting from maternal blood flow Resulting from maternal blood flow disturbances : disturbances : massive perivillous fibrin deposition; massive perivillous fibrin deposition; subchorionic fibrin deposition (maternal floor infarction, subchorionic fibrin deposition (maternal floor infarction, placental infaction)placental infaction)

Resulting from disturbances of fetal blood flow : Resulting from disturbances of fetal blood flow : fetal artery thrombosis, 5%, GDM, coagulation disordersfetal artery thrombosis, 5%, GDM, coagulation disorders

Thrombi and hematomas : Thrombi and hematomas : retroplacental retroplacental hematomas; subchorionic or marginal hematoma; hematomas; subchorionic or marginal hematoma; intervillous thrombi; decidual septal cystsintervillous thrombi; decidual septal cysts

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NONTROPHOBLASTIC NONTROPHOBLASTIC PLACENTAL TUMORSPLACENTAL TUMORS

Chorioangioma : Chorioangioma : the most common benign neoplasm the most common benign neoplasm of the placenta, consisting of a vascular mass arising of the placenta, consisting of a vascular mass arising from chorionic tissue, similar to a hemangioma.from chorionic tissue, similar to a hemangioma.

Incidence : 1%Incidence : 1%

Sonographic appearance : Sonographic appearance : well-circumscribed, well-circumscribed, rounded, predominantly hypoechhoic lesion near the rounded, predominantly hypoechhoic lesion near the chorionic surface, often around the cord insertion site. chorionic surface, often around the cord insertion site. There may be hyperechoic foci reflecting prior There may be hyperechoic foci reflecting prior hemorrhage, infarction, or fibrosis. Calcification occurs hemorrhage, infarction, or fibrosis. Calcification occurs very infrequently.very infrequently.

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PLACENTAL DOPPLERPLACENTAL DOPPLER In the 1In the 1stst and early 2 and early 2ndnd

trimesters has not been trimesters has not been generally successful or useful.generally successful or useful.

Retroplacental hematoma does Retroplacental hematoma does not induce hemodynamic effects not induce hemodynamic effects < 14 W GA.< 14 W GA.

Later in pregnancy, the use of Later in pregnancy, the use of intraplacental Doppler may have intraplacental Doppler may have some benefits.some benefits.

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OTHERSOTHERS

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Placenta from dizygotic twinPlacenta from dizygotic twin

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THE UMBILICAL CORDTHE UMBILICAL CORD

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SONOANATOMYSONOANATOMY Usually contain 2-A and 1-V surrounded by Usually contain 2-A and 1-V surrounded by

mucoid connective tissue (Wharton’s jelly)mucoid connective tissue (Wharton’s jelly)

Because the umbilical vessels are longer Because the umbilical vessels are longer than the cord, twisting and bending of the than the cord, twisting and bending of the vessels are common.vessels are common.

Diameter : 1 – 2 cmDiameter : 1 – 2 cm

Length : 30 – 60 cmLength : 30 – 60 cm

Insertion : abdominal wall and placentaInsertion : abdominal wall and placenta

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19 W 19 W

30 W38 W

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Umbilical Cord AreaUmbilical Cord Area

Thin UC (< 10Thin UC (< 10thth centile) is associated with centile) is associated with adverse pregnancy outcome and adverse pregnancy outcome and unexplained IUFDunexplained IUFD

UC cross-sectional area is correlated with UC cross-sectional area is correlated with fetal biometry fetal biometry (Raio L et al, Eur J Obstet Gynecol Reprod (Raio L et al, Eur J Obstet Gynecol Reprod Biol,1999)Biol,1999)

Umbilical coiling index & vein blood flow is Umbilical coiling index & vein blood flow is lower in IUGR lower in IUGR (Di Naro E et al, Acta Obstet Gynecol Scand, 2002)(Di Naro E et al, Acta Obstet Gynecol Scand, 2002)

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Umbilical Cord AreaUmbilical Cord Area

Edoardo Di Naro et al, Donald School,2003

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UC Diameter (UCD) in the 1UC Diameter (UCD) in the 1stst TrimesterTrimester

UC diameter increases UC diameter increases steadly from 8 to 15 Wsteadly from 8 to 15 W

Significant correlation : Significant correlation : UCD-CRL and UCD-BPDUCD-CRL and UCD-BPD

Marker for risk of Marker for risk of spontaneous miscarriage, spontaneous miscarriage, pre-eclampsia, and pre-eclampsia, and chromosomal chromosomal abnormalities abnormalities (Edoardo Di (Edoardo Di Naro et al, Donald School, 2003)Naro et al, Donald School, 2003)

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UC CoilingUC Coiling

Umbilical Coiling Index (UCI) : Strong et Umbilical Coiling Index (UCI) : Strong et al, Am J Obstet Gynecol, 1994)al, Am J Obstet Gynecol, 1994)

Obtained by dividing the total number Obtained by dividing the total number of complete vascular coils by the UC of complete vascular coils by the UC length.length.

Hypercoiled : UCI > 0,3 coils/cmHypercoiled : UCI > 0,3 coils/cm Hypocoiled : UCI < 0,1 coils/cmHypocoiled : UCI < 0,1 coils/cm

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UC CoilingUC Coiling The absence or paucity of umbilical The absence or paucity of umbilical

vascular coils frequently associated vascular coils frequently associated with unexplained fetal demise, IUGR, with unexplained fetal demise, IUGR, abnormal fetal karyotype, the need of abnormal fetal karyotype, the need of interventional delivery and intra interventional delivery and intra partum FHR disturbancespartum FHR disturbances (Degani S et al, J (Degani S et al, J Ultrasound Med, 2001; Georgiou HM et al, Am J Obstet Ultrasound Med, 2001; Georgiou HM et al, Am J Obstet Gynecol, 2001)Gynecol, 2001)

Differen UCI at different segments of Differen UCI at different segments of the UCthe UC

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Discordant Umbilical arteriesDiscordant Umbilical arteries Associated with placental abnormalities, Associated with placental abnormalities,

variation of the UC insertion and GDM, SGA, low variation of the UC insertion and GDM, SGA, low APGAR score, and preterm deliveryAPGAR score, and preterm delivery

Each of umbilical artery supplies one lobe of the Each of umbilical artery supplies one lobe of the placenta (end artery)placenta (end artery)

Small interarterial vessel (Hyrtl anastomosis) Small interarterial vessel (Hyrtl anastomosis) located within 3 cm from the placental cord located within 3 cm from the placental cord insertion connects both the arteries : function of insertion connects both the arteries : function of a pressure-equalizing system between umbilical a pressure-equalizing system between umbilical arteries and between the two lobes of the arteries and between the two lobes of the placenta placenta (Raio L et al, Placenta, 2001)(Raio L et al, Placenta, 2001)

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SUSPEK LILITAN TALI SUSPEK LILITAN TALI PUSATPUSAT

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SINGLE UMBILICAL ARTERYSINGLE UMBILICAL ARTERY

0.72% of single live births0.72% of single live births 2.4% in twins2.4% in twins Female : male = 1.4 : 1Female : male = 1.4 : 1

Etiology : Etiology : aplasia or atrophy of the missing aplasia or atrophy of the missing vessels, persistence of the normally transient vessels, persistence of the normally transient SUA of early development in association with SUA of early development in association with degeneration of the truncal portion of either the degeneration of the truncal portion of either the right or the left umbilical artery.right or the left umbilical artery.

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SINGLE UMBILICAL ARTERYSINGLE UMBILICAL ARTERY When SUA occurs, traces of the absent When SUA occurs, traces of the absent

artery are seldom found in the cord.artery are seldom found in the cord.

Results in hypoxia that leads to embryonic Results in hypoxia that leads to embryonic abnormalityabnormality

Clinical Application : Clinical Application : associated with 18% associated with 18% infant abnormalities (15 – 48%), the organ infant abnormalities (15 – 48%), the organ systems most often involved are the systems most often involved are the gastrointestinal, skeletal, cardiovascular, and gastrointestinal, skeletal, cardiovascular, and CNS CNS (Bryan EM et al, 1974; Harris RJ et al, 1968; Byrne J et al, 1985)(Bryan EM et al, 1974; Harris RJ et al, 1968; Byrne J et al, 1985)

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UMBILICAL CORD TUMORSUMBILICAL CORD TUMORS Omphalomesenteric duct cystOmphalomesenteric duct cyst Allantoid cystAllantoid cyst Solid tumors : teratomaSolid tumors : teratoma Vascular tumors : hemangiomaVascular tumors : hemangioma

Often located close to the fetal insertionOften located close to the fetal insertion Vary widely in sizeVary widely in size Multiple UC cyst and cyst detected in the 2Multiple UC cyst and cyst detected in the 2ndnd and and

33rdrd trimester are highly associated with structural trimester are highly associated with structural and chromosomal abnormalities, especially and chromosomal abnormalities, especially Trisomy 18Trisomy 18 (Stella A et al, Prenatal Diagnosis,2000)(Stella A et al, Prenatal Diagnosis,2000)

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HEMANGIOMA UMBILIKUSJJE-13/07/2009JJE-13/07/2009 Hanya untuk Pendidikan dan KesehatanHanya untuk Pendidikan dan Kesehatan

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Allantoid cyst

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THE NEXT GENERATIONTHE NEXT GENERATION

DIVISI KEDOKTERAN FETO MATERNALDEP. OBGIN RSPAD GATOT SOEBROTO /

FK UPN VETERAN - JAKARTA

Karya : M. Adesa NP2007(Putera dr. Judi JE)

JJE-20071027

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Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan

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REFERENCESREFERENCES

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THANK YOUTHANK YOU

JJE-20071022JJE-13/07/2009JJE-13/07/2009 Hanya untuk Pendidikan dan KesehatanHanya untuk Pendidikan dan Kesehatan