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When to take a

decision of delivery
Dr. Rasha Salem
trainee

Obst. & Gyne. specialist/MRCOG

Obstetric and Gynaecology


Department

Introduction
Termination of Pregnancy before
spontaneous labor in non routine
patients
represents
a
major
challenge to clinician.
we should weigh between:

Fetal risk from iatrogenic prematurity

Maternal and sometimes fetal risks


from
continuation pregnancy.

Introduction
Theme are 3 clinical situations in which
it would be useful to have an objective
assessment of fetal lung maturity:
1.Preterm patient at high risk for imminent
delivery secondary to premature labor.
2.Women whom early delivery is mandated
by maternal and/or fetal indication: e.g. sever
PIH, IUGR, chronic HTN and diabetes.
3.Patient
with
previous
C.S
with
uncomplicated pregnancy but unsure of her
dates.

Introduction
Assessment

of fetal lung maturity in


former 2 categories is less critical, Since
maternal or fetal factors may dictate
immediate delivery, regardless the status
of fetal lung maturity.

Introduction
Amniocentesis represents a gold standard
for evaluation of FLM (L/S ratio<2 &
presence of PG).
Amniocentesis is an invasive technique with
a complication rate of up to 15% in the third
trimester of pregnancy (Sabbagha, 1979).
Maternal complications include infection,
bleeding, Rh iso immunization.
Fetal Complications include fetal injury &
fetal demise.

Introduction
Its

more
dangerous
or
contraindicated in obese patients,
oligohydramnios & anteriorly located
placenta.
Repeat amniocentesis if the analysis
yields premature results is another
cause of desperate to both doctor &
mother.

Then what to do
Ultrasound:
(very
charming
alternative to amniocentesis):
1. Easy to do.
2. Non invasive.
3. Safely repeatable.

The use of sonographic quantitative


parameters (BPD, FL, HC and AC) is
complicated by marked biometric
variability in 3rd trimester & is
inaccurate for assessment of FLM.
Hence
the need for Qualitative
parameters reflecting lung maturity &
not somatic growth.

Lung Maturity
Sonographic indices of fetal lung
maturity:
Placental maturity.
Free floating particles in amniotic fluid.
Fetal lung echogenicity.
Fetal intestinal indices.
Fetal epiphyseal ossification center.
Ongoing research:
1. Cerebellar echogenicity.
2. Thalamic echogenicity.

Placental Maturity
Grannum, 1979 reported that:
Since the placenta is fetal organ, It
should mature in a fashion similar to
that of fetal lung.
He classified placental maturation
into 4 grades: 0, I, II, III.
All grade III placenta has L /S
ratio<2.
He assigned the placenta according
to the highest grade.

Placental grading

Placental grading

grade I: 18-29 weeks


occasional parenchymal
calcification/ hyperechoic areas
subtle indentations of chorionic plate

grade II: >30 weeks

occasional basal calcification/


hyperechoic areas.
deeper indentations of chorionic plate
(does not reach up to basal plate).

Placental grading

Grade III: >39 weeks.


Significant basal calcification.
Chorionic plate interrupted by
indentations (frequently calcified) that
reach up to basal plate: cotyledons.

Placental grading
Modified placental grading (Kazzi
et al, 1985):
Immature placenta: Grade 0,I or
II , according to Grannumms
classification.
Intermediate placenta: Partly
Grade III.
Mature placenta: Totally grade III.

Free floating particles


Free

floating particles (FFP) in AF are


flakes of fetal vernix.
Criteria (Gross et al, 1985):
n Multiple linear densities 2-5 mm in
length.
n Suspended but gradually settling in
amniotic fluid.
n Fetal movement causes a movement of
these particles simulating a blizzard.

Free floating particles


Presence:

Not reliable: detected as


early as 15 weeks of pregnancy
(Parulekar, 1983)
Measurements : More reliable
I.AF
FFP <3.8 mm predicts RDS
(sensitivity 86%).
i.AF FFP >5.1 mm is a useful sonographic
index for fetal lung maturity.

Free floating particles

Fetal lung/ liver ratio


< 1 immature

= 1 borderline

> 1 mature

With fetal lung maturity there


is dramatic increase in number
of alveoli increase number of
acoustic interfaces brighter &
coarser lung (Morris, 1984).

Fetal lung/ liver ratio

Fetal Colonic grading


As
gestation
advances
fetal
meconium changes its consistency
from fluid (sonolucent) into
semisolid (echogenic).
Echogenecity
of
meconium
increases at term.
Fetal stomach & bladder & liver,
have constant sonographic texture
during pregnancy.

Fetal intestinal indices


Grade 0 : Colon is not identified.
Grade I : Echogenecity of colonic contents is
identical to that of bladder and stomach.
Grade II: Echogenecity is more dense than
the bladder but less than the liver.
Grade III : Echogenecity of colonic contents
is equal to that of the liver.

Fetal intestinal indices

Fetal intestinal indices

Fetal epiphyseal ossification


centers (EOC)
Three EOC could be detected
prenatally : DFE , PTE & PHE .
EOC appear in the most central
part of the joint .
Each OC
is first ellipsoid then
becomes rounded (concentric
calcification) .

Fetal epiphyseal ossification


centers (EOC)

EOC Appear in sequence:


1st DFE at 30 weeks & reaches 5 mm
at GA >37 weeks.
2nd PTE at 35 weeks & PTE reaches 3
mm at GA >37 weeks.
Rate of growth of PTE is more than
that of DFE therefore it catches the
PFE at GA > 38 weeks.

Fetal epiphyseal ossification


centers (EOC)

Fetal epiphyseal ossification


centers (EOC)

Fetal epiphyseal ossification


centers (EOC)

3rd PHE at > 38 weeks.

Fetal EOC are useful indices


for FLM if:
PHE present.
DFE 1mm larger than PTE.

Sonographic indices of
fetal lung maturity
Mature placenta: Totally grade III.
Amniotic fluid FFP: >5.1 mm.
Colon Grade III: (echogenecity = liver ).
Fetal EOC if :
PHE present.
DFE 1mm larger than PTE.
Liver /lung echogenecity: >1

Thank you