KORAI FEJLESZT

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KORAI FEJLESZTÉS ÉS NEUROREHABILITÁCIÓINTRAUTERIN
ÉS SUBPARTALIS OKOK

• PROF. DR. TÓTH ZOLTÁN
• Debreceni Egyetem
• Orvos- és Egészségtudományi Centrum
• Szülészeti és Nogyógyászati Klinika
• Seregélyes 2006. 05. 04.

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Screening in pregnancy
Obstetrics vs Fetal Medicine
Fetal Medicine Fundation, London Kypros
Nicolaides 2006
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Screening in pregnancy
Detection rate
Maternal Maternal Fetal

• Fetal abnormalities
• Impaired placentation
• Preterm delivery

5-30 80-100 30
90 30 75

• Kypros Nicolaides 2006

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Congenital defects
Contribution to post natal death
Effectiveness of prenatal diagnosis
60

50
40
30
20
10
0
Others
CNS
Cardiac
GIT / Facial
Respiratory
Musculoskeletal
Genitourinary
Chromosomal
Grandjean et al 1998, Eurofetus project Kypros
Nicolaides 2006
OPCS 1996 data series DH3
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Avoidance of Death Handicap

• Fetal abnormalities
• Impaired placentation
• Preterm delivery

• Kypros Nicolaides 2006

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The 11-136 weeks scan

• Increased NT is associated with
• All major chromosomal abnormalities
• More than 50 defects genetic syndromes
• The risk increases with NT thickness

• Kypros Nicolaides 2006

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Successful examination of fetal anatomy at
11-136 weeks
Transabdominal and / or transvaginal scan

• Kypros Nicolaides 2006

Souka et al 2004
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The 18-23 week scan

• Fetal biometry
• Fetal anatomy
• Fetal activity
• Placental localisation
• Amniotic fluid volume

• Kypros Nicolaides 2006

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ULTRAHANG-SZUROVIZSGÁLATOK OPTIMÁLIS
IDOPONTJAIMSZNUT AJÁNLÁS 1993

• 0. vizsgálat elso jelentkezés
• I. vizsgálat 12. hét
• II. vizsgálat 18. hét
• III. vizsgálat 32. hét
• IV. vizsgálat 38. hét

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100
Effectiveness of prenatal diagnosis of trisomy 21

• Kypros Nicolaides 2006

National Down syndrome Cytogenetic Register 2003
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The 11-136 weeks scan
Screening for chromosomal defects other than
trisomy 21
Fetal heart rate
Crown-rump length
Ultrasound markers
Free ß-hCG
PAPP-A
Exomphalos Single umbilical artery
Trisomy 18
?
?
?
?
Megacystis Holoprosencephaly
Trisomy 13
?
?
?
?
Turrners
?
?
?
?
Triploidy
?
?
Small / molar placenta

• Screening for trisomy 21 by NT, fß-hCG PAPP-A
  can detect 90 of other chromosomal defects
• Each chromosomal defect has its own syndromal
  pattern of sonographic and biochemical markers

• Kypros Nicolaides 2006

Sherrod et al 1997 Jauniaux et al 1997 Spencer
et al 2000 Spencer Nicolaides 2002
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Outcome in twins depends on chorionicity

• Kypros Nicolaides 2006

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Abnormalities in twins
Prevalence DCMC 41
Defects in DC X1 singleton
Defects in MC X4singleton
Discordancy for defectsMCDC

• Kypros Nicolaides 2006

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Spontaneous preterm delivery
Multiple pregnancy Cervical length at 22-24 wks
Twins 1163 Triplets 43
100
75
Risk of delivery lt33 wks ()
50
25
0
0
10
20
30
40
50
60
70
Cervical length (mm)

• Kypros Nicolaides 2006

Skentou et al 2000 To et al 2001 2005
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• Kypros Nicolaides 2006

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Prediction of spontaneous delivery lt34 wks
TWINS Maternal factors cervical length at 22
wks

• Kypros Nicolaides 2006

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Premature birth

• Kypros Nicolaides 2006

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Premature birth
N 32,150
4.0

3.0
2.0
1.0
0
30-33 wks
Iatrogenic
Spontaneous

• Kypros Nicolaides 2006

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• Kypros Nicolaides 2006

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Starved Small Fetuses

• Kypros Nicolaides 2006

Hecher et al 2001 Baschat et al 2001 Bilardo et
al 2004
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Prediction of premature birth
Screening by maternal history
N39,284 spontaneous delivery lt33w 1
Screen ve 5
30

• Kypros Nicolaides 2006

To et al 2006
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Prediction of premature birth
False ve 5
100
90
N39,284
70
Detection rate ()
80
60
70
50
60
40
Risk ()
50
30
40
20
30
10
20
0
0
10
20
30
40
50
60
10
Cervical length (mm)
0

• Kypros Nicolaides 2006

History
Cervical length
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Prediction of Pre-eclampsia
Screening by maternal history
Maternal history
LR
N30,784 PETlt34w 0.5
Age (yrs) lt20 20-35 gt35
0.7 1.0 1.5
Screen ve 5
100
90
80
Body Mass Index lt20 20-30 gt30
0.7 1.0 1.5
70
60
Detection rate ()
50
Ethnicity White Black
1.0 1.5
40
33
30
Obstetric history Nullipara no
PET PET
1.6 0.5 4.0
20
10
0
PET lt33w
Cigarette smoking
0.6

• Kypros Nicolaides 2006

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Prediction of Pre-eclampsia
Maternal blood and urine analysis
RENAL FUNCTION TESTS Serum uric acid Urinary
calcium Urinary kallikrein Urinary
microtransferrine Urinary N-acetyl-ß-glucosaminida
se
ENDOTHELIAL AND OXIDANT STRESS TESTS platelet
activation and endothelial cell adhesion
molecules, antithrombin III, endothelin,
plasminogen activator inhibitor, placenta growth
factor, prostacyclin, thromboxane, vascular
endothelial growth factor, soluble fms-like
tyrosine kinase 1, cytokines, homocysteine,
isoprostanes platelet count, hematocrit,
ferritin, transferring, plasma proteins, serum
lipids, magnesium, calcium, haptoglobin,
fibronectin, insulin resistance, atrial
natriuretic peptide, and ß2-microglobulin.

• Kypros Nicolaides 2006

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Prediction of Pre-eclampsia
Screening by uterine artery Doppler
Detection rate ()
Detection rate
Disease
100
85
90
80
80
All early PET
70
70
85
Early PET FGR
60
70
Early PET noFGR
45
50
45
Early FGR noPET
40
30
30
All late PET
20
45
Late PET FGR
10
15
Late PET no FGR
0
PET FGR
PET no FGR
FGR no PET
10
Late FGR no PET

• Kypros Nicolaides 2006

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Screening in pregnancy
Detection rate
Maternal Maternal Fetal

• Fetal abnormalities
• Impaired placentation
• Preterm delivery

5-30 80-100 30
90 30 75

• Kypros Nicolaides 2006

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MAGZATI ÁLLAPOT MEGÍTÉLÉSÉNEK LEHETOSÉGEI

• Magzatmozgás számolása
• Auscultatio
• Muszeres szívhangellenörzés
• Biokémiai vizsgálatok
• Ultrahang-diagnosztika 2D,3D,4D
• Morphologia, biometria
• Funkcionális jelek
• Biophysicalis profil
• Magzati- uteroplacentaris keringés
• Amnioscopia
• CTG fejborvér pH mérés
• Magzati pulzoxymetria

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FELADATOK

• Terhesgondozás fejlesztése
• Szurovizsgálatok kiterjesztése
• Prenatalis diagnosztikai központok
• Perinatológiai centrumok (4-5)
• Szülok felkészítése a rehabilitációra
• Személyi és tárgyi feltételek biztosítása

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IRODALOM

• Kypros Nicolaides A 11-136 hetes ultrahang
• Fetal Medicine Fundation, London 2006
• Papp Z. A szülészet-nogyógyászat tankönyve
• Semmeweis Kiadó, Budapest 2002
• Papp Z. Szülészet-nogyógyászati protokoll
• Golden Book Kiadó, Budapest 2002
• Tóth Z., Papp Z. Szülészet-nogyógyászati
  ultrahang- diagnosztika, Golden Book Kiadó
  Budapest 2006.