Future. pathophysiology of preeclampsia. ? hypoxia. Also in. marker. 1st trim. In combi w PE s.flt-1 -- seng, PlGF, VEGF, US. Manifest.

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1 Take-home message Basics How to predict placental syndrome? Maternal history and exam markers Uterine artery doppler 3D Power Doppler Biochemical Salwan Al-Nasiry Gynaecoloog perinatoloog MUMC Future challenge Take-home message Basics How to predict placental syndrome? Maternal history and exam markers Uterine artery doppler 3D Power Doppler Biochemical The placenta may predict the baby Harvey Kliman Future challenge Preeclampsia: a historical prespective Take-home message Basics How to predict placental syndrome? Maternal history and exam Biochemical Uterine 3D artery doppler Power Doppler Future Placental bed

2 Preeclampsia: defective spiral artery remodelling Take-home message Basics How to predict placental syndrome? Maternal history and exam Biochemical markers Uterine artery doppler 3D Power Doppler Future Normal pregnancy preeclampsia pathophysiology of preeclampsia defective spiral artery remodelling? hypoxia release of placental factors? trophoblast microparticles Endothelial dysfunction Clinical preeclampsia?ros/cytokines?angiogenic factors genetic immune environment marker 1st trim 2nd trim Manifest In combi w PE s.flt-1 -- seng, PlGF, VEGF, US Also in seng -- Sflt-1, PlGF, US IUGR, SGA, HELLP PlGF seng, sflt-1 SGA PP-13 US IUGR, preterm P-Selectin sflt-1, Activin-A cf-fetal DNA Inhibin-A Tris21, IUGR, preterm cf-dna ADAM Tris21/18, SGA PTX-3 IUGR PAPP-A Birth wt Grill et al. Reproductive Biology and Endocrinology 2009, 7:70

3 Cell-free fetal DNA Cell-free fetal DNA Uterine artery Dopplers Uterine A. Dopplers wk N= 1067 unilateral notch 23% bilateral notch Dugoff et al. American Journal of Obstetrics and Gynecology (2005) 193, Prospectieve cohort High-risk pregnancy for placental insufficiency (medical/obs Hx) N= 61, all had screening at: wk Serum: PAPP-A Ut A doppler Placental structure wk Serum: hcg+afp Ut A doppler Placental structure Test # Adverse # Adverse P value LR+ (95% CI) LR- (95% CI) outcomes test abnormal (total) outcomes test normal (total) Ut A Doppler PI 6 (16) 5 (41) ( ) 0.71( ) Placental morphology 5(11) 6 (47) ( ) 0.63 ( ) Biochemistry 4 (9) 6 (44) ( ) 0.64 ( ) 1 abnormal tests 9 (24) 2 (34) (1.6 24) 0.68 ( ) 2 abnormal tests 4 (8) 7 (50) ( ) 0.58 ( ) All abnormal tests 2 (3) 9 (55) ( ) 0.40 ( ) Costa et al. Placenta 29 (2008) Costa et al. Placenta 29 (2008)

4 Systematic review, total patients PE 74 studies IUGR 61 studies Placental 3D Power Doppler Results Dopplers in 2nd trimester performed better than 1st trimester Most Doppler indices had poor predictive characteristics, depending on: patient risk outcome severity. high PI with notching was the best predictor of: pre-eclampsia High risk LR low risk LR+ 7.5 IUGR overall LR+ 9.1 severe LR Cnossen et al. CMAJ 2008;178(6): Gudmundsson et al. Semin Perinatol 33: , 2009 Placental 3D Power Doppler Gebb et al. Best Practice & Research Clinical Obstetrics and Gynaecology 25 (2011) Odibo et al. Placenta 32 (2011) 230e234 Take-home message Basics How to predict placental syndrome? Maternal history and exam Biochemical Doppler Placental structure Future challenge Abnormal placental structure (placenta lakes)

5 Abnormal placental structure (placenta lakes) Abnormal placental structure (placenta lakes) Routine 20-wk scan N= 109 met placenta lakes (8.7% van de populatie), groepen: I = klein, verdwijnt later = 52 II = groot, verdwijnt later = 19 III = klein, persisteert = 27 IV = groot persistereert = 11 Huwang et al. European Journal of Obstetrics & Gynecology and Reproductive Biology 162 (2012) wk geplande sectio of inleiding Onderzoekers: G. Gruiskens C. Ghousein Begeleiders: K. vdvijver (patho) M. Baldewijn (patho) S. Al-Nasiry (gyn) M. Spaanderman (gyn) Huwang et al. European Journal of Obstetrics & Gynecology and Reproductive Biology 162 (2012) wk, prospectief cohort, placental lakes Klinische uitkomsten (moeder, kind) Onderzoekers: G. Gruiskens C. Ghousein Begeleiders: K. vdvijver (patho) M. Baldewijn (patho) S. Al-Nasiry (gyn) M. Spaanderman (gyn)

6 Acute atherosis Onderzoeker: D. Stevens Long term outcome (repeat preeclampsia, CV risk profile) Begeleiders: H. Bulten(patho) J. vd Vugt (gyn) S. Al-Nasiry (gyn) M. Spaanderman (gyn) Stevens et al Stevens et al. 2011

7 Clinical parameters DV Controls p-values Diastolic blood pressure a Urine protein-tocreatinine ratio a Thrombocytes b LDH a ASAT a ALAT a Gestational age 30w6d 32w5d Birthweight (grams) Birthweight (centile) APGAR 1 minute 5, APGAR 5 minute 6,9 7, Umbilical artery ph Histological DV Controls p-values parameters Placenta Weight (gram) Infarction degree a 1 0, Infarction location b Calcificatins degree a 0,3 0, Hematoma degree a 0,5 0, Ischemia degree a 1,7 1, Stevens et al. Placenta 33 (2012) 630e633 Stevens et al. unpublished final thoughts The placenta may predict the baby Harvey Kliman

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