Ecografia Obstetric A de Urgencia
Transcript of Ecografia Obstetric A de Urgencia
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ECOGRAFIA OBSTETRICA DE
URGENCIA
Dr. Michel Azpeitia De la OR4 GyO HIMES
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GENERALIDADES
Hemorragia es el signo mas frecuente
Visualización de gestación intrauterina vía TV 3.5 semanas
El saco gestacional se visualiza a 35 días
Embriocardio el día 43
hGC > 2,000 siempre se visualiza saco gestacional
hGC > 25,000 siempre se visualiza embriocardio
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ABORTO
1/5 de los embarazos fracasan
20% en las primeras divisiones
20% preimplantación
50% durante la implantación
10% postimplantación - 10-15% antes de notar el retraso menstrual - 10-15% despues del primer retraso
VISUALIZACION DE ACTIVIDAD CARDIACA
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EMBRION SIN ACTIVIDAD CARDIACA (HMR)
LCN < 5mm sin FC riesgo de Aborto 15-25%
Si se suman factores de riesgo + STV
riesgo > 97%
Hematoma perisacular sin FC riesgo 88%
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SACO GESTACIONAL SIN EMBRION (anembrionico)
Vía abdominal: SG > 25mm sin embrión > 20mm sin saco vitelino
Vía vaginal: SG > 8mm sin saco vitelino > 16mm sin embrion
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Signos ecográficos de mal pronostico
Bradicardia embrionaria
Tamaño y aspecto del saco vitelino
Tamaño y aspecto del saco gestacional
Hemorragia subcorionica
Discrepancia entre el tamaño embrionario y edad gestacional
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FC embrionaria
Se evalúa fácilmente a partir de los 45 días
Aumento progresivo inicial- Sem 6 100-140- Sem 7 120-160- Sem 8 150-180- > sem 9 estabilización 120-160
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BRADICARDIA EMBRIONARIA
LCN + FCE Y PRONOSTICO
LCN 10-15mm + FCE < 115; malo
LCN 5-9mm + FCE > 120; normal
LCN 5-9mm + FCE < 100; malo
LCN < 5mm + FCE > 100; normal
LCN < 5mm + FCE < 90; pésimo
EG + FCE Y PRONOSTICO
Sem 6 + FCE < 90; alto riesgo de aborto
Sem 7 + FCE < 100; alto riesgo de aborto
> 7 sem + FCE < 110; riesgo elevado de aborto
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TAMANO Y ASPECTO DEL SACO VITELINO
Mal pronostico:- SV < 2mm- SV > 6mm entre sem 5 y 10
SV ausente y embrión visible, alto riesgo de muerte embrionaria
Morfología y ecogenicidad ???
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HEMORRAGIA SUBCORIONICA
Explica la hemorragia transvaginal
Diferente valor pronostico - Tamaño - Localización - Cantidad de STV - Crecimiento - Signos y síntomas asociados
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TAMANO EMBRIONARIO Y EDAD GESTACIONAL
Generalmente una FUM dudosa
Puede indicar anomalía grave
Restricción del crecimiento embrionario --- anomalía cromosómica o infección viral
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EMBARAZO ECTOPICO
1-1.5% de gestaciones
5-15% de mortalidad materna
Triada (45%): dolor, hemorragia y masa anexial
10% sin Dx pre Qx
USG TV x3 la sensibilidad
Curvas de ß-hGC
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Signos
Embrión o imagen sugestiva en uno de los anexos
No hay gestación intrauterina y ß-hCG> 2,000UI/ml
Pseudosaco gestacional en presencia de liquido libre intraabdominal o masa anexial
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HALLAZGOS UTERINOS
Reacción decidual- Engrosamiento
endometrial- Endometrio ecogenico
y homogeneo- Endometrio trilaminar
Pseudosaco gestacional
HALLAZGOS ANEXIALES
Presencia de embrion vivo en una trompa
Masa heterogenea con útero vacio y liquido libre en fondo de saco de Douglas
- Ecogenicidad mixta- Bordes mal definidos- Anillo ecogenico con
centro hipoecoico
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HALLAGOS PERITONEALES
Liquido libre- Ecogenico – sangre- Hipoecoico – liquido
Saco de Douglas
Espacio de Morrison > 400ml
LOCALIZACIONES POCO FRECUENTES
Embarazo cornual
Embarazo cervical
Embarazo abdominal
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Imágenes para-obstetricas del 1er trimestre
CUERPO LUTEO
- < 5cm
- Desaparece entre sem 12-16
- Anecoico VS ecos
Liquido libre – Dx diferencial con quiste torcido
MIOMAS
30% crecen
20% degeneración precoz
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Miomas
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Cuerpo Luteo
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Quistes Tecaluteinicos
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DPPNI
0.25% de embarazos
35% de las hemorragias de la segunda mitad
Mortalidad fetal 30-60%
Clínica: - Dolor abdominal- STV- Hipertonía uterina- Variaciones en FCF
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Signos
Zonas hipoecoicas retroplacentarias
Zonas hipoecoicas intraplacentarias
Grosor placentario
Anomalías en el borde placentario
Configuración general de la placenta
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EMBARAZO MOLAR
Degeneración hidrópica del trofoblasto
Aumento del tamaño uterino
Completa o parcial
Quistes tecaluteinicos
Dx histopatologico
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Signos
Imagen de ecotextura mixta, solida-liquida, predominio solido
Imágenes anecoicas son redondas (vellosidades hidropicas) de hasta 30mm
Imagen en tormenta de nieve
Quistes ovaricos multiloculares (tecaluteinicos)
Puede simular un embarazo anembrionico o aborto incompleto
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PLACENTA PREVIA
Situacion en la que la placenta ocluye parcial o totalmente el OCI
0.5-1% de embarazos
Factores de riesgo
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VARIEDADES ANATOMOCLINICAS
Placenta de insercion baja
Placenta marginal
Placenta previaa) Parcialb) Total
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PLACENTA DE INSERCION BAJA
El borde inferior no llega al OCI
Menos de 10cms del OCI
Insertada en el segmento uterino
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PLACENTA MARGINAL
Borde placentario toma contacto con el borde del OCI
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PLACENTA PREVIA
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Signos
Via transvaginal, ideal para Dx
Abdominal:Polo inferior placentario a mas de 20mm excluye el Dx
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ULTRASONIDO
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PLACENTA ACRETA
Presencia de vellosidades coriales en contacto con el miometrio
Acreta, increta y percreta
3-5% sin cesárea previa
40-50% con cesárea previa
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Signos
Perdida de ecogenicidad de la serosa uterina y pared vesical posterior
Estructura placentaria fuera de la serosa uterina
Lagos vasculares intraplacentarios (queso)
Perdida de hipoecogenicidad miometrial entre la placenta y la decidua
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USG EN TRABAJO DE PARTO
Confirmar vitalidadConfirmar presentaciónPeso fetalILA# productosEtiología de hemorragiasVasa previaHisterorrafiaVariedad de posiciónAlumbramiento (Fases)
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NEMOTECNIA DE RASTREO
C orazon U unico o M ultiple P presentacion, posicion, placenta L iquido E xtras
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USG
10-14 sem (genetico)
18-22 sem (estructural y de cromosomopatias)
30-34 sem (de desarrollo fetal y anexos)
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Traslucencia nucal
11-14 sem
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ILA
- Oligohidramnios ILA < 5
- Normal ILA 5 a 24
- Polihidramnios ILA >24
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Phelan: Cuatro cuadrantesChamberlain: Pool unico
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Embriometria
LCN 6-12 sem
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FetometriaLONGITUD FEMORAL DIAMETRO BIPARIETAL
LF 14-22 sem DBP 15-26
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Perfil biofisico
Movimientos corporales fetales
Movimientos respiratorios fetales
Tono fetal
ILA
P.S.S.
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Longitud cervical
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<25mm <32 sem Sens
11-82% VPP 11-
52%
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Modificaciones cervicales APP
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